A AMPUTAÇÃO NA PERCEPÇÃO DE QUEM A VIVENCIA: UM ESTUDO SOB A ÓTICA FENOMENOLÓGICA

Diante da inquietação com a questão da amputação, suas implicações e sentimentos experimentados pela pessoa que a vivencia, realizou-se esse estudo, com a proposta de compreender esse fenômeno. Inicialmente, a revisão da literatura possibilitou conhecer esse tema sob diversos enfoques, além de permitir a apropriação de algumas idéias do pensamento filosófico de Merleau-Ponty sobre o corpo e a percepção. Após o conhecimento sob essa ótica, realizou-se entrevistas com as pessoas submetidas à amputação, habitando seu mundo, ouvindo seus depoimentos. Compartilhando desses momentos, pôde-se compreender seus significados, a partir da experiência de quem os vivencia, expressando-os sob a forma de seis categorias temáticas. Desse modo, foi possível desvelar algumas facetas do fenômeno amputação, à luz do referencial fenomenológico, além de compreender a pessoa amputada em sua situcionalidade, tal como ela se mostra em si mesma, em sua essência.


INTRODUCTION
As a nursing undergraduate and scientific initiation student, I became concerned with amputations, their implications and feelings aroused in the people who experience them, a concern generated by personal experiences.To obtain further knowledge about the theme, I carried out a bibliographic survey, which allowed me to get to know amputation from an anatomic-physio-pathological focus, as well as nursing production about the subject.Thus, in theoreticalpractical activities, I started to have contact with people who experienced this phenomenon.Amputation is the eldest of all surgical procedures and, for a long time, it represented the only surgical possibility for man.In surgery, the term designates the removal of an organ or part of it, located at an extremity.However, when used isolatedly, it is considered to be the amputation of limbs.Its current concept refers to a reconstructive surgery instead of simple ablation and should be the first step for the patient's return to a normal and productive place in society (1) .The surgery should be considered as yet another phase in treatment.The mutilation only affects the limb and not the patients' soul (2) .
Upper and lower limb amputations can be carried out at different levels and derive from: peripheral vascular diseases (most common cause among the elderly), congenital malformations, tumors, traumas (predominant cause among young people) and infections (1,(3)(4)(5) .
There are no exact statistics about the number of existing amputees or the number of amputations carried out each year.However, about 85% are lower limb amputations (1) .These are common in diabetics with lower limb ulcers (6) .Diabetes patients with larger amputations also present a reduced quality of life (7) .However, disabled persons can have a good quality of life when they overcome limits and achieve a balance between mind, body and spirit (8) .
Nurses have stood out as educators for diabetes patients, and their integration into the multidisciplinary team becomes increasingly important, with a view to contributing to educational strategies and minimizing health problems (9) .However, there is a lack of nursing publications about the subject, which makes it important to carry out and publish studies about the theme (10) .
Despite the literature review, something still remained hidden to me, because I hadn't managed to answer my concern and, thus, understand the emotions and feelings, that is, the experience of human beings submitted to amputation.Hence, I carried out this study to unveil some facets of the amputation phenomenon from the perspective of the people who experience it.

THE METHODOLOGICAL COURSE
Phenomenology is a descriptive, rigorous science that is concerned with the essence of experiences (11) .It calls upon us to take up the qualitative course of existence again, to rediscover the global meaning of existing (12) .The phenomenological method seeks what transcends the empirical particularities of the phenomenon, with a view to understanding it (13) .
Starting from the philosophical premises of phenomenology, I saw the possibility to understand the phenomenon "experiencing an amputation situation" in the way it appears in itself, which is the goal of this study.

THE CONSTRUCTION OF THE RESULTS
While reading the 52 testimonies obtained through the interviews, initially, I attempted to become familiar with the experiences.Next, I identified the units of meaning and the meanings they contained.
Finally, these units were synthesized to arrive at the essence of the phenomenon.This synthesis took the form of the construction of thematic categories (14)   .
Merleau-Ponty's philosophical thinking was used to support discourse analysis, as he is the philosopher of existence, of the body, and the phenomenologist of perception.I perceive and I am perceived through my body, as it is my vehicle of being-in-the-world and, this way, I do not have a body, but I am a body.The "own body" or the "lived body" is the one that, through the sensitive, exercises vital communication with the world, which is what I live and not what I think.The body is our means of having the world and it is through the body that one relates with others, with things, with the world itself, experiencing my own body (15) .
In an amputated person, this relation between the body and the world is changed, as a part is questioned in the body which no longer exists and is silenced.Thus, the research subjects perceived the amputation as follows: Living the preoperative period in an attempt to keep up appearances During the preoperative period, the patient experiences ambiguous feelings, as this moment in life at which the person is about to assume a new way of being-in-the-world arouses an infinite range of feelings, which are expressed or not.
Although the patients affirmed their agreement with the surgery, they displayed feelings of discouragement, pain, anguish, fear, sadness and crying and remained downcast.At all times, their gestures communicated the difficulty to live with the imminence of a mutilating surgery.In spite of the suffering experienced because of the imminent loss, the patients see their family as a reason to try and hide the pain they suffer.Protecting their relatives from the suffering they experience seems to be a primordial issue.In a way, their concern with their family reveals to be something determinant to try and keep up appearance and for their continuous effort no to let their pain come to the surface.
... everybody stayed there, at home, crying.I don't cry, things will get solved.I make the decision.Strength -I1 The surgical experience shows its possibilities to the patient, as it makes possible a different existence.We can see the perspective of an incomplete existence, as a body part is lost, or simply In looking at the amputation as a phenomenon, I noticed that it can be good and bad, pleasant and sad, happy and unhappy, easy and difficult, in the eyes of the people who experience it.
Opposite but mutually united feelings and sensations coexist in one and the same scenario.How, then, can one consider a surgery that is mutilating and leads to such important changes in the lives of the human being and his relatives as good?This experience becomes more pleasant to the extent that the amputated persons perceive it as a source of hope to return to life, to keep on living, as being-there-in-the world, with a singular will and desires.
In the case of patients affected by vascular problems, the definitive relief of their pain reveals to be a priority.Pain is discouraging, unbearable, sad and limiting and, at this moment, any attempt to relieve/eliminate the pain is considered positively, even if this demands the loss of a body part.
Amputation starts to be seen as a necessary evil.

