Research Progress of Inpatients’ Living Wills / 中国医学伦理学

By reviewing the necessity, current status of cognitive attitudes, influencing factors, and improvement strategies of inpatients’ living wills, this paper proposed to strengthen the publicity and promotion of living wills to advance the development of death with dignity, improve relevant influencing factors, and provide feasible solutions for living wills, and actively develop tools to assess the cognition and attitude of living wills, with a view to providing reference for further promoting the application of living wills in inpatients and improving related research.

Reflexiones sobre profesionalismo y muerte digna: ¿Condiciones vitales no disponibles?

este artículo de reflexión hace un llamado a retornar a la compasión y el profesionalismo médico que se han visto sensiblemente afectados por la pandemia. En el contexto de la pérdida de un familiar, los autores reflexionan sobre los medicamentos vitales no disponibles para aliviar el sufrimiento y el dolor de los pacientes que se encuentran al final de la vida. El texto invita a los pacientes a ejercer su derecho a la salud y a la muerte digna y hace un llamado a los lectores a pensar en la investigación e innovación como alternativas para enfrentar la coyuntura nacional de escasez de medicamentos y dispositivos médicos.

This reflective article calls for a return to compassion and medical professionalism that have been sensitively affected by the pandemic. In the context of bereavement, the authors reflect on the vital medications unavailable to alleviate the suffering and pain of patients at the end of life. The text invites patients to exercise their right to health and dignified death and calls on readers to think about research and innovation as alternatives to confront the national conjuncture of shortages of medicines and medical devices.

neste artigo de reflexão, pede-se um retorno à compaixão e ao profissionalismo médico que foram sensivelmente afetados pela pandemia da covid-19. No contexto do luto, os autores refletem sobre os medicamentos vitais indisponíveis para aliviar o sofrimento e a dor dos pacientes no final da vida. O texto convida os pacientes a exercerem seu direito à saúde e a uma morte digna, e convoca os leitores a pensarem em pesquisa e inovação como alternativas para enfrentar a escassez nacional de medicamentos e dispositivos médicos.

Court decisions and legal considerations about the withdrawal of the life-prolonging medical care

The Supreme Court decision made on May 21, 2009 about the withdrawal of futile life-prolonging medical care from a persistently vegetative patient provided a legal basis for patients to consent to death with dignity, and also spurred a lively debate in Korea. The legal grounding of this decision was based on the principles of human dignity, worth, and the right to pursue happiness articulated in the Article 10 of the Constitution. The Death with Dignity Act was legislated to regulate decisions about life-prolonging medical care on February 3, 2016, after extensive debate and a focus on consensus that led to two revisions. However, the issue has not been completely resolved. First, the definition of the process of dying is unclear, because the points that determine whether a patient is dying are different from a simple assessment of whether an artificial ventilator should be attached or detached. Second, the purpose of this law is the protection of human dignity, worth, and the right to pursue happiness. However, nutrition, fluids, and oxygen must continue to be supplied, even after cessation of life-prolonging medical care. Is providing a continuous supply of nutrition, fluids, and oxygen a reasonable way to satisfy the goals of Article 10 of the Constitution? Third, if the withdrawal of life-prolonging medical care is possible based on the family's agreement without the patient's input, what is the legal value of advance directives? In conclusion, it may be necessary to partially revise the law regulating decisions on the withdrawal of life-prolonging medical care through further debate.

Communication about Death and Confidence Levels concerning Death-Related Issues among Koreans

BACKGROUND: This study investigated the current status of communication about death and confidence levels concerning death-related issues among Korean adults.METHODS: A survey was conducted to ascertain the frequency of death related communication, factors promoting and impeding such communication, and confidence levels concerning death-related issues. Data of 112 participants who completed the survey were analyzed using descriptive statistics, a chi square test, and multiple logistic regression.RESULTS: More than half of the participants (52.7%–84.0%) appeared to have infrequent (never/at least one) conversations about death or death-related issues. Owing to socio-cultural aspects, death-related communication was considered a taboo or an unpleasant topic of conversation. Additionally, indifference toward death inhibited people from communicating; however, personal experiences of death or morbidity and favorable social contexts promoted communication. Overall, the confidence levels concerning death-related issues was low. Only 17.9%–32.2% of the participants were confident/very confident about their preferences concerning death-related issues. The more people talked about death, the more likely they were to develop a confident attitude toward death-related issues (odds ratio, 3.45; 95% confidence interval, 1.37–8.69).CONCLUSION: This study confirmed that communication about death is being withheld among Koreans, and this could possibly lower their level of confidence regarding death-related issues. To achieve death with dignity, a ‘death culture’ needs to be promoted alongside legislation and infrastructure.

