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A experiência vivida dos profissionais de medicina com pedidos de eutanásia e de suicídio medicamente assistido
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Contexto: Existe evidência empírica de que alguns médicos oncologistas portugueses receberam pedidos explícitos, persistentes e bem-refletidos de eutanásia (EUT) e suicídio medicamente assistido (SMA), formulados por pessoas com doenças incuráveis, avançadas e progressivas. Todavia, pouco se sabe sobre o modo como os oncologistas e os médicos portugueses de outras especialidades experienciam os pedidos de morte medicamente assistida (MMA), interpretam esses pedidos, deliberam e respondem aos doentes que lhes solicitam ajuda médica para morrer. Objetivos: Compreender a natureza das experiências vividas por profissionais de Medicina com pedidos de EUT e SMA que lhes foram dirigidos por doentes adultos e mentalmente competentes durante a prática clínica. Apreender e interpretar os múltiplos significados que as experiências com pedidos de MMA tiveram para os médicos que as vivenciaram. Metodologia e Participantes: Investigação fenomenológico-hermenêutica, de cariz exploratório, descritivo e interpretativo, na qual participaram nove médicos portugueses, especialistas em Anestesiologia, Medicina Interna e Paliativa, Hematologia Clínica, Oncologia Médica, Nefrologia e Neurologia, que exercem e exerceram até à reforma a prática clínica em unidades hospitalares públicas e privadas. O material experiencial sobre os pedidos de EUT e de SMA foi recolhido entre Junho e Outubro de 2014, através de entrevistas semi-diretivas, áudio-gravadas e transcritas na íntegra; tendo sido, posteriormente, submetido a análises temáticas para descobrir os seus núcleos de sentido. Resultados: Quatro temas fenomenológicos emergentes das entrevistas. Tema I-Estar Aberto para Ouvir os Pedidos de MMA revelou que ficar para ouvi-los foi uma escolha difícil e que a recepção de pedidos explícitos foi a mais frequente, tendo sido raros os pedidos implícitos. Todos os médicos receberam pedidos de EUT, tendo os pedidos de SMA sido recebidos só por dois médicos. Tema II-Interpretar e Explorar os Significados dos Pedidos de MMA: a interpretação incluiu manifestações de sofrimento existencial/altruísta, racionalização da situação clínica e ausência de esperança, perda de autonomia, redução da qualidade de vida e degradação física; tendo a exploração de pedidosfracassos de EUT sido evitada por evasão, a exploração de pedidos-ordens de EUT sido bloqueada por inaptidão; e a exploração de pedidos de MMA sido consolidada por escalpelização. Tema III-Responder aos Pedidos de MMA traduziu-se na recusa explícita pela maioria dos entrevistados, que em alternativa implementou três decisões médicas em fim de vida: controlo sintomático e cuidados paliativos (três médicos), a par da sedação paliativa (três médicos). Atipicamente, a recusa explícita de um pedido de EUT, a par da permissão implícita da concretização do plano de um doente (colega de profissão) e um membro próximo da família (enfermeira), ocorreu uma vez. Os únicos dois médicos que aceitaram pedidos de MMA estiveram, respetivamente, envolvidos num ato de SMA (prescrevendo fármacos em doses letais e fornecendo instruções necessárias para a utilização dos mesmos por parte de um doente que faleceu sem os ter auto-administrado) e em quatro atos de EUT (administrando fármacos em doses letais a doentes e a amigos que morreram na sequência da hetero-administração desses fármacos). Estas sete respostas negativas aos pedidos de MMA foram justificadas com base em restrições deontológicas e constrangimentos legais, enquanto as respostas positivas aos pedidos de SMA e de EUT atenderam às circunstâncias específicas dos doentes e dos amigos com quem haviam pré-estabelecido duradouras relações terapêuticas e de amizade (a par de relações profissionais, num caso). Tema IV-Refletir sobre os Pedidos de MMA recebidos implicou: olhar para trás e reviver experiências perturbadoras, conflituantes e emocionalmente dolorosas com pedidos e com práticas ilícitas de MMA; olhar em frente e constatar que a maioria dos entrevistados é tendencialmente favorável à legalização da MMA em Portugal, mas teria sérias reservas a prestar auxílio no suicídio e, sobretudo, a estar envolvido em práticas de EUT; e observar a existência de um código de silêncio sobre as práticas subterrâneas de MMA no momento presente. Conclusão: Os entrevistados revelaram que a experiência da recepção de pedidos de MMA é um fenómeno raro no decurso das suas trajetórias profissionais, isto apesar de ter causado um forte impacto emocional e desafiado as suas fronteiras morais. Enquanto a maioria dos médicos os recusou liminarmente, uma minoria de entrevistados sentiu-se compelida a aceitar os pedidos de MMA formulados por doentes e por colegas de profissão com quem mantinham longas relações terapêuticas e de amizade. Estas práticas subterrâneas de EUT e SMA foram silenciadas e mantidas em segredo, num ambiente de cumplicidade e conluio. Os médicos envolvidos na prestação de cuidados em fim de vida precisam de encontrar um lugar seguro na profissão para partilhar as suas experiências com pedidos de MMA e beneficiariam da implementação de um modelo colaborativo e de consultoria para discuti-los, que incluísse o acesso regular a cuidados paliativos, aconselhamento psiquiátrico e o parecer célere das comissões de ética hospitalares.
