Ethical principles and dilemmas in the discourse of healthcare practitioners involved with end-of-life care based on the Advanced Directives Document
Abstract
Introduction. The Advanced Directives Document (ADD) is an efficient tool to plan for future medical care in case of a potential loss of autonomy. Ethical dilemmas arise in end-of-life care, including the principle of respect for autonomy and potential beneficence involved in health care, leading to moral distress of practitioners.
Objective. To identify the ethical principles and dilemmas arising from the discourse of healthcare practitioners involved with end-of-life care based on the ADD.
Methodology. Qualitative study with a hermeneutics approach based on 253 answers to the following exploratory question: Are you willing to respect the ADD of an unconscious patient when you think that the patient may benefit otherwise?
Results. Most practitioners acknowledge their respect for the ADD as an ethical obligation, whilst a minority consider it a legal right. For the large majority of practitioners, the ethical principles of respect for the ADD are recognized under the ethical theory of liberal individualism. Respect for autonomy is associated with the principle of non-maleficence and the value of human dignity. The principle of beneficence and the quality of life concept were presented as genuine moral dilemmas. A reversible clinical condition, the request for euthanasia, the family and the legibility of anticipated directives were submitted as apparent moral dilemmas.
Conclusions. During the end-of-life decision making process, there are other valid ethical considerations beyond principlism. The dilemmas identified show the ethical complexity healthcare practitioners face based on the ADD.
References
Álvarez Acuña AM, Gomezese Ribero ÓF. Advance directives document: knowledge and experiences of healthcare professionals in Colombia. Colombian Journal of Anesthesiology. 2022;50:e1012. doi: https://doi.org/10.5554/22562087.e1012
Herreros B, Benito M, Gella P, Valenti E, Sánchez B, Velasco T. Why have advance directives failed in Spain? BMC Med Ethics. 2020;21(113):2-13. doi: https://doi.org/10.1186/s12910-020-00557-4
Zunzunegui MV. End of life care. Gac Sanit. 2018;32(4):319-20. doi: https://doi.org/10.1016/j.gaceta.2018.04.007
Altisent R. Advance care planning. An educational revolution is needed. Aten Primaria. 2013;45(8):402-3. doi: http://dx.doi.org/10.1016/j.aprim.2013.08.001
Arruda LM, Abreu KPB, Santana LBC, Sales MVC. Variables that influence the medical decision regarding Advance Directives and their impact on end-of-life care. Einstein (São Paulo). 2019;18:eRW4852. doi: https://doi.org/10.31744/einstein_journal/2020RW4852
Moore N, Detering K, Baja T, Nolte L, Fraser S, Sellars M. Doctors’ perspectives on adhering to advance care directives when making medical decisions for patients: an Australian interview study. BMJ Open. 2019;9:e032638. doi: https://doi.org/10.1136/bmjopen-2019-032638
Porteri C. Advance directives as a tool to respect patients’ values and preferences: discussion on the case of Alzheimer’s disease. BMC Med Ethics. 2018;19:9. doi: https://doi.org/10.1186/s12910-018-0249-6
Blanco L. Directivas Anticipadas. En J. C. Tealdi (Ed.), Diccionario Latinoamericano de bioética [internet]. Bogotá: UNESCO, Universidad Nacional de Colombia; 2008, p. 425-7 [cited 2022 Jan 24]. Available at: https://sgmd.nute.ufsc.br/content/sgmd-resources-conselheiros/ebook/medias/pdf/dicion%C3%A1rio-latinoamericano-de-bioetica.pdf
Lack P, Biller-Andorno N, Brauer S. On The Sco-Pe and limits of advance directives and pros-pective autonomy. En: Advance Directives. International Library of Ethics, Law, and the New Medicine. Editorial Board; 2014. p. 53-71. [cited 2022 Jan 24]. Available at: https://link.springer.com/book/10.1007/978-94-007-7377-6 http://www.springer.com/series/6224.
Coleman AM. Physician attitudes toward advanced directives: a literature review of variables impacting on physicians attitude toward advance directives. Am J Hosp Palliat Care. 2013;30(7):696-706. doi: https://doi.org/10.1177/1049909112464544.
Morley G, Ives J, Bradbury-Jones C, Irvine F. What is 'moral distress'? A narrative synthesis of the literature. Nurs Ethics. 2019;26(3):646-62. doi: https://doi.org/10.1177/0969733017724354
Mieles MD, Tonon G, Alvarado SV. Qualitative Resarch: the Thematic Analysis for the Treatment of Information from the Approach of the Social Phenomenology. 2012;74:195-225.
Ministerio de Salud y Protección Social de Colombia. Resolución 8430 de 1993 [Internet]. [cited 2022 Jan 21]. Available at: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/RESOLUCION-8430-DE-1993.PDF
Realpe Quintero S. Dilemas morales. Estudios Gerenciales. [Internet]. 2001;80:83-113 [cited 2022 Jan 21]. Available at: https://www.redalyc.org/pdf/212/21208004.pdf
Escobar J. El morir como ejercicio final del derecho a una muerte digna (2.a ed.). Colección Bíos y Ethos. Bogotá: Ediciones el Bosque. Editorial Kimpres Ltda; 2000. p.20.