"Death with Dignity" or "Painful Alive":Analysis of the Ethical Dilemma and Countermeasures of China' s Living Will / 中国医学伦理学

This paper summarized the current ethical dilemmas of living will in our country including life ethical dilemmas, medical ethical dilemmas and family ethical dilemmas, and then proposed several suggestions for the promotion of living will in China:strengthening the theoretical research on related contents of living will, increasing the intensity of death education, carrying out related activities in the communities, strengthening the policy support and establishing hospital or regional pilots, to provide the feasible problems for the advancement of our country's living will.

O direito à morte digna da criança hospitalizada: ações de enfermagem / The hospitalized child's right to a dignified death: nursing actions

Diante da complexidade dos aspectos que envolvem a assistência de enfermagem à criança em momento final de vida no cenário da Unidade de Internação Pediátrica, objetivou-se descrever as ações de enfermagem frente ao direito à morte digna da criança hospitalizada; analisar as (im)possibilidades para promover o direito à morte digna da criança hospitalizada; e discutir as implicações das ações de enfermagem para a promoção do direito à morte digna da criança hospitalizada. Estudo qualitativo, baseado no conceito de morte digna, com 16 membros da equipe de enfermagem, que atuam em uma Unidade de Internação Pediátrica, por meio da Entrevista Não Diretiva em Grupo. Os depoimentos foram analisados de acordo com a análise temática. Resultados: As ações de enfermagem minimizam o sofrimento por meio de medidas farmacológicas e não farmacológicas que aliviam a dor, o desconforto físico e respiratório, tornam o ambiente mais acolhedor com a implementação de estratégias que buscam resguardar a privacidade, e ampliam os acompanhantes da criança. A morte digna é possível quando a criança e família são preparadas para vivenciar esse momento final da vida da criança; a decisão é compartilhada entre criança, família e equipe; existe vínculo e confiança com a equipe; os aspectos religiosos são respeitados; o quadro de irreversibilidade da criança é reconhecido, e não há transferência para a Unidade de Terapia Intensiva Pediátrica, nem tampouco a realização de medidas invasivas e dolorosos para prolongar a vida da criança. Esses fatores garantem fortalecimento da família; princípios bioéticos; aceitação da morte da criança e atenuação dos aspectos estressores. Conclusões: A equipe de enfermagem promove a morte digna da criança baseada em convicções individuais de dignidade, uma vez que ainda não existem modelos de cuidado à criança no momento final de vida e morte, na unidade de internação pediátrica, cenário do estudo. As ações contribuem para criação de novos modelos de cuidado à criança que resguardem prioritariamente a dignidade humana no momento da morte da criança.

In view of the complexity of the aspects that involve nursing assistance to the child at the end of life in the scenario of the Pediatric Internment Unit, the objective was to describe the nursing actions regarding the right to a decent death of hospitalized children; to analyze the (im) possibilities for promoting the right to a decent death in hospitalized children; and discuss the implications of nursing actions for the promotion of the right to a dignified death in hospitalized children. A qualitative study based on the concept of dignified death, with 16 members of the nursing team, who work in a Pediatric Internment Unit, through the Non-Directive Group Interview. The statements were analyzed according to the thematic analysis. Results: Nursing actions minimize suffering through pharmacological and non-pharmacological measures that alleviate pain, physical and respiratory discomfort, make the environment more welcoming with the implementation of strategies that seek to protect privacy, and expand the child's companions. Decent death is possible when the child and family are prepared to experience this final moment of the child's life; the decision is shared between child, family and team; there is a bond and trust with the team; religious aspects are respected; the irreversibility of the child is recognized, and there is no transfer to the Pediatric Intensive Care Unit, nor any invasive and painful measures to prolong the life of the child. These factors ensure family strengthening; bioethical principles; acceptance of the child's death and attenuation of the stressors. Conclusions: The nursing team promotes the dignified death of the child based on individual convictions of dignity, since there are still no models of child care at the final moment of life and death in the pediatric hospitalization unit, the study scenario. The actions contribute to the creation of new models of child care that safeguard human dignity at the moment of the child's death.