Background: There is empirical evidence that some Portuguese oncologists have received explicit, persistent and consistent requests for Euthanasia (EUT) and Physician-Assisted Suicide (PAS) from patients with progressive, advanced and incurable diseases. However, little is known about how Portuguese oncologists and physicians from different specialties experience those requests for Physician-Assisted Death (PAD), understand them, deliberate and answer to patients who ask for their help to die. Objectives: Understand the nature of physicians’ lived experiences with requests for EUT and PAS made by mentally competent adult patients throughout their clinical practice. Uncover and interpret the multiple meanings embedded in physicians’ lived experiences with requests for PAD. Methods and Participants: Hermeneutic phenomenological research. Based on the chosen research method, an exploratory, descriptive and interpretative approach was adopted to study the physicians’ lived experiences with requests for PAD. Semi-structured interviews were conducted with nine Portuguese physicians from a broad range of medical (sub-) specialties (Anesthesiology, Internal Medicine, Palliative Medicine, Clinical Hematology, Medical Oncology, Nephrology and Neurology) who are currently practicing, or practiced until the retirement, in public and private hospital care units. A total of nine face-to-face interviews were performed between June and October 2014, audiotaped and fully transcribed. The experiential material gathered from all interviews was submitted to thematic analysis seeking to gain meaningful insights of physicians’ experiences with requests for EUT and PAS. Results: Four major themes emerged from the interviews. Theme I-Being Open to Hear Requests for PAD revealed that staying present and being open to hear requests was a difficult choice for all physicians, who most frequently received explicit requests instead of implicit ones. Although only two physicians received PAS requests, all of them reported having received EUT requests. Theme II-Interpreting and Exploring the Meanings of Requests for PAD: physician’s perceptions of patient’s reasons for requesting physician aid in dying included a combination of factors related to existential and altruistic suffering, rationalization of medical conditions with poor prognosis, hopeless, loss of autonomy, poor quality of life, and physical deterioration; three physicians avoided to explore requests for EUT that were perceived as a result of clinical failure (evasive actions), only two physicians were unable to explore authoritarian requests for EUT (blocked actions), while four physicians were able to dig deeper into EUT and PAS requests (reinforced actions). Theme III-Responding to Requests for PAD: most physicians (seven out of nine) unequivocally refused requests for EUT and have taken alternative end-of-life decisions, such as: controlled physical symptoms and provided palliative care (three physicians); initiated palliative sedation (three physicians). An atypical case of physician’s explicit refusal of request for EUT is characterized by its concomitant implicit permission given to a patient (who was also a physician) and a close family member (who was a nurse) to pursue their plans to hasten dying without his interference but acknowledge. Only two physicians completely agreed with patients and friends’ requests for PAD and were willing to help them die. Therefore, one physician provided a patient with a lethal dose of prescribed medication upon his request for PAS (who died without having self-administered the medication), and other physician administered lethal doses of medications to patients and friends (one of them was also a physician) upon their requests for EUT. Negative answers to patient’s requests for PAD were justified mainly on the basis of deontological and legal constraints (rule-oriented). Positive answers to requests for PAD, by contrast, were compelled to specific circumstances of long lasting patients or close friends (context-driven). Theme IV-Reflecting on previous Requests for PAD: looking back, physicians realized how disturbing, challenging and emotionally painful the past experiences with requests for EUT and illicit practices of EUT were for themselves. While looking ahead, most physicians tended to favor a legal change on PAD in Portugal, but they would remain cautious in providing assistance in suicide, as they would be even more reluctant to practice EUT on a regular basis. Most physicians admitted existing an unspoken code of silence about both requests for and practices of PAD nowadays. Conclusion: Despite being a rare phenomenon over the course of their professional careers, physician’s experiences with requests for PAD and practices of EUT had a tremendous emotional impact on them and challenged their moral boundaries. While most physicians in this study unequivocally refused requests for PAD, there were a few (two out of nine) physicians who felt compelled to accept one implicit request for PAS and four explicit requests for EUT, which were made by patients, very close friends and professional colleagues with whom they had established longstanding therapeutic relationships and friendships. The underground practices of EUT and PAS were kept secret and silenced by physicians who described tacit complicities and a collusion environment around them. Physicians providing end-of-life care need to find a safe place within profession to share their experiences with requests for PAD. They would also greatly benefit from the implementation of a collaborative and consultant model, including regular access to palliative care, psychiatric consultation, and a prompt assistance from hospital ethics committees.
