Portuguese Advance Directives-a twist against futility? A cross sectional study

ABSTRACT BACKGROUND: Advance Directive documents allow citizens to choose the treatments they want for end-of-life care without considering therapeutic futility. OBJECTIVES: To analyze patients' and caregivers' answers to Advance Directives and understand their expectations regarding their decisions. DESIGN AND SETTING: This study analyzed participants' answers to a previously published trial, conceived to test the document's efficacy as a communication tool. METHODS: Sixty palliative patients and 60 caregivers (n = 120) registered their preferences in the Advance Directive document and expressed their expectations regarding whether to receive the chosen treatments. RESULTS: In the patient and caregiver groups, 30% and 23.3% wanted to receive cardiorespiratory resuscitation; 23.3% and 25% wanted to receive artificial organ support; and 40% and 35% chose to receive artificial feeding and hydration, respectively. The participants ignored the concept of therapeutic futility and expected to receive invasive treatments. The concept of therapeutic futility should be addressed and discussed with both the patients and caregivers. Legal Advanced Directive documents should be made clear to reduce misinterpretations and potential legal conflicts. CONCLUSION: The authors suggest that all citizens should be clarified regarding the futility concept before filling out the Advance Directives and propose a grammatical change in the document, replacing the phrase "Health Care to Receive / Not to Receive" with the sentence "Health Care to Accept / Refuse" so that patients cannot demand treatments, but instead accept or refuse the proposed therapeutic plans. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT05090072 URL: https://clinicaltrials.gov/ct2/show/NCT05090072.

Ethical Investigation of the Living Will and the Comparison and Enlightenment of Chinese and Japanese Practical Experience / 中国医学伦理学

The revised revision of the Shenzhen Special Economic Zone Medical Regulations passed in 2022 is an important institutional innovation in China, while many problems still need to be solved in the specific practice and application. This paper compared the practical development characteristics of the living will system between China and Japan, and analyzed the relationship between doctor-patients relationship under the intervention of the living will system and the symbolic representation mechanism of living will by using the semiotics theory. According to the links of "addresser-symbolic text" and "symbolic text-addressee", the six types of problems faced by current living will system in China were discussed, and the relevant experience and enlightenment were summarized to provided reference for the development of the living will system in China.

Exploration of the Autonomy Issues in Addiction Treatment / 中国医学伦理学

Addiction is a state of chronic neurological dysfunction with repetitive and compulsive behavior as the main manifestation. One of the characteristics of this state is that addicts have significantly reduced autonomy for compulsive behaviors. The emergence of addictive behavior is based on the impaired autonomy of addicts, so the assessment of their condition, prognosis, and related moral responsibility are all related to their autonomy. By exploring whether the treatment of addicts should be based on autonomy as the core indicator to evaluate whether they can end treatment, and exploring the debate on addicts’ autonomy based on the disease model and moral model of addiction, it is believed that whether addicts have autonomy cognition is influenced by the causes of addiction. Furthermore, the issue of moral responsibility of addicts after treatment termination and the quantitative feasibility of autonomy were discussed, and it was advocated to determine the moral responsibility after addiction treatment based on their autonomy.

Learning Situation Analysis on "Living Will" and "Hospice Care" in Teaching Practice of Geriatrics / 中国医学伦理学

Objective: To investigate the cognitive status of "living will" and "hospice care" among geriatrics students with different identities, and to provide a basis for improving teaching in corresponding sections of geriatric medicine. Methods:An online questionnaire was used to collect data from 426 students participating in specific courses in geriatric medicine and compare their differences in understanding of different issues. Results: There was no statistically significant difference in the understanding of the concept of "living will" among students with different identities (χ2=5.84, P=0.054). In terms of the concept of "hospice care" , geriatricians and general practitioners had a better understanding than that of medical undergraduates (χ2=37.932, P<0.001). Compared to geriatricians and medical undergraduates, general practitioners had a lower level of autonomy in deciding whether to use life support treatment, and the difference was statistically significant (χ2=28.737, P<0.001). There was a statistically significant difference between general practitioners and medical undergraduates in the understanding of "signing living will" (χ2=12.75, P=0.01). Conclusion: The promotion of "living will" and "hospice care" in humanities courses of medical undergraduate and continuing medical education needs to be strengthened, and the popularization and publicity among the general public should be enhanced to lay the groundwork for improving the quality of hospice care.

Advance Directives Document: knowledge and experiences of healthcare professionals in Colombia / Documento Voluntades Anticipadas: conocimientos y experiencias de los profesionales de la salud en Colombia

Abstract Introduction: The Advanced Directives Document (ADD) is a bioethical quality benchmark for healthcare and assurance of compliance with the rights of autonomy, self-determination and dignity of the patient. This document was established over the past decade and currently there is no evidence about the attitudes and knowledge of the healthcare professionals with regards to the use of this tool in clinical practice in Colombia. Objective: To describe the knowledge and experiences of healthcare professionals members of six Colombian Scientific Societies regarding the right to sign an ADD and explore the barriers to its applicability in clinical daily practice. Methods: Descriptive, cross-sectional study conducted using an anonymous and voluntary e-survey with the participation of six Colombian Medical Societies. A questionnaire was designed comprising five groups of variables: general, ADD knowledge, medical experiences and personal experiences regarding advanced directives and potential obstacles to its implementation. Results: 533 professionals participated in the survey. 54 % (n = 286) expressed their lack of awareness about the fact that there is law governing the ADD in Colombia; 34.33 % (n = 183) said they were familiar with the requirements of the document. Over the last year, 24 % of the professionals received one or more ADDs from their patients. Only 11.7 % of healthcare practitioners had themselves completed an ADD. 77.1 % of the professionals surveyed believe that the number of individuals with an ADD has not changed after the approval and regulation of the right to an advanced directives document. 86.6 % of the practitioners said they respected the ADD, notwithstanding the fact that the patient could benefit otherwise. Conclusions: The overall perception of healthcare professionals with regards to the number of ADDs signed by patients is that the number has not changed after the approval of the Law in Colombia. This study evidenced that medical practitioners have a poor knowledge about the ADD and that there is a need to educate healthcare professionals about the ADD and to promptly implement institutional programs about Planning of Advanced Directives (PAD). Both strategies are challenging for the applicability of AD in Colombia.