Debates parlamentarios sobre la muerte digna en Argentina: los derechos de los pacientes terminales en la agenda legislativa, 1996-2012 / Parliamentary debates on death with dignity in Argentina: the rights of terminal patients on the legislative agenda, 1996-2012

Resumen: El artículo examina la producción legislativa sobre derechos de los pacientes terminales en Argentina en dos momentos: los primeros intentos de regular los derechos en el final de la vida (1996) y la sanción de la ley de "muerte digna" en el Congreso Nacional (2011-2012). El análisis comparativo permite observar variaciones en torno a las personas y situaciones incluidas en la legislación, la forma en que se conceptualiza la autonomía y las intervenciones que se considera legítimo rechazar. El contexto político y la forma diferencial en que la "muerte digna" ingresó en la agenda legislativa en cada periodo determinaron la construcción pública del problema y con ello los alcances y el resultado de los debates.

Abstract: This article examines the regulation on terminal patients' rights in Argentina at two points in time: the first attempts to regulate end-of-life rights (1996), and the "death with dignity" law passed by the National Congress (2011-2012). Comparative analysis allows us to observe variations among the individuals and situations included in the legislation, as well as in the conceptualization of autonomy and the interventions that is considered lawful refuse. The political context and the differential way that "death with dignity" entered the legislative agenda in each period determined the public's construction of the problem and thus the extent and result of the debates.

Personas enfermas al final de la vida: vivencias en la accesibilidad a recursos sociosanitarios / Sick persons at the end of their lives: Experiences related to their accessibility to social-sanitary resources / Pessoas doentes no final da vida: vivencias na acessibilidade a recursos sociosanitários

Objetivo: Identificar cuáles han sido las principales limitaciones y dificultades en el acceso a los recursos sociosanitarios que han vivido las personas al final de la vida, a través de las vivencias y las percepciones de los cuidadores de estos enfermos. Método: Estudio cualitativo multicéntrico con enfoque fenomenológico, mediante 5 grupos de discusión y 41 entrevistas en profundidad, en Andalucía, España. La selección de los participantes se realizó intencionadamente entre los cuidadores que habían sufrido la muerte de su familiar, entre 2 meses y 2 años después del fallecimiento. Se optó por el método de Giorgi para el análisis de la información, y como soporte informático utilizamos Atlas ti 6.0. Resultados: Se han obtenido una serie de categorías relacionadas con distintos niveles de asistencia sanitaria: el sufrimiento en los servicios de urgencias, la necesidad de intimidad, la sensación de soledad y la vivencia en el domicilio. Conclusiones: Los cuidadores han descrito una serie de obstáculos de acceso a los distintos recursos sociosanitarios, entre los que destacan la existencia de protocolos muy generales de atención que no tenían en cuenta el proceso de enfermedad de su familiar y la necesidad de una habitación individualizada, durante el ingreso hospitalario. En el domicilio se sienten protegidos por los profesionales de atención primaria, pero presentan dificultades de acceso a apoyo psicológico y a las unidades de cuidados paliativos. Por tanto, es prioritario que desde el sistema sanitario se puedan fomentar los aspectos asistenciales esenciales en la atención a estos enfermos y favorecer una muerte con dignidad.

Objective: From the perspective of their health providers, to identify the main limitations and difficulties which persons at the end of their lives have experienced in relation to their accessibility to social-sanitary resources. Method: This is a phenomenological-focused qualitative and multi-centric study which conducted 5 discussion groups and 41 in-depth interviews in Andalucia, Spain. The participant selection was limited to those health providers who had suffered the death of a family member within the past two years. The Giorgi method was chosen to analyze and back-up the data. Atlas ti 6.0 was also used. Results: From the analysis, several sanitary-assistance-level categories arose including: the suffering at the urgency services, the need of intimacy, the feelings of loneliness, and the life at home. Conclusions: The care providers described a series of barriers to the access to social-sanitary resources highlighting the very general attention protocols which did not integrally consider the illness process of the beloved, and the need to an individualized room while admission at the hospital. Although while at home, these persons feel protected under the attention of the primary care professionals, they have difficulties to having access to psychological support at the palliative care units. Therefore, it is a priority that, from the sanitary system, the essential assisting attention can be warranted, thus supporting these sick persons to go through death in dignity.