Overcoming -I1
Being dependent is extremely painful and discouraging and, in some cases, the patients even prefer death to being a source of pity, compassion or even work/effort for their relatives. .

.. I want to live, but provided that it does not cause trouble to my family. If I cause trouble, I prefer to leave. I don't want to leave (die). Force -I1
Amputated patients are concerned with their dependence and display difficulties to visualize what they can do.Mainly the elderly show dependence to perform activities of daily living.It is important for health professionals to stimulate patients towards selfcare, acceptance of limits and return to activities (16) .
In a phenomenological perspective, I consider that there is a need for a multi and interdisciplinary look, which helps the people to redimension their existence, opening up to new life projects and contemplating them in this new way of being-in-the-world.Receiving individualized and planned care is essential for the rehabilitation process to take place as adequately as possible and to achieve the proposed objectives.Hospital discharge ends up being seen as the "passport" to life and to the return to activities.The patients affirm that, outside the hospital, they will do everything they were used to before the surgery, often denying the limitations imposed by the surgical procedure, as well as their new condition in the world.Mainly long hospitalizations give rise to an infinite range of feelings that demand the patients' efforts to achieve a balance and overcome any crises ahead.In this sense, humanitarian contact with health professionals becomes important in order to minimize the negative effects of hospitalization.
The phantom limb as the extension of one's own body As a way of maintaining the body's expression and language, the phantom limb is present to a greater or lesser extent.The absent limb takes forms and continues living in the amputee's world, as the project that guarantee the human being's integrity are possible if their bodies are complete and, in amputees, this is possible by the unquestionable presence of the phantom limb.The feelings are so intense and true that the patients are able to describe their sensations in detail.

The arch of the foot hurts. It pounds. It pricks. But it's like that, in the arch of my foot... Will -I1
The phantom limb is a way of being-in-theworld, staying complete, open to actions in the world, fully, and to the possibilities of one's becoming, of one's existential projects.In the attempt to describe the belief in the phantom member and the refusal of the mutilation, the idea of an organic thinking is constituted, through which the relation between the mental and the physical could be conceived.The phantom members allows for neither a physiological, nor a psychological or mixed explanation, although it can be related to the two series of conditions.In the physiological explanation, the phenomenon appears as the simple persistence of interoceptive stimulations while, in the psychological explanation, the phantom members becomes a recollection, a perception (15) .
Starting from these objective and mechanistic, physiological and/or psychological explanations, and looking at these only, we would highly reduce the existential dimension of the phantom limb phenomenon and its importance for amputated patients.Connecting and relating the physiological with Amputation in the perception of those... Chini GCO, Boemer MR.

It is. It is part of my life (amputated leg). You feel it, undoubtedly. The functioning of the rest of your body also belongs to it (amputated leg). Hope -I9
Hence, what we find behind the substitution phenomenon is the movement of being-in-the-world.
The phantom limb is not a simple effect of objective causality.The patients seem to ignore the mutilation and consider their phantom as an actual limb (15) .The phantom limb, as a part of one's own body, maintains the amputee fully in the world, trying to complete the void left by the body part through the substitution.
The prosthesis as a way of fully continuing in the world It is believed that the prosthesis makes it possible to perform any activity, improving self-esteem and, thus, minimizing the negative effects that result from the amputation.Although they are adequate to any amputation level, those performed at more distal levels provide for a more efficient rehabilitation.
Hence, rehabilitation has been considered increasingly important as, if the process occurs adequately, the patients will practically have a normal life and can do any activities they want or need to.
Prostheses are normally expensive, turning into a source of concern for the amputee, as it is a dream that often will not come true, impeding their movement towards the world.Purchasing the prosthesis seems to be an unquestionable dream; any amputee wants it as early as the preoperative period.In communicating the need for the surgery, the medical team itself already addresses rehabilitation with the help of a prosthesis, perhaps in the attempt to mitigate the suffering caused by the amputation.
...the doctor said that it's fast.Three months of treatment here, I put on the prosthesis and I can walk fine...Strength -E1 Although the prosthesis is considered extremely important for people who have already undergone the amputation, sometimes, it is seen as a source of difficulties, suffering, which demands adaptation, starting and starting over.The patients acknowledge that the organic part of their body is no longer there.
For the amputee, the prosthesis becomes something that moves further, as it is not only a facilitating object, but also something that will be a part of one's own body.It represents a horizon of possibilities.It will become a fundamental part of the body, allowing for the full and complete perception of a form similar to the phantom limb.