Resumen Introducción: El Documento Voluntades Anticipadas (DVA) es un referente bioético de calidad de atención en salud y garantía de cumplimiento de los derechos de autonomía, autodeterminación y dignidad de los pacientes. Este documento fue reglamentado en la última década, y actualmente, no existe evidencia sobre las actitudes y conocimientos de los profesionales de la salud sobre el uso de esta herramienta en la práctica clínica en Colombia. Objetivo: Describir los conocimientos y experiencias de los profesionales de la salud pertenecientes a seis sociedades científicas colombianas frente al derecho de suscribir el DVA e investigar sobre las barreras para la aplicabilidad del DVA en la práctica clínica diaria. Métodos: Estudio descriptivo de corte transversal, realizado mediante encuesta electrónica anónima y voluntaria en seis sociedades médicas colombianas. Se diseñó un cuestionario compuesto por cinco grupos de variables: generales, conocimiento de DVA, experiencias médicas y experiencias personales sobre voluntad anticipada y posibles limitaciones para su aplicación. Resultados: Participaron 533 profesionales. El 54 % (n = 286) afirmó no saber que existe la ley que regula el DVA en Colombia; un 34,33 % (n = 183) manifestó conocer los requisitos que debe cumplir dicho documento. En el último año, el 24 % de los profesionales recibió de sus pacientes uno o más DVA. Solo el 11,7 % de los profesionales de salud tenía un DVA elaborado. El 77,1 % de los encuestados perciben que el número de personas con DVA sigue igual después de aprobado y reglamentado el derecho de DVA. El 86,6 % de los profesionales de salud aseguraron respetar el DVA, aunque el paciente pueda beneficiarse de lo contrario. Conclusiones: La percepción general de los profesionales de la salud sobre el número de DVA suscrito por los pacientes sigue igual después de reglamentada la Ley en Colombia. Este estudio permitió evidenciar que los profesionales de la salud poseen poco conocimiento sobre el DVA. Es indispensable capacitar a todos los profesionales de salud sobre el DVA y la pronta implementación institucional de programas sobre Planificación de Decisiones Anticipadas (PDA). Ambas estrategias constituyen un desafío para la aplicabilidad de las VA en Colombia.

Testamentum tempore pestis: el derecho civil y la bioética frente al testamento en casos de epidemia / Testamentum tempore pestis Civil law and bioethics faced with the testament in cases of epidemics / Testamentum tempore pestis: o Direito civil e a bioética frente ao testamento em casos de epidemia

Resumen: El confinamiento por la pandemia del covid-19 afectó el otorgamiento de testamentos, siendo estos tan necesarios ante las crisis sanitarias cuando las personas precisan decidir el destino de sus bienes y otros actos individuales ante el riesgo de vida. La solemnidad del testamento impide el ejercicio de testar de los pacientes, incluso de las personas sanas. Facilitar el derecho de testar en tiempos de peste tiene contenido bioético, al estar de por medio la vida, salud, autodeterminación y el derecho de decidir el destino patrimonial. El testamento en épocas de pandemia, apoyado en las TIC, es una solución que debe viabilizarse con la ayuda de la digitalización y tecnología, con el fin de permitir el ejercicio de los derechos de última voluntad en aislamiento por contagio.

Abstract: The confinement due to the Covid pandemic affected the granting of wills, which are so necessary in the health crisis when people need to decide the fate of their property and other individual acts at the risk of life. The solemnity of the will impedes the exercise of testamentary rights of patients, even healthy people. Facilitating the right to testament in times of plague has a bioethical content since life, health, self-determination and the right to decide the destiny of property are at stake. The will in times of pandemic, supported by ICTs, is a solution that should be made feasible with the help of digitization and technology in order to allow the exercise of the rights of last will in isolation by contagion.

Resumo: O confinamento pela pandemia da covid-19 afetou a outorga de testamentos, sendo estes muito necessários durante as crises sanitárias, quando as pessoas precisam decidir o destino de seus bens e outros atos individuais diante do risco de vida. A solenidade do testamento impede o exercício de testar dos pacientes, inclusive das pessoas sadias. Facilitar o direito de testar em tempos de peste tem conteúdo bioético, al estar de por médio (no entendí el significado de esto) a vida, saúde, autodeterminação e o direito de decidir o destino patrimonial. O testamento em épocas de pandemia, apoiado nas TIC, é uma solução que deve viabilizar-se com a ajuda de digitalização e tecnologia, a fim de permitir o exercício dos direitos de última vontade no isolamento por contagio.

Application of individualized teaching based on the good-will preposing theory in the teaching of practical nursing students in the department of oncology / 中华医学教育探索杂志

Objective:To analyze the effectiveness of individualized teaching based on the good-will preposing theory in the teaching of practical nursing students in the department of oncology.Methods:Eighty practical nursing students who were accepted by the department of oncology from January 2019 to October 2020 were selected, and they were randomly divided into routine group and research group with 40 students in each group. The routine group was taught by conventional methods and the research group was taught by individualized teaching methods based on the good-will preposing theory, respectively. The scores of theory and practice assessment and the changes of willingness and confidence of practical nurses in the department of oncology before and after the teaching, and the satisfaction with the teaching mode were compared between the two groups. SPSS 25.0 was used for t test and rank sum test. Results:The scores of theoretical and practical assessment in the two groups after teaching were higher than those before teaching ( P<0.05), and the scores of theoretical and practical assessment in the study group were higher than those in the routine group ( P<0.05). There were statistically significant differences in the grade distribution of willingness and confidence to undertake the career of oncology between the two groups of practical nursing students after teaching compared with that before teaching ( P<0.05). In the study group, the satisfaction scores of meeting learning willingness, improving learning enthusiasm, improving teaching efficiency, and strengthening the interaction between teachers and students in study group were higher than those in routine group ( P<0.05). Conclusion:Application of individualized teaching based on the good-will preposing theory among practical nursing students in the department of oncology may improve assessment performance, enhance their willingness and confidence to undertake the career of oncology, and improve their teaching satisfaction.

