Autonomia, cuidado e respeito: o debate sobre o prolongamento assistido da vida / Autonomy, care and respect: the debate on assisted extension of life

Os avanços tecnológicos associados às técnicas médicas têm levado os profissionais da saúde a terem como meta incansável o prolongamento da vida. O êxito de tais procedimentos, porém, em pacientes sem possibilidade de cura e com autonomia de decisão tem apenas prolongado o processo de morrer. Neste sentido, por um lado, a renúncia do tratamento passa a ser visualizada como uma forma de suicídio e, por outro, a sua interrupção pela equipe médica como eutanásia ativa. Assim, a qualidade de vida é associada ao curar, e não ao cuidar. Pretende-se, neste artigo, apresentar que o prolongamento assistido da vida significa compatibilizar as dimensões da autonomia, do cuidado e do respeito, sendo estes, portanto, responsáveis pela manutenção do conceito de dignidade (AU)

Technological advances associated to medical techniques have been leading health professionals to have life extension as their tireless goal. However, the success of such procedures in patients with no chance of recovery and presenting decision-making autonomy has been only extending the process of dying. In this sense, on the one hand giving up the treatment is viewed as a form of suicide, and on the other hand the interruption of the treatment by the medical staff is viewed as active euthanasia. Therefore, quality of life is associated to healing rather than caring. The present article aims to demonstrate that the assisted extension of life reconciles the dimensions of autonomy, care and respect, and that these are responsible for maintaining the concept of dignity (AU)

Beyond competence: advance directives in dementia research.

Dementia is highly prevalent and incurable. The participation of dementia patients in clinical research is indispensable if we want to find an effective treatment for dementia. However, one of the primary challenges in dementia research is the patients' gradual loss of the capacity to consent. Patients with dementia are characterized by the fact that, at an earlier stage of their life, they were able to give their consent to participation in research. Therefore, the phase when patients are still competent to decide offers a valuable opportunity to authorize research, by using an advance research directive (ARD). Yet, the use of ARDs as an authorization for research participation remains controversial. In this paper we discuss the role of autonomous decision-making and the protection of incompetent research subjects. We will show why ARDs are a morally defensible basis for the inclusion of this population in biomedical research and that the use of ARDs is compatible with the protection of incompetent research subjects.

[Advance Directives - Not a Lot of Margin for Error - The Surgeon's View of a Complex Medical-Legal Topic]. / Patientenverfügungen - welchen Spielraum erlauben sie? - Chirurgische Sicht auf ein komplexes medizinjuristisches Thema.

Since September 1st, 2009, the most recent version of the German "Betreuungsrechtsänderungsgesetz" has been validated by the legislators. It precisely sets out how physicians and nursing staff have to deal with a written declaration of a patient's will. This new law focuses in a special way on advance directives, describes the precise rules for the authors of an advance directive and shows both its sphere of action and its limitations. This article aims to give an overview on the legal scope of advance directives, and to illustrate potential limitations and conflicts. Furthermore, it shows the commitments and rights of the medical team against the background of an existing advance directive.

Advance directives, dementia, and withholding food and water by mouth.

People with dementia who are no longer competent have limited control over how their lives end. But an advance directive to withhold food and water by mouth could be used to ensure that one does not live for years in severe dementia. Such directives are arguably already legal.

Legal briefing: voluntarily stopping eating and drinking.

This issue's "Legal Briefing" column covers recent legal developments involving voluntarily stopping eating and drinking (VSED). Over the past decade, clinicians and bioethicists have increasingly recognized VSED as a medically and ethically appropriate means to hasten death. Most recently, in September 2013, the National Hospice and Palliative Care Organization (NHPCO) called on its 2,000 member hospices to develop policies and guidelines addressing VSED. And VSED is getting more attention not only in healthcare communities, but also in the general public. For example, VSED was recently highlighted on the front page of the New York Times and in other national and local media. Nevertheless, despite the growing interest in VSED, there remains little on-point legal authority and only sparse bioethics literature analyzing its legality.This article aims to fill this gap. Specifically, we focus on new legislative, regulatory, and judicial acts that clarify the permissibility of VSED. We categorize these legal developments into the following seven categories: 1. Definition of VSED. 2. Uncertainty Whether Oral Nutrition and Hydration Are Medical Treatment. 3. Uncertainty Regarding Providers' Obligations to Patients Who Choose VSED. 4. Judicial Guidance from Australia. 5. Judicial Guidance from the United Kingdom.

[Trusted person and living will: information and implementation defect]. / Personne de confiance et directives anticipées: défaut d'information et de mise en œuvre.

PURPOSE: The French law allows the persons of age to appoint a trusted person and to draft advance directives in case they are one day in a condition that prevents them from expressing their will regarding their health care. Our study objective was to assess patients' and relatives' knowledge and collecting their opinion regarding these means of expression of their will. METHODS: An anonymous survey by self-administered questionnaire was conducted in the admission offices of the University Hospital of Nancy in April 2011. The questions focused on trusted person and anticipated directives. RESULTS: We collected 367 answers, 61.8% of which were females. Average age of respondents was 48.7 years old (standard deviation: 15.6). Three fourths of respondents were informed of their possibility to appoint a trusted person and were able to establish the difference between a trusted person and a contact person. Respondents mainly chose their spouse (52%). They thought that the trusted person's opinion takes precedence over the family's or relatives' one (64.7%), given that this opinion is based on indications previously provided by the patient (74.8%). The majority of people surveyed were ignorant of the possibility to draft advance directives but were glad of it (57.5%). They would include herein their refusal of unreasonable obstinacy (75.8%), their wishes to withhold/withdraw of some treatments, to stop active treatments in case of high odds of chronic coma or vegetative state (52.8%) or their will to donate organ after death (50.6%). More than three fourths of the patients wished to include these informations on their health care card chip. CONCLUSION: Legal means of expression of the patient's wishes and are not systematically known by the population. The possibility to appoint a trusted person is much more known than that to draft advance directives. After the release in December 2012 of the Sicard report regarding the end of life in France, an important information campaign of the general public remains to be undertaken.

Implementing physician orders for life-sustaining treatment in California hospitals: factors associated with adoption.

Physician Orders for Life-Sustaining Treatment (POLST) is a tool to document and ensure continuity of end-of-life treatment decisions across healthcare settings that became a legal document in California in January 2009. Hospitals were surveyed to evaluate factors associated with uptake of this intervention and whether a grassroots community coalition intervention facilitated dissemination. A mail and telephone survey of all acute care hospitals in California was conducted between August 2011 and January 2012, and community coalition reports of interaction with hospitals and hospital characteristics from the California Office of Statewide Planning and Development and Census ZIP Code Tabulation Areas were analyzed. Of 349 hospitals, 286 (81.9%) responded to the survey. Sixty-five percent of hospitals had a policy about POLST, 87% had available blank POLST forms, 84% had educated staff, and 94% reported handling POLST properly in the emergency department and on admission. In multivariable analyses, hospitals in poor areas and for-profit (vs nonprofit) hospitals were less likely to stock blank POLST forms and to have educated staff, and hospitals with community coalition interaction and in wealthier areas were more likely to handle POLST forms correctly. Although POLST is widely used in California, a significant minority of hospitals remain unprepared 3 years after implementation. Efforts to improve implementation should emphasize dissemination in poorer areas and in for-profit hospitals.