Objetivo: Identificar quais têm sido as principais limitações e dificuldades no acesso aos recursos sociosanitários que viveram as pessoas no final da vida, através das vivencias e as percepções dos cuidadores destes doentes. Método: Estudo qualitativo multicêntrico com abordagem fenomenológica, mediante 5 grupos de discussão e 41 entrevistas a profundidade, em Andaluzia, Espanha. A seleção dos participantes realizou-se intencionadamente entre aqueles cuidadores que sofreram a morte de seu familiar, entre dois meses e dois anos depois da morte. Optou-se pelo método de Giorgi par análise da informação e como suporte informático, utilizamos Atlas ti 6.0. Resultados: Obtiveram-se uma série de categorias relacionadas, com diferentes níveis de assistência sanitária: o sofrimento nos serviços de pronto socorro, a necessidade de intimidade, a sensação de solidão e a vivencia no domicílio. Conclusões: Os cuidadores, descreveram uma série de obstáculos de acesso aos diferentes recursos sociosanitários nos quais salienta, a existência de protocolos muito gerais de atenção que não tinham em conta o processo de doença de seu familiar e a necessidade de um quarto individualizado, durante o ingresso hospitalar. No domicilio sentem-se protegidos pelos profissionais de atenção primaria, mas, apresentam dificuldades de acesso ao apoio psicológico e às unidades de cuidados paliativos. Portanto, é prioritário que desde o sistema sanitário se possam promover aqueles aspectos assistenciais essenciais na atenção destes doentes e favorecer uma morte com dignidade.

Eutanasia en Chile: una discusión pendiente / Euthanasia in Chile

Euthanasia is a complex medical procedure. Even though end of life decisions are common situations in health practice, there is a lack of consensus about their terminology. In this manuscript, the main concepts about this issue are defined and delimited; including active and passive euthanasia and limitation of therapeutic effort. Then, a revision is made about the international experience on euthanasia, to then go through the Chile’s history in euthanasia and the population’s opinion. In Chile, euthanasia is an act that has been removed from the social dialogue and legislation. In order to have an open discussion in our population about the issue, the debate has to be opened to the citizens, accompanied by clear medical information about the procedure.

El derecho a una muerte digna en Argentina: la judicialización de la toma de decisiones médicas en el final de la vida / O direito a uma morte digna na Argentina: a judicialização da tomada de decisões médicas no final da vida / The right to a dignified death in Argentina: the judicialization of end-of-life care decisions

Resumen El artículo discute desde una perspectiva socio-histórica el contexto y las implicancias de los procesos de judicialización en torno a la gestión médica de la muerte y el morir. El objetivo del artículo es describir y analizar la judicialización de la toma de decisiones médicas en el final de la vida en Argentina, a partir de fallos judiciales producidos entre 1975 y 2015. Se examina el contexto y las principales características de la litigación respecto a estas decisiones, así como los cambios producidos en el periodo: los casos que son objeto de disputa (desde el rechazo de transfusiones al pedido de retiro de medidas de soporte vital), los argumentos y leguajes utilizados (de la objeción de conciencia a la autonomía) y la emergencia de nuevos derechos. Por último se discuten las consecuencias y las perspectivas futuras de la judicialización en este campo.

Resumo O artigo discute, a partir de uma perspectiva sócio-histórica, o contexto e implicações sociais da judicialização da gestão médica da morte e o morrer. O objetivo do artigo é descrever e analisar a judicialização da tomada de decisões médicas no final da vida na Argentina, a partir de julgamentos produzidos entre 1975 e 2015. O artigo examina o contexto e as principais características da litigação em torno a essas decisões, assim como as mudanças no período: nos casos disputados (de rejeitar transfusões a pedidos de retirada de suporte vital), em os argumentos e linguajem usados (de objeção de consciência à autonomia) e o surgimento de novos direitos. Por fim, são discutidas as consequências e perspectivas futuras da judicialização neste campo.

Abstract The paper discusses, from a socio-historical perspective, the context and implications of judicialization processes regarding medical decisions making on death and dying. This paper aims to describe and analyze the judicialization of end-of-life care decisions at the end of life in Argentina, considering courts decisions produced between 1975 and 2015. The context and the main features of litigation regarding those decisions are examined, as well as the changes within the period: the cases disputed (from rejecting blood transfusions to withdrawal of life support), the arguments and languages that frame the legal cases (form conscientious objection to autonomy) and the emergence of new rights. Finally, the social consequences and the future prospects of judicialization in this field are discussed.

Actores y discursos religiosos en la esfera pública: los debates en torno a la educación sexual y a la "muerte digna" en Argentina / Atores e discursos religiosos na esfera pública: os debates em torno da educação sexual e da "morte digna" na Argentina / Religious actors and discourses in the public sphere: the sex education and "death with dignity" debates in Argentina

Resumen La educación sexual y las condiciones para una "muerte digna" han sido objeto de debate parlamentario en la última década en Argentina. El artículo aborda comparativamente el proceso que desembocó en la aprobación de las leyes de Educación Sexual Integral y "muerte digna" por parte del Congreso de la Nación, examinando las estrategias de intervención y los fundamentos discursivos de instituciones religiosas -principalmente, de la Iglesia católica- en los debates públicos. El análisis de ambos procesos permite describir estrategias disímiles de posicionamiento de actores y discursos religiosos en la esfera pública, tendientes a incidir en la legislación y en las políticas públicas.