Voluntades anticipadas como referente ético de conocimiento en los enfermeros que laboran en servicios de oncología / Advance Directives as an Ethical Reference of Knowledge in Nurses who Work in Oncology Services / Diretivas antecipadas de vontade como referencial ético de conhecimento em enfermeiros que atuam em servidos de oncología

Resumen: El propósito del presente artículo es identificar los conocimientos sobre la Voluntad Anticipada (VA) en enfermeros que laboran en servicios de oncología. Para ello, se utilizó como metodología un estudio observacional con intención analítica que midió el nivel de conocimiento a través de un cuestionario autodiligenciado. En él participaron 50 enfermeros, seleccionados por muestreo no probabilístico. Así, se analizaron las variables cualitativas con distribuciones de frecuencia, y las cuantitativas con estadística descriptiva y análisis bivariado. El nivel de conocimiento se categorizó así: 0 a 10 puntos (nivel bajo), 11 a 20 puntos (nivel medio), 21 a 30 puntos (nivel alto). Los resultados de la investigación arrojaron como dato que, para un grupo donde el 86 % eran mujeres, con promedio de edad de 37 años, el promedio de años de experiencia como enfermeros fue de 11.5 años. Por otra parte, el promedio de años de experiencia en el área de oncología fue de 6.2 años. De los que hacían parte de este último promedio, el 48 % tenían diplomado en oncología y el 46 % especialización. El 70 % de los participantes tenía un conocimiento medio, el 26 % un conocimiento alto, y el 4 %un nivel bajo. Cabe mencionar que solo el nivel de formación de postgrado se relacionó de manera significativa con el nivel de conocimientos. Como conclusión, se encontró que los profesionales en enfermería poseen un nivel de conocimiento medio sobre la legislación que aborda las voluntades anticipadas en Colombia y esto está relacionado con el nivel de formación.

Abstract: The purpose of this article is to identify the knowledge about the Advance Directive (AD) in nurses who work in oncology services. Consequently, an observational study with analytical intention was used as a methodology that measured the level of knowledge through a self-administered questionnaire. 50 nurses participated in it, selected by non-probabilistic sampling. Thus, qualitative variables were analyzed with frequency distributions, and quantitative variables with descriptive statistics and bivariate analysis. The level of knowledge was categorized as follows: 0 to 10 points (low level), 11 to 20 points (medium level), 21 to 30 points (high level). The results of the research showed that, for a group where 86% were women, with an average age of 37 years, the average number of years of experience as nurses was 11.5 years. On the other hand, the average number of years of experience in the oncology area was 6.2 years. Of those who were part of the latter average, 48% had a degree in oncology and 46% specialization. 70% of the participants had a medium knowledge, 26% a high knowledge, and 4% a low level. It is worth mentioning that only the level of postgraduate training was significantly related to the level of knowledge. In conclusion, it was found that nursing professionals have a medium level of knowledge about the legislation that addresses advance directives in Colombia and this is related to the level of training.

Resumo: O objetivo deste artigo é identificar o conhecimento sobre a Diretiva Antecipada (VAI) em enfermeiros que atuam em serviços de oncologia. Para isso, utilizou-se como metodologia um estudo observacional com intenção analítica que mediu o nível de conhecimento por meio de um questionário autoaplicável. Participaram 50 enfermeiros, selecionados por amostragem não probabilística. Assim, as variáveis qualitativas foram analisadas com distribuição de frequência e as variáveis quantitativas com estatística descritiva e análise bivariada. O nível de conhecimento foi categorizado da seguinte forma: 0 a 10 pontos (nível baixo), 11 a 20 pontos (nível médio), 21 a 30 pontos (nível alto). Os resultados da pesquisa mostraram que, para um grupo em que 86% eram mulheres, com média de idade de 37 anos, a média de anos de experiência como enfermeiros foi de 11,5 anos. Por outro lado, a média de anos de experiência na área de oncologia foi de 6,2 anos. Dos que faziam parte desta última média, 48% tinham graduação em oncologia e 46% especialização. 70% dos participantes tinham um conhecimento médio, 26% um conhecimento alto e 4% um nível baixo. Vale ressaltar que apenas o nível de formação de pós-graduação se relacionou significativamente com o nível de conhecimento.

Participação e autonomia de pessoas que moram nos serviços residenciais terapêuticos: contribuições da terapia ocupacional / Participation and autonomy of people who live in residential therapeutic services: contributions from occupational therapy1

Resumo Introdução Os Serviços Residenciais Terapêuticos (SRTs) representaram grande avanço no processo de desinstitucionalização brasileiro. Porém, faz-se necessário investir nas discussões que contribuam para que esses dispositivos sejam espaços potentes de habitação e de valorização da subjetividade de seus moradores. Objetivo Investigar a participação e o exercício da autonomia dos moradores de SRTs do tipo II, a partir da sua própria percepção. Método Trata-se de pesquisa qualitativa, exploratória e documental, realizada por meio de coleta de dados documentais e de entrevistas. Participaram do estudo 8 moradores de SRTs tipo II. O material produzido foi submetido à análise temática. O conceito do Cotidiano embasa o estudo, a partir das perspectivas da terapia ocupacional, da Teoria do Cotidiano de Agnes Heller e da Reabilitação Psicossocial. Resultados A institucionalização prolongada está estreitamente relacionada com a pouca participação e autonomia dos participantes em seu cotidiano, com a pouca ou inexistente apropriação do SRT e com a percepção que eles têm de si como pacientes, e não como moradores de suas casas. O exercício da autonomia pelos participantes é relacionado ao seu desempenho e funcionalidade na realização das atividades diárias e à assistência integral pré-estabelecida para o SRT tipo II. Conclusão Concluiu-se que a terapia ocupacional traz contribuições fundamentais relacionadas à participação e à autonomia de pessoas que, devido às institucionalizações prolongadas, encontram-se em situação importante de cronificação. A participação nas atividades cotidianas e a possibilidade do exercício de autonomia no SRT são o primeiro passo rumo à definitiva possibilidade de inclusão social de seus moradores.