Beauchamp TL., Childress JF. Principios de ética biomédica. Cuarta edición. Masson; 1999. p.313.
Hottois G. Dignidad humana y bioética. Un enfoque filosófico crítico. Revista Colombiana de Bioética. 2009;4(2):53-83.
Soto C, Rubio M, Córdova, MF. Ethical dylemas regarding the care of people in vegetative state. Enfermería Global. 2013;29:297-306. [Internet]. [cited 2022 Jan 21]. Available at: https://revistas.um.es/eglobal/article/view/157941/144101
Declaración Universal sobre Bioética y Derechos Humanos de la UNESCO. 33.ª Sesión de la Conferencia General de la UNESCO. París el 19 de octubre de 2005 [Internet]. [cited 2022 Nov 5]. Available at: https://es.wikipedia.org/wiki/Declaraci%C3%B3n_Universal_sobre_Bio%C3%A9tica_y_Derechos_Humanos_de_la_UNESCO
Bolívar PL, Gómez AI. Advanced wishes for the end of life.An approach from the Colombian regulation and in comparative law. Rev Latinoam Bioet. 2016;1:128-53. http://dx.doi.org/10.18359/rlbi.1444
Ministerio de Salud y Protección Social de Colombia. Resolución 0971 de 2021 [Internet]. [cited 2021 Dic 16]. Available at: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/resolucion-971-de-2021.pdf
Roscoe L, Schenck D. Case 9. When parents contest an adult child’s advance directive. En: Communication and bioethics at the end of life. Real cases, real dilemmas. Springer International Publishing; 2017. p. 89-98. doi: https://doi.org/10.1007/978-3-319-70920-8
Feely MA, Albright R, Thorsteinsdottir B, Moss A, Swetz K. Ethical challenges with hemodialysis patients who lack decision-making capacity: Behavioral issues, surrogate decision-makers, and end-of-life situations. Kidney International. 2014;86(3):475-80. doi: http://doi.org/10.1038/ki.2014.231
Enríquez Canto Y, Chaparro Gamarra K. Perspectives of Peruvian professionals on declarations of advance directives. 2021; 4(1):102-21. doi: https://doi.org/10.35383/apuntes.v4i1.584
Andrade J, García V, Martínez D, Miranda C, Quesada M, Vargas K. Attitude assumed by nurses in regards to end of life decisions of people: Case of Costa Rica, 2011. Enferm Actual Costa Rica. 2012;23:1-14. doi: https://doi.org/10.15517/REVENF.VOI23.2971
Trarieux-Signol S, Moreau S, Gourin MP, Penot A, de Lafont GE, Preux PM, et al. Factors associated with the designation of a health care proxy and writing advance directives for patients suffering from haematological malignancies. BMC Palliat Care. 2014;13(1):57. doi: http://doi.org/10.1186/1472-684X-13-57
Akdeniz M, Yardımcı B, Kavukcu E. Ethical considerations at the end-of-life care. SAGE open medicine. 2021:1-9. doi: https://doi.org/10.1177/20503121211000918
Forero J, Vargas I, Bernales M. Advance directives: ethical challenges in patient care. Persona y Bioética. 2019;23(2):224-44. doi: https://doi.org/10.5294/pebi.2019.23.2.5
Peicius E, Blazeviciene A, Kaminskas R. Are advance directives helpful for good end of life decision making: a cross sectional survey of health professionals. BMC Med Ethics. 2017;18:40. doi: https://doi.org/10.1186/s12910-017-0197-6
Burkle CM, Mueller PS, Swetz KM, Hook C, Keegan M. Physician perspectives and compliance with patient advance directives: the role external factors play on physician decision making. BMC Med Ethics. 2012;13:31. doi: https://doi.org/10.1186/1472-6939-13-31
Calvache J, Moreno S, Prue G, Reid J, Ahmedzai S, Arango-Gutiérrez A, et al. Knowledge of end-of-life wishes by physicians and caregivers in cancer patients. BMC Palliative Care. 2021. doi: https://doi.org/10.1186/s12904-021-00823-1
Restrepo D, Cossio C, Ochoa F, Jaramillo JC, Bedoya J, Duque D, et al. Conocimientos, actitudes y prácticas frente a la limitación de esfuerzos terapéuticos en personal de salud de un hospital universitario. Persona y Bioética. 2013;17(2):216-26.
Yllera C. Do we meet our duties regarding Living Wills?. Revista de Bioética y Derecho. 2014;32:82-94. http://scielo.isciii.es/pdf/bioetica/n32/08_articulo7.pdf
Aguilar-Sánchez JM, Cabañero-Martínez MJ, Puerta F, Ladios-Martín M, Fernández-de-Maya J, Cabrero-García J. Knowledge and attitudes of health professionals towards advance directives. Gac Sanit. 2018;32(4):339-45. doi: https://doi.org/10.1016/j.gaceta.2017.08.006
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