Resumo A educação sexual e as condições para uma "morte digna" foram objeto de debate parlamentar na última década na Argentina. O artigo aborda comparativamente o processo que desembocou na aprovação das leis de Educação Sexual Integral e "morte digna" por parte do Congresso da Nação, examinando as estratégias de intervenção e os fundamentos discursivos das instituições religiosas - principalmente da Igreja Católica - nos debates públicos. A análise de ambos os processos permite descrever diferentes estratégias de posicionamento dos atores e discursos religiosos na esfera pública, tendentes a incidir na legislação e nas políticas públicas.

Abstract Sex education and the conditions for a "death with dignity" have been the subject of parliamentary debates over the past decade in Argentina. This paper compares the process leading to the adoption of laws regulating the adoption of a Comprehensive Sex Education and the right for a "death with dignity" by the Argentinean Congress, focusing the analysis in the participation of religious institutions--particularly the Catholic Church--in public debates and the discursive arguments of those actors. The description of both processes shows the different strategies of religious actors and their discourses in the public sphere designed to influence legislation and public policies.

La eutanasia en Colombia desde una perspectiva bioética / Euthanasia in Colombia from a bioethical perspective

La eutanasia es la terminación voluntaria de la vida de una persona que padece una enfermedad terminal, pudiendo aplicarse de forma activa o pasiva, así como de forma voluntaria o involuntaria. Este procedimiento debe ser visto desde la perspectiva del paciente, priorizando su autonomía y libertad en la toma de decisiones con respecto a su enfermedad y a la solicitud de una muerte digna. En Colombia, la Corte Constitucional, despenalizó la eutanasia en 1997, creando la opción para que las personas que sufren una enfermedad incurable y en fase terminal puedan pedir poner fin a su vida; sin embargo el Congreso de la República, en 18 años no realizó su reglamentación, por lo que la Corte en el 2014, le ordenó al Ministerio de Salud y Protección Social que creara una ruta administrativa para efectuar la regulación, formando así un comité para atender las solicitudes de eutanasia activa y presentando los lineamientos generales para hacer efectivo el derecho a morir con dignidad, del paciente en fase terminal. De este modo, Colombia se convierte en el primer país en desarrollo en legalizar la eutanasia activa, aunque algunos conceptos quedaron incompletos en la resolución del Ministerio de Salud, proponiendo de este modo que se continúe la discusión con expertos que asegure que las prácticas en salud recomendadas, cumplan con los términos señalados por la Corte Constitucional.

Euthanasia is the voluntary termination of a person life that suffers a terminalillness; it can be applied actively or passively, as well as voluntary or involuntary.This procedure must be viewed from the perspective of the patient, prioritizingtheir autonomy and freedom in making decisions about their disease andthe application of a dignified death. In Colombia, the Constitutional Court,legalized euthanasia in 1997, creating the option for people suffering anincurable and terminally ill, can seek to end their life; however the Congress,in 18 years failed to conduct its regulations, so the Court in 2014 ordered theMinistry of Health and Social Protection to create an administrative route tomake the adjustment, thus forming a committee to meet active euthanasiarequests and presenting the general guidelines for implementing the right todie with dignity on terminally ill patients. Thus, Colombia became the firstdeveloping country to legalize active euthanasia, although some conceptswere incomplete in the resolution of the Ministry of Health, thus suggestingthat the discussion with experts will continue to ensure that health practicesrecommended comply with the terms stated by the Constitutional Court.

Some Barriers to the Legalization of Death with Dignity in China / 中国医学伦理学

Death with dignity is now not legislation in our country .This paper mainly discussed about some barriers to the legalization of death with dignity in China , from the viewpoint of Chinese traditional ideas , the lack of death education , risk of abusing , the subject change of the informed consent right , doctor-patient communica-tion and trust lsot and so on .It is proposed that our country should perfect the medical security system , strengthen the education of death at the same time and help the citizen set up the view of science .Outside, still need to fur-ther deepen the reform of medical system in our country , the maintaining patient ’ s autonomy and right of choosing , protect the informed consent right of patients .Create the doctor-patient relationship of mutual trust .