Abstract Introduction Therapeutic Residential Services (RSTs) represented a great advance in the Brazilian deinstitutionalization process, but it is necessary to invest in discussions that contribute to these devices being powerful spaces for housing and for valuing the subjectivity of its residents. Objective To investigate the participation and exercise of autonomy of residents of type II RSTs, based on their own perception. Method This is qualitative, exploratory, and documentary research, carried out through the collection of documentary data and interviews. Eight residents of type II RSTs participated in the study. The material produced was submitted to thematic analysis. The concept of Daily Life underlies the study, from the perspectives of Occupational Therapy, the Theory of Daily Life by Agnes Heller, and Psychosocial Rehabilitation. Results Prolonged institutionalization is closely related to the participants' little participation and autonomy in their daily lives, with little or no ownership of the SRT, and with the perception, they have of themselves as patients and not as residents of their homes. The exercise of autonomy by the participants is related to their performance and functionality in carrying out daily activities and pre-established comprehensive care for type II SRT. Conclusion It was concluded that Occupational Therapy brings fundamental contributions related to the participation and autonomy of people who, due to prolonged institutionalization, are in an important situation of chronicity. Participation in daily activities and the possibility of exercising autonomy in the SRT is the first step towards the definitive possibility of social inclusion for its residents.

La importancia de implementar y difundir la Ley de Voluntad Anticipada en México

Propósito/Contexto. Identificar mediante un cuestionario si personas con diferentes características sociodemográficas que viven en la República Mexicana conocen la importancia de la Ley de Voluntad Anticipada (LVA). Metodología/Enfoque. Se realizó un estudio cuantitativo observacional, descriptivo y transversal. También se llevó a cabo una encuesta de opinión a la población general con una representatividad a nivel nacional, el margen de error fue de +/- 3,46 % con un nivel de confianza del 95 %. Resultados/Hallazgos. El 49,6 % de las personas encuestadas desconocen la LVA y el 41,4 % considera que ayudaría a tener una muerte digna. En cuanto a la pregunta de si en su estado existe esta ley, el 63 % opina que no lo sabe y respecto a la pregunta de si en el estado en el que viven es necesario implementarla, el 41,3 % está totalmente de acuerdo. Discusión/Conclusiones/Contribuciones. En este estudio se observó que la población no tiene información acerca de esta ley y expresa su interés en conocer y en afirmar que están de acuerdo con una muerte digna, evitar el sufrimiento y el dolor.

Purpose/Context. Identify through a questionnaire if people with different sociodemographic characteristics living in the Mexican Republic know the importance of the Advance Will Law (LVA). Methodology/Approach. An observational, descriptive, cross-sectional quantitative study was performed. An opinion survey of the general population was carried out with a national representation; the margin of error was +/- 3.46% with a confidence level of 95%. Results/Findings. 49.6% of the people surveyed do not know the LVA and 41.4% consider that it would help people to have a dignified death. As for the question of whether this law exists in their state, 63% think they do not know; and regarding the question of whether in the state in which they live it is necessary to implement the LVA, 41.3% totally agree. Discussion/Conclusions/Contributions. In this study it was observed that the population does not have information about this law and expresses their interest in knowing and affirming that they agree with a dignified death, avoiding suffering and pain.

Objetivo/Contexto. O objetivo deste artigo é identificar, mediante um questionário, se pessoas com diferentes características sociodemográficas que vivem na República Mexicana, conhecem a importância da Lei de Vontade Antecipada (LVA). Metodologia/Abordagem. Realizou-se um estudo quantitativo observacional, descritivo, transversal. Foi realizado um inquérito de opinião à população em geral com uma representatividade a nível nacional; a margem de erro foi de +/-3,46 %, com um nível de confiança de 95 %. Resultados/Conclusões. O 49,6 % das pessoas entrevistadas desconhecem a LVA e 41,4 % consideram que isso ajudaria a ter uma morte digna. No que se refere à questão de saber se a lei existe no seu Estado, o 63% consideram que não sabem; e no que se refere à questão de saber se, no Estado-Membro em que vivem, é necessário implementá-la, 41,3% concordam plenamente. Discussão/Conclusões/Contribuições. Neste estudo observou-se que a população não tem informação sobre esta lei e expressa seu interesse em conhecer e em afirmar que estão de acordo com uma morte digna, evitar o sofrimento e a dor.

Desejo, Vontade, nada: de Schopenhauer a Freud, Freud com Schopenhauer / Deseo, Voluntad, nada: desde Schopenhauer hasta Freud, Freud con Schopenhauer / Desire, Will, nothingness: from Schopenhauer to Freud, Freud with Schopenhauer

O artigo visa estabelecer uma articulação entre as categorias de Vontade - referida à filosofia da Schopenhauer - e de desejo - recuperada desde o Wunsch proposto por Freud em seu Projeto para uma psicologia científica -, para, com isso, refazer o caminho percorrido por eles e indicar sua lógica interna diante de outra categoria: o nada, a elas intimamente ligada. Concluímos que há maior solidariedade entre elas do que se supõe, pois, se a Vontade é "sem extensão" e se o desejo é uma ficção cuja mecânica exige alívio, então sua própria satisfação seria uma negação interna da Vontade.

The article aims to establish an articulation between the categories of Will - referred to Arthur Schopenhauer's philosophy - and desire - recovered from the Wunsch proposed by Freud in his Project for a scientific psychology - in order to retrace their path and to indicate their internal logic in the face of another category: nothingness, internally linked with them. We conclude that these concepts seem to be more intimate than it is supposed, because if Will is "without extension" and desire is a fiction whose mechanics demand relief, then its own satisfaction would be an inner denial of the Will.

El artículo intenta establecer una articulación entre los conceptos de Voluntad - referido a la filosofía de Schopenhauer - y de deseo - recuperado desde el Wunsch propuesto por Freud en su Proyecto para una psicología científica. Intentamos rehacer el camino para indicar su lógica interna frente a otra categoría: la nada, íntimamente ligada. Llegamos a la conclusión de que voluntad, deseo y nada parecen ser más íntimos de lo que se supone, pues si la Voluntad es "sin extensión" y el deseo una ficción cuya mecánica exige alivio, entonces la propia satisfacción sería una negación interna de la Voluntad.