Background: There is empirical evidence that some Portuguese oncologists have received explicit, persistent and consistent requests for Euthanasia (EUT) and Physician-Assisted Suicide (PAS) from patients with progressive, advanced and incurable diseases. However, little is known about how Portuguese oncologists and physicians from different specialties experience those requests for Physician-Assisted Death (PAD), understand them, deliberate and answer to patients who ask for their help to die. Objectives: Understand the nature of physicians’ lived experiences with requests for EUT and PAS made by mentally competent adult patients throughout their clinical practice. Uncover and interpret the multiple meanings embedded in physicians’ lived experiences with requests for PAD. Methods and Participants: Hermeneutic phenomenological research. Based on the chosen research method, an exploratory, descriptive and interpretative approach was adopted to study the physicians’ lived experiences with requests for PAD. Semi-structured interviews were conducted with nine Portuguese physicians from a broad range of medical (sub-) specialties (Anesthesiology, Internal Medicine, Palliative Medicine, Clinical Hematology, Medical Oncology, Nephrology and Neurology) who are currently practicing, or practiced until the retirement, in public and private hospital care units. A total of nine face-to-face interviews were performed between June and October 2014, audiotaped and fully transcribed. The experiential material gathered from all interviews was submitted to thematic analysis seeking to gain meaningful insights of physicians’ experiences with requests for EUT and PAS. Results: Four major themes emerged from the interviews. Theme I-Being Open to Hear Requests for PAD revealed that staying present and being open to hear requests was a difficult choice for all physicians, who most frequently received explicit requests instead of implicit ones. Although only two physicians received PAS requests, all of them reported having received EUT requests. Theme II-Interpreting and Exploring the Meanings of Requests for PAD: physician’s perceptions of patient’s reasons for requesting physician aid in dying included a combination of factors related to existential and altruistic suffering, rationalization of medical conditions with poor prognosis, hopeless, loss of autonomy, poor quality of life, and physical deterioration; three physicians avoided to explore requests for EUT that were perceived as a result of clinical failure (evasive actions), only two physicians were unable to explore authoritarian requests for EUT (blocked actions), while four physicians were able to dig deeper into EUT and PAS requests (reinforced actions). Theme III-Responding to Requests for PAD: most physicians (seven out of nine) unequivocally refused requests for EUT and have taken alternative end-of-life decisions, such as: controlled physical symptoms and provided palliative care (three physicians); initiated palliative sedation (three physicians). An atypical case of physician’s explicit refusal of request for EUT is characterized by its concomitant implicit permission given to a patient (who was also a physician) and a close family member (who was a nurse) to pursue their plans to hasten dying without his interference but acknowledge. Only two physicians completely agreed with patients and friends’ requests for PAD and were willing to help them die. Therefore, one physician provided a patient with a lethal dose of prescribed medication upon his request for PAS (who died without having self-administered the medication), and other physician administered lethal doses of medications to patients and friends (one of them was also a physician) upon their requests for EUT. Negative answers to patient’s requests for PAD were justified mainly on the basis of deontological and legal constraints (rule-oriented). Positive answers to requests for PAD, by contrast, were compelled to specific circumstances of long lasting patients or close friends (context-driven). Theme IV-Reflecting on previous Requests for PAD: looking back, physicians realized how disturbing, challenging and emotionally painful the past experiences with requests for EUT and illicit practices of EUT were for themselves. While looking ahead, most physicians tended to favor a legal change on PAD in Portugal, but they would remain cautious in providing assistance in suicide, as they would be even more reluctant to practice EUT on a regular basis. Most physicians admitted existing an unspoken code of silence about both requests for and practices of PAD nowadays. Conclusion: Despite being a rare phenomenon over the course of their professional careers, physician’s experiences with requests for PAD and practices of EUT had a tremendous emotional impact on them and challenged their moral boundaries. While most physicians in this study unequivocally refused requests for PAD, there were a few (two out of nine) physicians who felt compelled to accept one implicit request for PAS and four explicit requests for EUT, which were made by patients, very close friends and professional colleagues with whom they had established longstanding therapeutic relationships and friendships. The underground practices of EUT and PAS were kept secret and silenced by physicians who described tacit complicities and a collusion environment around them. Physicians providing end-of-life care need to find a safe place within profession to share their experiences with requests for PAD. They would also greatly benefit from the implementation of a collaborative and consultant model, including regular access to palliative care, psychiatric consultation, and a prompt assistance from hospital ethics committees.
Descrição
Tese de mestrado, Bioética, Universidade de Lisboa, Faculdade de Medicina, 2017
Palavras-chave
Eutanásia Suicídio medicamente assistido Morte medicamente assistida Pedidos Experiência vivida Fenomenologia hermenêutica Teses de mestrado - 2017