Tradição e fundamentos éticos hipocráticos aplicáveis à terminalidade da vida / Hippocratic tradition and ethical foundations applicable to the life terminality

A medicina ocidental tem sua origem na Grécia antiga, quando o pensamento mítico e a prática médica sobrenatural e empírica dão lugar a uma racionalidade médica - tékhnē-iatrikē - baseada na observação da natureza. A tékhnē-iatrikē compreende a enfermidade e o enfermo como partes constitutivas da natureza, regidas por leis universais e normas preconcebidas, não devendo, por isso, ser utilizados meios irracionais para superá-las. A racionalidade técnica dominante na medicina atual afastou a prática médica contemporânea da arte hipocrática, e os avanços da ciência e da tecnologia proporcionam condições de manutenção da vida que geram dilemas éticos em pacientes terminais, relegando a dignidade humana a segundo plano. A ética hipocrática, baseando-se no respeito às leis naturais e à pessoa humana, é importante instrumento que, aliado à cultura, à técnica e à arte, proporcionam ao médico o exercício da medicina em conformidade com os preceitos de sua tradição...

Occidental medicine has its origins in ancient Greece, when mythical thoughts and supernatural and empirical medical practice gave place to ideas which favored the development of the pre-technical era of medicine - tékhnē iatrikē - based on observations of nature. tékhnē iatrikē understands the illness and the sick as constitutive parts of nature, driven by universal laws and preconceived rules, and, as a consequence, no irrational means should be used to surpass them. The technical rationality dominant in current medicine has departed contemporary medical practice from the Hippocratic art, and advances in science and technology allow conditions of maintenance of life that bring ethical dilemmas in terminal patients, not considering human dignity. Hippocratic ethics, based on the respect for natural laws and the human being is an important instrument that, allied to culture, to technique and to art allow doctors to practice medicine in conformity with the precepts of its traditions...

La medicina occidental tiene sus orígenes en la antigua Grecia, cuando el pensamiento mítico y la práctica médica sobrenatural y empírica dan lugar a una racionalidad médica - tékhnē iatrikē - basado en la observación de la naturaleza. La tékhnē iatrikē entiende la enfermedad y el enfermo como partes constituyentes de la naturaleza, que se rigen por leyes universales y normas preconcebidas, y por eso no se debe utilizarse medios irracionales para superarlas. La racionalidad técnica dominante en la medicina actual distanció la práctica de la medicina contemporánea del arte hipocrático, y los avances de la ciencia y la tecnología ofrecen condiciones del mantenimiento de la vida que generan dilemas éticos en los pacientes terminales, relegando la dignidad humana a un segundo plano. La ética hipocrática, basándose en el respeto a las leyes naturales y a la persona humana, es una importante herramienta que, combinada con la cultura, el arte y la técnica, proporcionan al médico la práctica de la medicina de acuerdo con los preceptos de su tradición...

Eutanásia na visão dos graduandos em enfermagem: concepções e desafios / Euthanasia from the perspective of nursing undergraduate students: concepts and challenges / La eutanasia en la visión de los estudiantes de enfermería: concepciones y desafíos

O objetivo é apresentar as rodas de conversa com acadêmicos de enfermagem sobre a eutanásia, antes de cursar a disciplina "Exercício profissional e Bioética" para verificar se até aquele período o estudante já havia conseguido competência e habilidade de debate sobre o tema. Trata-se de um estudo com caráter descritivo e exploratório, com abordagem qualitativa do tipo estudo de caso. A amostra foi por adesão de 31 alunos matriculados na disciplina. A coleta de dados deu-se em três rodas de conversa com 10 e uma com 11 alunos. Os discursos foram analisados segundo a Análise de Conteúdo, consoante Lawrence Bardin. Percebeu-se a realidade do acadêmico no cotidiano, que os fez buscar no mundo divino as forças para enfrentar a terminalidade da vida, sem vincular sua ação como profissional ao Código de Ética da Enfermagem, ao Código Penal Brasileiro e o desconhecimento do testamento vital (CFM Resolução 1995/2012), como documento de respeito à vontade preestabelecida de pacientes terminais. A pesquisa serviu para compreender o discurso dos participantes e estruturar dentro da disciplina "Exercício profissional e Bioética" o módulo de eutanásia e ampliar a consciência dos direitos dos profissionais e dos usuários na prática dos serviços, que requer um trabalho educativo fundamentado. Isso porque a garantia constitucional e os códigos legitimados não são suficientes para efetivar os direitos do paciente na prática.