Investigation on the current status of recognition and acceptance of living will in elderly inpatients in Shanxi Province / 中华老年医学杂志

Objective To analyze related factors for whether or not to make the living will by investigating the current status of recognition and acceptance of living will among elderly inpatients in Shanxi Province,in order to provide the evidence for promoting the living will in elderly hospitalized patients in Shanxi Province.Methods A questionnaire survey was conducted on elderly inpatients in Shanxi Province from January 2017 to December 2017,including general information (age,gender,ethnicity,religious belief,dwelling place,education and profession,children,spouse),awareness of living wills and willingness to sign documents of"My Five Wishes".The chi-square test and Logistic regression analysis were used to analyze the related factors for elderly inpatients' willingness to sign living will documents Results The 411 elderly inpatients in Shanxi Province had a low level of cognition of living will(146 cases,35.5 ％).In general socio-demographic characteristics,only education level and profession were related to the cognition of living will(x2 =12.093 and 11.906,P =0.001 and 0.008).Multivariate Logistic regression analysis showed that as compared with inpatients aged 60-69 years,inpatients aged 70-79 years (OR =0.592,95 ％ CI:0.360 ～ 0.974,P =0.039) and 80-89 years (OR =0.408,95％ CI:0.238 ～ 0.701,P =0.001) held a significantly negative attitude towards signing the living will documents.According to dwelling place,as compared with countryside,urban elderly inpatients were more willing to sign living will documents in advance(OR =2.293,95％CI:1.335～3.940,P =0.003).At the comparison of other occupations with medical workers,teachers (P=0.429),civil servants (P =0.068),only medical workers (OR =3.156,95 ％ CI:1.419-7.020,P=0.005)were more willing to sign living will documents in advance.As comparing elderly inpatients with children,the childless elderly inpatients were more willing to sign living will documents in advance(OR=3.156,95％CI:1.287～7.740,P=0.012).Conclusions Elderly inpatients in Shanxi Province have a low level of cognition of living will and a poor acceptance of signing the document of "my five wishes"in advance.In order to benefit the public,we need to increase the promotion and popularization of signing documents of living will in our province.

Investigation on the current status of recognition and acceptance of living will in elderly inpatients in Shanxi Province / 中华老年医学杂志

Objective@#To analyze related factors for whether or not to make the living will by investigating the current status of recognition and acceptance of living will among elderly inpatients in Shanxi Province, in order to provide the evidence for promoting the living will in elderly hospitalized patients in Shanxi Province.@*Methods@#A questionnaire survey was conducted on elderly inpatients in Shanxi Province from January 2017 to December 2017, including general information(age, gender, ethnicity, religious belief, dwelling place, education and profession, children, spouse), awareness of living wills and willingness to sign documents of "My Five Wishes" . The chi-square test and Logistic regression analysis were used to analyze the related factors for elderly inpatients' willingness to sign living will documents@*Results@#The 411 elderly inpatients in Shanxi Province had a low level of cognition of living will(146 cases, 35.5%). In general socio-demographic characteristics, only education level and profession were related to the cognition of living will(χ2=12.093 and 11.906, P=0.001 and 0.008). Multivariate Logistic regression analysis showed that as compared with inpatients aged 60-69 years, inpatients aged 70-79 years(OR=0.592, 95%CI: 0.360~0.974, P=0.039)and 80-89 years(OR=0.408, 95%CI: 0.238~0.701, P=0.001)held a significantly negative attitude towards signing the living will documents.According to dwelling place, as compared with countryside, urban elderly inpatients were more willing to sign living will documents in advance(OR=2.293, 95%CI: 1.335~3.940, P=0.003). At the comparison of other occupations with medical workers, teachers(P=0.429), civil servants(P=0.068), only medical workers(OR=3.156, 95%CI: 1.419-7.020, P=0.005)were more willing to sign living will documents in advance.As comparing elderly inpatients with children, the childless elderly inpatients were more willing to sign living will documents in advance(OR=3.156, 95%CI: 1.287~7.740, P=0.012).@*Conclusions@#Elderly inpatients in Shanxi Province have a low level of cognition of living will and a poor acceptance of signing the document of "my five wishes" in advance.In order to benefit the public, we need to increase the promotion and popularization of signing documents of living will in our province.

Voluntades anticipadas: desafíos éticos en el cuidado del paciente / Advance Directives: Ethical Challenges in Patient Care / Diretivas antecipadas de vontade: desafios éticos no cuidado do paciente

Resumen Las voluntades anticipadas en salud tienen como finalidad que la persona manifieste de manera anticipada su voluntad sobre los cuidados y el tratamiento de su salud, lo cual le permite expresar personalmente y de forma previa sus preferencias. Esta revisión de la literatura tiene por objetivo describir el concepto y la estructura de las voluntades anticipadas, así como los aspectos éticos involucrados durante el cuidado del paciente. Con las palabras clave "Advanced Health Care Directive" AND "Ethical Implication" y sus símiles en español (voluntades anticipadas, implicaciones éticas), se revisaron cinco bases de datos: ProQuest, Philosophy (JSTOR), PubMed, Web of Science y SciELO; las publicaciones se agruparon entre los años 2010 y 2018. Se obtuvieron 31 artículos de los cuales se realizó una lectura crítica. Los resultados de esta revisión fueron agrupados en las siguientes categorías: concepto, estructura, situaciones clínicas donde se aplican las voluntades anticipadas, fortalezas y limitaciones; así como los aspectos éticos involucrados. Actualmente, son más comunes las vivencias relacionadas con las situaciones al final de la vida, donde la persona pierde su capacidad de decidir y no puede manifestar sus deseos, por lo que es imposible conocer su voluntad. Gran parte de los profesionales de la salud no tienen capacitación adecuada sobre el desarrollo y la aplicación de las voluntades anticipadas, escenario que se convierte en una oportunidad para la investigación y profundización sobre el tema. Las voluntades anticipadas son una herramienta que proporciona al equipo de salud información fidedigna de los valores y deseos del paciente, por lo que es importante capacitar a estos profesionales para brindar una atención respetuosa y de calidad.