REFLECTIONS ABOUT THE REVELATIONS
This study made it possible to unveil some facets of the amputation phenomenon, at a moment of transition in the patient's life, from the possibility of becoming to the concreteness of this possibility, through the realization of the surgery.An infinite range of feelings is involved in the change process of the body and, thus, of the entire existence, as the body is of vital importance as a means of being inserted in and relating with the world, through perception.
Amputation is loaded with ambiguous feelings that mutually interact and remain united, permeating existence in the preoperative period, during hospitalization and possibly after discharge.Losing a part of one's body is painful and imposes a new way of life, of being-in-the-world and relating with it, which requires a redimensioning, as the body and, consequently, the perception of the world and things was affected.No matter how difficult or painful it is to be an amputated person, the patients surrender to the limit/limiting situation they are in, in the chronic disease, and chooses to do the surgery, hoping to put an end to the physical pain or to stay in the world, distancing the idea of a close death.
In the relation with the world, in questioning a body part that no longer exists, there will be a real and no longer ideal or habitual answer.This new reality creates fear, pain, anguish, as having to readapt to a new way of existing and overcoming barriers towards actual possibilities is, at first, something complex and difficult.
While the patients do not clearly visualize the possibilities that appear, which demand redimensioning, they suffer due to the lack of perspective and dependence expands through experience.The amputee starts to be concerned about dependence, seeing it as a future marked by suffering.
Thus, the importance of harmonically developing the rehabilitation process becomes evident, as rehabilitating a patient does not only mean returning him/her to society as an independent person, despite the impairment.Rehabilitation should be capable of granting the patient perspectives of ideal daily activities, of a modified existence that allows him/her to stay open to the world and to things.
The patients showed that experiencing an amputation is sad, difficult and painful.However, despite all of these difficulties and suffering, they do not lose courage.The expectation of a new life is a reason for happiness and for the desire to want to keep on living.
The surgery is incorporated into the existence and, as a part of it, it is accepted but not wanted.
Understanding this moment is essential for a more effective and complete performance of health The study was previously submitted to the Research Ethics Committee and carried out at the University of São Paulo at Ribeirão Preto Medical School Hospital das Clínicas (HCFMRP-USP)-Campus, more specifically the vascular and orthopedic surgery clinics, due to the fact that these offer the highest possibility of finding people who are going through an amputation situation.To collect the amputated patients' testimonies, I carried out individual interviews from January to May 2005, when I accompanied the hospitalization period of 13 adult patients, who were hospitalized for the surgery, from the preoperative stage until discharge.
the perspective of standing open to new experiences, free from the pain, from the deformed part, from the organic part that also causes suffering and that often modifies the movement of the being-in-the-world.Experience permeated by a dualism: the logical and the experience Experiencing an amputation implies an experience marked by bio-socio-psycho-spiritual and cultural changes, loaded with stigmas, deriving from the installed disability and from different converging and diverging feelings, which interweave and join, constituting a whole.This experience consists of feelings that are mixed up and permeated by reason on the one hand, which visualizes the surgery as necessary, and emotion on the other, which does not accept the loss.
professionals' activities.Looking at amputated persons from their perspective permits care delivery directed at these persons' singularity and at the particularity of their experience.Nursing needs to awake to what goes beyond the biological dimension, as the objective of the profession is care, which should be delivered in a way that expands through experience.In opening up to the private world of experience, the profession opens up to the human being who is there, providing him/her with complete and humanitarian care.Recebido em: 28.11.2006Aprovado em: 26.10.2006 Besides an alternative for pain relief, amputation is a possibility to maintain life, mainly for patients with tumors.It is seen as a procedure that must be done, despite all of its physical and psychological consequences, provided that it allows for a prolonged existence.The hope to save the whole body is an essential factor in making the decision and choosing the surgery.Death is the finitude that must be avoided, and the sacrifice of losing a body part is valued.
... not sleeping for six months is hard... it hurt when I lay down, when I stood up, it's hard, it's sad, I suffered so much, so much, so much.Now, if I had to do it again, I'd do it again, because all of the suffering ends... Strength -I2 of fear.Not performing daily activities or doing them with help causes feelings of inferiority, low self-esteem and concern in the patients.It bothers you, you know.Perhaps the person helps you now, then you call him again.Perhaps he comes to help you with the same good will as the first time, but you don't think like that in your head.I think like, I'm causing too much trouble...It gets difficult (pause)... but what can you do? (silence).