The aim of this study is to present rounds of conversation carried out with nursing students on the issue of euthanasia before they begin theuniversity course of “Professional Practice and Bioethics” in order to verify whether or not, before that semester, the student had in fact achieved acompetence and ability to debate the topic itself. This is a descriptive and exploratory study, which follows a case-study-type qualitative approach.The sample consisted of 31 students enrolled in the course. Data collection was performed in three rounds of conversation with 10 students andone with 11 students. The discourses were analyzed using content analysis, as set forth by Lawrence Bardin. It was possible to see the reality ofthe students’ daily lives, which led them to seek in God the strength to face the end of life, without binding their action as a professional to theNursing Code of Ethics or to the Brazilian Penal Code and the lack of knowledge of the living will (CFM Resolution 1995/2012) as a document ofrespect towards the pre-established will of terminal patients. The study helped to understand the discourse of the participants and to structurethe euthanasia module within the university course of “Professional Practice and Bioethics” as well as to broaden the awareness of the rightsof professionals and users in the rendering of medical services, which requires a well-founded educational work. This is due to the fact that theconstitutional guarantees and legitimated codes are not enough to assure the rights of the patient in practice.

El objetivo de este trabajo es presentar las ruedas de conversación con estudiantes de enfermería sobre la eutanasia antes de cursar la asignatura “Ejercicio profesional y Bioética” para comprobar si hasta ese período el estudiante ya había alcanzado la competencia y la capacidad de debatir sobre el tema. Se tratade un estudio descriptivo exploratorio cualitativo, tipo estudio de caso. La muestra fue por adhesión de 31 estudiantes matriculados en la materia. La recogidade datos se llevó a cabo en tres ruedas de conversación con 10 y otra con 11 estudiantes. Los discursos fueron analizados según su contenido, de acuerdo conLawrence Bardin. Se constató la realidad del alumno en su vida cotidiana, que lo hace buscar en lo divino las fuerzas para enfrentar la terminalidad de la vida,sin vincular su acción al código de ética profesional de Enfermería ni al Código Penal Brasileño. También se observó la falta de conocimiento del testamentovital (Resolución CFM 1995/2012) como un documento de respeto a la voluntad de los pacientes terminales. La encuesta sirvió para entender el discurso de particilos participantes y estructurar el modulo de la eutanasia dentro de la disciplina “Ejercicio profesional y Bioética” y, asimismo, para aumentar la conciencia delos derechos de los profesionales y de los usuarios en la práctica de los servicios, lo cual requiere un trabajo educativo fundamentado. Esto se debe a que la garantía constitucional y los códigos legitimados no son suficientes para consolidar los derechos del paciente en la práctica.

Alcances de la nueva legislación sobre muerte digna / Death with Dignity: Scope of the New Legislation

Durante el año 2011, fuertemente impulsado por algunos casos relevantes, se inició en la Argentina un profundo debate público acerca del morir con dignidad. El día 9 de Mayo del año 2012 fue sancionada en Argentina la Ley N° 26742, llamada "ley de muerte digna". Promulgada de hecho el 24 de Mayo del mismo año, incorpora importantes modificaciones a la Ley N° 26529 de octubre de 2009 sobre "Derechos del Paciente en su relación con los Profesionales e Instituciones de la Salud", ampliando los derechos de las personas respecto de las medidas médicas a tomarse al final de sus vidas. El presente artículo presenta y analiza el impacto de esta nueva disposición sobre los derechos de los pacientes y las obligaciones de los profesionales de salud, desde una perspectiva bioética.

In 2011, heavily driven by some relevant cases, in Argentina began a thorough public debate about dying with dignity. On May 9, 2012 the Law N° 26742, called "death with dignity law" was enacted. Promulgated on May 24, that same year, it incorporates major amendments to the Law N° 26529 on "Patient Rights in relation to the Professionals and Health Institutions" expanding the rights of individuals with regard to medical measures to be taken at the end of their lives. This article presents and analyzes the impact of this new law on patient´s rights and health professionals´ obligations from a bioethical perspective.

Pace Maker Implantation for Elderly Individuals Over 90 Years Old / Journal of Rural Medicine

<b>Objective:</b> The aim of this report was to discuss validity of pacemaker surgery for elderly individuals over 90 years old.<br><b>Patient:</b> We operated on 12 individuals over 90 years old who had syncope or congestive heart failure in association with bradycardia, between January 2005 and November 2012.<br><b>Methods:</b> All 12 patients were referred to us by the cardiology department of our hospital for pacemaker surgery. We applied our routine technique: cutdown of the cephalic vein, creation of a subpectoral pocket, use of screw-in leads, and use of generators with an automatic output control system.<br><b>Results:</b> All of the patients received a dual chamber system with atrial and ventricular leads and recovered uneventfully. The follow-up period was between 1 month and 7 years.<br><b>Conclusion:</b> An advanced age over 90 years old is not a contraindication for pacemaker surgery.