Abstract Advance healthcare directives are intended for the individual to personally express their will and preferences about healthcare and treatment ahead of time. This literature review aims to describe the concept and structure of advance directives and the ethical aspects involved in patient care. Using the keywords "Advance Healthcare Directive" AND "Ethical Implication" and its Spanish equivalents (voluntades anticipadas, implicaciones éticas), five databases were accessed: ProQuest, Philosophy (JSTOR), PubMed, Web of Science and Scielo. Publications were narrowed down to the 2010-2018 period. Thirty-one articles were obtained and read critically. Results of this review were grouped into the following categories: concept, structure, clinical situations in which advance directives apply, strengths and limitations, as well as the ethical aspects involved. End of life-related experiences in which a person loses their ability to make decisions and cannot express their wishes, so it is impossible to know their will, are more common nowadays. Most health workers are not appropriately trained in the preparation and application of advance directives, which becomes an opportunity to research and delve deeper into the subject. Advance directives are a tool that gives health workers reliable information on a patient's values and wishes, so it is vital to train them to provide respectful quality care.

Resumo As diretivas antecipadas de vontade na saúde têm como finalidade que o paciente manifeste, de maneira antecipada, sua vontade e preferências sobre os cuidados e o tratamento de sua saúde. Esta revisão da literatura tem como objetivo descrever o conceito e a estrutura das diretivas antecipadas de vontade, bem como os aspectos éticos envolvidos durante o cuidado do paciente. Com as palavras-chave "advanced health care directive" AND "ethical implication" e seus equivalentes em espanhol ("voluntades anticipadas", "implicaciones éticas"), foram revisadas cinco bases de dados: ProQuest, Philosophy (JSTOR), PubMed, Web of Science e SciELO; as publicações são de 2010 a 2018. Foram obtidos 31 artigos, dos quais foi realizada uma leitura crítica. Os resultados desta revisão foram agrupados nas seguintes categorias: conceito, estrutura, situações clínicas em que são aplicadas as diretivas antecipadas de vontade, fortalezas, limitações, bem como aspectos éticos envolvidos. Atualmente, são mais comuns as vivências relacionadas com as situações no final da vida, em que a pessoa perde sua capacidade de decidir e não pode manifestar seus desejos, portanto é impossível conhecer sua vontade. Grande parte dos profissionais da saúde não tem capacitação adequada sobre o desenvolvimento e a aplicação das diretivas antecipadas de vontade, o que se torna uma oportunidade para pesquisar e aprofundar sobre o tema. As diretivas antecipadas de vontade são uma ferramenta que proporciona, à equipe de saúde, informação fidedigna dos valores e desejos do paciente, por isso é importante capacitar os profissionais para oferecer uma atenção respeitosa e de qualidade.

Approaches and reflexions on advance healthcare directives in Brazil / Enfoques y reflexiones sobre las directivas anticipadas en Brasil / Abordagens e reflexões sobre diretivas antecipadas da vontade no Brasil

ABSTRACT Objective: to explain the approaches and discussions about the Advance Healthcare Directives spread among health professionals, lawyers and society. Method: bibliographic search in the databases SciELO, LILACS, BDENF, in Portuguese, carried out from December 2017 to January 2018. Results: 22 articles were considered for analysis with interviews and testimonies of physicians, intensivists and geriatricians, nurses, technicians and Nursing auxiliaries, Medical students, lawyers and Law students. Conclusion: there is a small number of papers on the Advance Healthcare Directives in Brazil, and a wide range of approaches that have not yet been clarified. The theme is not widely spread and little clarified in its essence.

RESUMEN Objetivo: explicitar los enfoques y discusiones sobre las Directivas Anticipadas difundidas entre los profesionales de la salud, los abogados y la sociedad. Método: investigación bibliográfica realizada en las bases de datos SciELO, LILACS, BDENF, en portugués, del diciembre 2017 hasta enero 2018. Resultados: se consideraron 22 artículos para el análisis con entrevistas y testimonios médicos, intensivistas y geriatras, enfermeros, técnicos y auxiliares de Enfermería, estudiantes de Medicina, de Derecho y abogados. Conclusión: hay un pequeño número de trabajos sobre las Directivas Anticipadas en Brasil, y una amplia gama de enfoques poco elucidados. El tema sigue siendo poco difundido y poco esclarecido en su esencia.

RESUMO Objetivo: explicitar as abordagens e discussões sobre as Diretivas Antecipadas da Vontade difundidas entre os profissionais de saúde, advogados e a sociedade. Método: pesquisa bibliográfica nas bases de dados SciELO, LILACS, BDENF, em Língua Portuguesa, realizada no período de dezembro de 2017 a janeiro de 2018. Resultados: foram considerados 22 artigos para análise com entrevistas e depoimentos de médicos, intensivistas e geriatras, enfermeiros, técnicos e auxiliares de Enfermagem, estudantes de Medicina, de Direito e advogados. Conclusão: há um pequeno número de trabalhos sobre as Diretivas Antecipadas da Vontade no Brasil, e uma ampla gama de abordagens ainda pouco elucidadas. O tema ainda é pouco difundido e pouco esclarecido em sua essência.

A Review of Advance Care Planning in Research and Clinical Settings

Objective: To review the current advance care planning (ACP) in research and clinical settings globally, and identify immediate needs in Japan. Methods: We searched reviews in MEDLINE and original articles in ICHUSHI published up to July 2019, using the Medical Subject Heading (MeSH) thesaurus term ACP; we specifically searched for papers in English or Japanese. Results: We selected 849 reviews from MEDLINE. The majority were published in the United States, and approximately 50 in the United Kingdom. We selected 2,264 articles from ICHUSHI, although 186 were original and there were few reviews. Clearly, there are far fewer ACP publications in Japan than in the US. In Japan, a common concept of ACP is not defined among researchers, medical providers, and the government for Japanese culture and social background. Furthermore, there are limited interventional ACP studies among community-dwelling people, regardless of their use of medical or long-term care services, and despite the Japanese government’s efforts to encourage ACP use. Conclusion: The concept of ACP in the Japanese culture should be identified immediately, and it is essential to provide evidence of the effectiveness of ACP among community-dwelling people. In particular, further ACP studies are needed among people provided with different kinds of home care to help support their satisfaction of end-of-life care, which is a part of community integrated care.

