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.

Dilemas éticos na tomada de decisões no fim da vida: sob a ótica do cuidado humanizado

“…No contexto da medicina moderna, a utilização de recursos médicos extraordinários tem por objetivo prolongar a vida do paciente a qualquer custo, portanto, tornou-se um ponto central de discussões ética e prática clínica (24). Os benefícios da utilização de recursos médicos extraordinários podem oferecer esperança a pacientes e familiares, já que, podem prolongar a vida e assim proporcionar mais tempo juntos, em determinados casos podem até resultar na estabilização do estado de saúde do paciente, oferecendo melhoria significativa (25).…”