Euthanasia: a misunderstood term

Although the word 'euthanasia', a compound word of eu- (good, well) and thanatos (death) is widely known, it is greatly misunderstood. With regard to end-of-life medicine, several phrases, including death with dignity, passive euthanasia, and natural death also need to be clarified. A review of their meanings and connotations is provided along with a brief history of the discussion in Korea on forgoing life support. Korea has no law regarding the cessation of artificial ventilation, but several judgments of law courts provide us with a general principle that cessation could be applied if the patient is in an irreversible or dying condition medically, and has presented his or her intention with something like an advance directives, or is reasonably presumed to have such a will.

Sofrimento e dor em cuidados paliativos: reflexões éticas / Sufrimiento y dolor en los cuidados paliativos: reflexiones éticas / Suffering and pain in palliative care: ethical reflections

Os avanços tecnológicos associados à medicina levam os médicos a terem como meta incansável vencer a doença e prolongar a vida. Contudo, para os pacientes sem possibilidade de cura, prolonga-se o sofrimento e o processo de morrer. Os cuidados paliativos destinam-se aos pacientes cuja enfermidade não mais responde ao tratamento, tendo como prioridade melhorar sua qualidade de vida, mediante alívio da dor física e sofrimentos psicológicos, sociais e espirituais. Para a introdução deste conceito discute-se a mudança de paradigmas na formação dos profissionais de saúde, que representam uma nova visão da vida, da morte e do atendimento médico, sobrepondo-se o cuidar ao curar, quando isto não for mais possível. No estágio final da vida dos pacientes terminais busca-se manter digna e confortável a existência destes, até o último momento, tendo como pilares o atendimento multidisciplinar e o respeito à autonomia, integridade e dignidade do paciente.

Los avances tecnológicos asociados a la medicina, llevan a los médicos a tener como meta incansable vencer la enfermedad y prolongar la vida. A pesar de ello, para los pacientes que ya no tienen posibilidad de cura, se prolonga también el sufrimiento y el proceso de morir. Los cuidados paliativos se destinan a los pacientes cuya enfermedad ya no responde al tratamiento teniendo como prioridad mejorar su calidad de vida a través del alivio del dolor físico y los sufrimientos psicológicos, sociales y espirituales. Para la introducción de este concepto, se discute el cambio de paradigmas en la formación de los profesionales de salud, que representan una nueva visión de la vida, de la muerte y de la atención médica, sobreponiéndose el cuidar al curar, cuando esto último ya no sea posible. En la etapa final de la vida de los pacientes terminales, se busca mantener digna y confortable la existencia de éstos hasta el último momento, teniendo como pilares la atención multidisciplinaria y el respeto a la autonomía, integridad y a la dignidad del paciente.

The technological advancements associated to medicine lead physicians to have as tireless goal to overcome illness and to extend life. However, for patients who do not present any healing possibility, one extends suffering and the dying process. Palliative care is aimed at these patients whose disease does not respond to treatment anymore, and it has as priority the improvement of their life quality, through relief of physical pain and psychological, social and spiritual suffering. In order to introduce this concept one debates the change of paradigms regarding health professionals formation, which represent a new view of life, death and medical assistance, superposing care to healing whenever this is not possible anymore. One seeks, in the terminal patients´ final phase of life, to maintain their existence honorable and comfortable, up to the last moment, having as bases the multidisciplinary care and the respect for the patient?s autonomy, integrity and dignity.

The change of perspective on brain death, euthanasia and withdrawal of the life supporting medical treatments in Korea for pediatric patients / 소아과

A recent High Court's decision regarding the withdrawal of life supporting medical treatment (artificial ventilator) from an elderly female patient in the terminal stage has opened up a new era of the "euthanasia dispute" in Korea. With this decision, the legitimate withdrawal of life supporting treatment became possible under certain conditions and the Korean Medical Association is working toward the establishment of practical guidelines for the terminal-stage patients. However, there are still very few debates on the cases of pediatric patients in the terminal stage or suffering from fatal diseases. For pediatric patients, the core principle of autonomy and following procedure of "advance directives" are hardly kept due to the immaturity of the patients themselves. Decisions for their lives usually are in the hands of the parents, which may often bring out tragic disputes around "child abuse", especially in Korea where parents have exclusive control of the destiny of their children. Some developed countries such as the U.S.A., the U.K. and Canada have already established guidelines or a legal framework for ensuring the rights of the healthcare system regarding children suffering from severe illness, permitting the withdrawal of Life supporting medical treatment (LSMT) in very specific conditions when the quality of life of the children is severely threatened. For the protection of the welfare and interest of the children, we should discuss this issue and develop guidelines for the daily practice of pediatricians.