Igualdade subversiva contra o cinismo democrático liberal / Igualdad subversiva contra el cinismo democrático liberal / Subversive equality against liberal democratic cynicism

Resumo O objetivo do artigo é discutir teoricamente a relação entre democracia liberal e desigualdade, na defesa da ideia de que a luta pela igualdade é sempre um profundo e necessário ato de subversão política contra uma estrutura de poder estabelecida. Para a consecução desse objetivo, inicialmente, apresentamos a discussão acerca do fundamento democrático da vontade dos iguais. Na sequência, articulamos a relação entre um sistema político e a necessária exclusão que ele promove. Na seção seguinte, analisamos a ideia da lei como a arbitrariedade. Por fim, propomos, tendo em vista o fundamento democrático da vontade dos iguais, que a lei seja preterida em nome desta vontade, que o sistema jurídico seja um meio de execução da decisão política e não o contrário, como comumente tem ocorrido nas democracias ocidentais.

Resumen El objetivo del artículo es discutir teóricamente la relación entre democracia liberal y desigualdad, en la defensa de la idea de que la lucha por la igualdad es siempre un profundo y necesario acto de subversión política contra una estructura de poder establecida. Para la consecución de ese objetivo, inicialmente, presentamos la discusión acerca del fundamento democrático de la voluntad de los iguales. En consecuencia, articulamos la relación entre un sistema político y la necesaria exclusión que promueve. En la sección siguiente, analizamos la idea de la ley como la arbitrariedad. Por último, proponemos, teniendo en cuenta el fundamento democrático de la voluntad de los iguales, que la ley sea preterida en nombre de esta voluntad, que el sistema jurídico sea un medio de ejecución de la decisión política y no lo contrario, como comúnmente ha ocurrido en las democracias occidentales.

Abstract This article aims at theoretically discussing the relation between liberal democracy and inequality, by defending the idea that the struggle for equality is always a profound and necessary political subversive act against an established power structure. For this, initially, we present a discussion on the democratic foundation of the will of equals. After that, we articulate the relationship between a political system and the necessary exclusion that it promotes. Next, we analyse the idea of the law as arbitrary. In the end, we propose, according to the democratic foundation of the will of equals, that law has to be overlooked in the name of such will, that the legal system be just a mean of the execution of the political decision and not the opposite, as commonly has occurred in the West democracies.

Voluntad e intelecto: encuentros y desencuentros entre Tomás de Aquino y Duns Escoto / Will and Intellect: agreements and disagreements between Thomas Aquinas and Duns Scotus / Vontade e do intelecto: acordos e desacordos entre Tomás de Aquino e Duns Scotus

Resumen Introducción: la voluntad y el intelecto, dos potencias fundamentales que obran en el espíritu de los hombres determinando de una manera u otra sus elecciones, han sido desarrolladas y comprendidas de formas distintas por diferentes filósofos a la lo largo de la historia, entre ellos, los filósofos medievales Santo Tomás de Aquino y Juan Duns Escoto, cuyo pensamiento sobre estos asuntos se analiza en el presente artículo a partir de referencias como la Suma Teológica de Aquino, Giovanni Duns Scoto: una introduzione bibliografica de Todescan y La vida del espíritu de Hannah Arendt, entre otras. Objetivo: el objetivo del presente artículo es analizar los conceptos de voluntad e intelecto al interior del pensamiento de Tomás de Aquino y Duns Escoto, con el fin de identificar los puntos de encuentro y desencuentro entre ambos autores. Materiales y métodos: este análisis hace parte de una investigación cualitativa con enfoque hermenéutico, que empleó como instrumento de interpretación la revisión documental. Resultados: se logró establecer que la diferencia principal entre el pensamiento de ambos autores se refiere a la primacía que una potencia tiene sobre la otra: en Tomás de Aquino prima el intelecto sobre el deseo, mientras que en Duns Escoto prima la voluntad sobre el intelecto. Conclusión: para efectos de la prevalencia de una potencia sobre la otra, juegan un papel fundamental asuntos como el libre albedrío y, sobre todo, la forma en que ambas potencias actúan en la psique del hombre al momento de la toma de decisiones.

Abstract Introduction: The Will and the Intellect, two fundamental powers that work in the spirit of men, determining in one way or another their choices, have been developed and understood in different ways by different philosophers throughout history, among them, the medieval philosophers St. Thomas Aquinas and John Duns Scotus, whose thinking on these matters is analyzed in this article, from references such as the "Theological Summa" of Aquinas, "Giovanni" of Duns Scoto, "A bibliographical introduction" by Todescan, and" The life of the spirit" by Arendt, among others. Objective: The objective of this article is to analyze the concepts of Will and Intellect within the thought of Thomas Aquinas and Duns Scotus, in order to identify the points of encounter and disagreement between both authors. Material and methods: This analysis is part of a qualitative research with a hermeneutic approach, which used documentary review as an instrument of interpretation. Results: It was established that the main difference between the thinking of both authors, refers to the primacy that one power has over the other: in Thomas Aquinas the intellect over desire, while in Duns Scotus the will prevails over the intellect. Conclusions. For the effects of the prevalence of one power over the other, issues such as free will play a fundamental role and, above all, the way in which both powers act in the psyche of man at the moment of decision making.

Resumo Introdução: Vontade e Intelecto, dois poderes fundamentais que operam no espírito dos homens, determinando de uma maneira ou de outra suas escolhas, foram desenvolvidos e compreendidos de diferentes maneiras por diferentes filósofos ao longo da história, entre eles, os filósofos medievais Santo Tomás de Aquino e João Duns Scotus, cujo pensamento sobre essas questões é analisado neste artigo, a partir de referências como a "Summa Teologico" de Aquino, "Giovanni" de Duns Scoto, "Uma introdução bibliográfica" de Todescan, e "A Vida do Espírito" de Arendt, entre outros. Objetivo: O objetivo deste artigo é analisar os conceitos de Vontade e Intelecto no pensamento de Tomás de Aquino e Duns Scotus, a fim de identificar os pontos de encontro e discordância entre os dois autores. Materiais e métodos: Esta análise é parte de uma pesquisa qualitativa com abordagem hermenêutica, que utilizou a revisão documental como instrumento de interpretação. Resultados: Foi estabelecido que a principal diferença entre os pensamentos de ambos autores refere-se à primazia que um poder tem sobre o outro: em Tomás de Aquino, o intelecto sobre o desejo, enquanto em Duns Scotus a vontade prevalece sobre o intelecto. Conclusões: Para os efeitos da prevalência de um poder sobre o outro, questões como o livre arbítrio jogan um papel fundamental e, sobretudo, o modo como ambos poderes atuam na psique do homem no momento da tomada de decisão.

Conversas de um psicodramatista com Nietzsche / Conversations between a psychodramatist and Nietzsche / Conversaciones de un psicodramatista con Nietzsche

O autor resgata, em sua trajetória profissional, as origens de seu interesse atual por ideias do filósofo Friedrich Nietzsche. Em seguida, mediante a descrição de instantes significativos acontecidos no seio de um processo psicoterapêutico, explora articulações com o método psicodramático, em especial entre as noções de vontade de poder e espontaneidade. O procedimento genealógico, as proposições de eterno retorno e de perspectivismo são outras contribuições do filósofo das quais o autor tem se valido em sua prática, permeada por uma concepção trágica de mundo. Alerta, no entanto, para os cuidados necessários ao se fazer interlocuções entre diferentes campos de saber, sob o risco de se descaracterizar conceitos. Por fim, avalia que as conexões têm se mostrado fecundas.

The author rescues, in his professional trajectory, the origins of his current interest in some ideas of the philosopher Friedrich Nietzsche. Then, through the description of significant moments that took place in a psychotherapeutic process, he explores articulations with the psychodramatic method, in particular between the concepts of will to power and spontaneity. The genealogical procedure, the propositions of eternal return and perspectivism are other contributions of the philosopher of which the author has used in his practice, permeated by a tragic worldview. He alerts, however, to the necessary care when making interlocutions between different fields of knowledge, under the risk of mischaracterizing concepts. Finally, he evaluates that the connections have been fruitful.

El autor rescata, en su trayectoria professional, los orígenes de su interés actual por ideas del filósofo Friedrich Nietzsche. En seguida, a través de la descripción de instantes significativos ocurridos en el seno de un proceso psicoterapéutico, él explora articulaciones com el método psicodramático, en especial entre las nociones de voluntad de poder y espontaneidad. El procedimiento genealógico, las proposiciones de eterno retorno y perspectivismo son otras contribuciones del filósofo de las cuales el autor se ha valido en su práctica, permeada por una concepción trágica de mundo. Por fin, él evalúa que las conexiones se han mostrado fecundas.

A vontade em Vygotski: contribuições para a compreensão da "fissura" na dependência de drogas / Le volonté chez Vygotski: contributions à la compréhension d'avidité dans la dépendance des drogues / La voluntad en Vygotski: contribuciones a la comprensión del craving en la drogadicción / The will in Vygotsky: contributions to the understanding of the "craving" in drug addiction

Resumo A fissura (craving) é questão central no cuidado a pessoas com problemas decorrentes do uso de álcool e outras drogas, sendo considerada uma incapacidade de controlar o desejo pelo consumo. Contudo, não há definição unívoca desse fenômeno. Investigou-se o conceito de vontade em Lev S. Vygotski (1896-1934), considerando-se que sua abordagem poderia contribuir para a compreensão da fissura. Realizou-se uma revisão da literatura acerca do craving e uma análise focal do conceito de vontade em textos selecionados de Vygotski. Não obstante as controvérsias sobre a definição do fenômeno da fissura, a proposição de Vygotski acerca da vontade como função psicológica superior mediada por motivos auxiliares possibilita ampliar a compreensão do craving. O manejo da fissura, assim, depende não somente de uma iniciativa individual, mas também de questionamentos sobre a lógica social, política e histórica que preside os significados sobre o uso de drogas.

Resumé L'avidité (craving) est un point central pour le soin des personnes ayant problèmes issus de l'utilisation de l'alcool et d'autres drogues envisagée comme l'incapacité de contrôler le désir de consommation. Cependant, il n'y a pas de définition univoque sur ce phénomène. On a recherché le concept de volonté chez Lev S. Vygotski (1896-1934) en envisageant que son approche pourrait contribuer à la compréhension de l'avidité. On a effectué une révision de littérature autour du craving et une analyse focale du concept de volonté dans des textes sélectionnés de Vygotski. Malgré les controverses sur la définition du phénomène d'avidité, la proposition de Vygotski autour de la volonté comme fonction psychologique supérieure médiate par motifs auxiliaires permet d'enrichir la compréhension du craving. Le maniement de l'avidité ne dépend pas seulement d'une initiative individuelle, mais aussi des interrogations sur la logique sociale, politique et historique qui oriente les sens de l'utilisation des drogues.

Resúmen La fisura (craving) es un tema central en la atención de personas con problemas derivados del uso de drogas, considerada una incapacidad para controlar el deseo de consumo. Sin embargo, no existe una definición única de este fenómeno. Se investigó el concepto de voluntad de Lev S. Vygotsky (1896-1934) teniendo en cuenta que podría contribuir a la comprensión de la fisura. Se realizó una revisión bibliográfica sobre el deseo, y un análisis focal del concepto de voluntad en textos seleccionados de Vygotski. A pesar de las controversias en la definición del fenómeno de la fisura, la proposición de Vygotsky sobre la voluntad como función psicológica superior mediada por motivos auxiliares hace posible ampliar la comprensión del craving. El tratamiento de la fisura no sólo depende de una iniciativa individual, sino también de preguntarnos acerca de la lógica social, política e histórica que preside los significados del consumo de drogas.

Abstract Craving is a central issue in the care of people with problems due to the use of alcohol and other drugs, and is considered an inability to control the desire for consumption. However, there is no clear definition of this phenomenon. We investigated the concept of will in the works of Lev S. Vygotsky (1896-1934), considering that his approach could contribute to understanding the craving. We reviewed the literature on craving and performed a focal analysis of the concept of will in selected texts by Vygotsky. Despite the controversies over the definition of the craving phenomenon, Vygotsky's proposition that the will is a superior psychological function mediated by auxiliary motives makes it possible to deepen the understanding of the craving. Craving management thus depends not only on individual initiative, but also on questions about the social, political, and historical logic that presides over the meanings of drug use.