Bioethics applied to palliative care: a public health issue

Cenedesi Júnior, Mario Angelo

doi:10.1590/1983-803420233532EN

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Research • Rev. Bioét. 31 • 2023 • https://doi.org/10.1590/1983-803420233532EN copy

Bioethics applied to palliative care: a public health issue

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Abstract

Palliative care is a set of actions aimed at improving patients’ and family members’ quality of life when no curative treatment is available. It encompasses physical, psychological, spiritual and social care, understanding death as a natural process whose outcome should be accelerated or delayed. Of the 131 articles on bioethics and palliative care published in the last five years selected, this integrative review analyzes 10. These studies highlight the importance of bioethics for palliative care, addressing themes such as definitions, death, end of life and the need for a multi-professional interdisciplinary team. Spirituality also plays a relevant role, putting the patient and family members as central to decisions made based on effective communication. Palliative care aims to provide comfort, dignity and comprehensive support for patients with advanced illnesses, allowing them the maximum quality of life possible.

Palliative care; Hospice care; Bioethics; Public health

	Authors; year	Journal	Title	Objective	Method	Conclusion
A	Chaves and collaborators; 2021 ¹⁴	Revista Bioética	“Cuidados paliativos: conhecimento de pacientes oncológicos e seus cuidadores”	Verify the perception of palliative care, advance directives, and do-not-resuscitate orders of cancer patients and their caregivers and their relationship with healthcare professionals.	Quantitative descriptive research between 2018 and 2019 in the high-complexity oncology center of a Brazilian university hospital. The sample had 200 participants (100 cancer patients and 100 informal caregivers).	Lack of knowledge on the part of participants related to issues related to the end of life, as well as a conflict between dysthanasia and obstinate resuscitation. The results also report the importance of training healthcare professionals to perform their role.
B	Lima MA, Manchola-Castillo; 2021 ¹⁵	Revista Bioética	“Bioética, cuidados paliativos e libertação: contribuição ao ‘bem morrer’”	Reflect on dying and bioethics’ contributions to the topic, whether through the traditional principles of autonomy and dignity or the defense of a new category, liberation, proposed by intervention bioethics based on Paulo Freire.	Qualitative research, with a hermeneutic, reflective, socio-critical, and analytical approach to demonstrate that liberation can contribute to training more critical, committed, and free professionals and patients capable of facing a moment of such vulnerability as death.	The article argues that adopting the concept of liberation in bioethical reflection on palliative care can contribute to the process of “dying well.”
C	Floriani; 2021 ¹⁶	Cadernos de Saúde Pública	“Considerações bioéticas sobre os modelos de assistência no fim da vida”	Discuss the three care fields institutionalized in contemporary societies for end-of-life care and their respective models of death: euthanasia/assisted suicide, medical futility, and kalothanasia, the foundation of the modern hospice movement.	Essay analyzing how the proposed models impact patients’ lives and the conceptual fragility of some of the traditionally used flags, such as human dignity.	A bioethical debate is proposed regarding the need to rethink some postulates, especially those referring to euthanasia. It presents and analyzes the ethical and philosophical foundations of kalothanasia and its implications for the organization of good care practices at the end of life.
D	Esperandio, Leget; 2021 ¹⁷	Revista Bioética	“Espiritualidade nos cuidados paliativos: questão de saúde pública?”	Present the state of the art on the topic, provide brief guidance on identifying spiritual needs, and describe four valuable tools for this care.	Integrative review, with studies from the Capes Journal Portal, the Virtual Health Library, SciELO, and PubMed, using the terms “spiritual care and palliative care,” “spirituality and palliative care,” and “bioethics.” Eighteen empirical studies published between 2003 and 2018 were found: four theses, two dissertations, and 12 articles.	It reflects on bioethics and public theology and their correlation with public health. The text presents recommendations to support public policies implementing spiritual care in Brazil’s palliative care.
E	Maingué and collaborators; 2020 ¹⁸	Revista Bioética	“Discussão bioética sobre o paciente em cuidados de fim de vida”	Identify factors that influence the decision-making of health professionals when dealing with end-of-life care patients admitted to intensive care units.	Quantitative research in two hospitals in Paraná between March and May 2018, with a sample of 45 multidisciplinary team members.	The article highlights the interviewees’ concerns regarding autonomy, protection of dignity, and preservation of patients’ and families’ quality of life through shared decision-making. However, the tendency of therapeutic obstinacy to fulfill professional duty showed the need for more discussions and training in palliative care to minimize ethical conflicts.
F	Fusculim and collaborators; 2022 ¹⁹	Revista Bioética	“Diretivas antecipadas de vontade: amparo bioético às questões éticas em saúde”	Analyze the current context of the implementation of advance directives in Brazil based on the knowledge of professionals in the field of medicine and nursing, as well as identify potential contributions of bioethics to their implementation.	Exploratory, cross-sectional study with a quantitative approach, with the participation of 143 physicians and nurses. An electronic questionnaire was applied on an online platform, aiming to analyze the current context of the implementation of advance directives in Brazil based on the participants’ perceptions.	According to the article, knowing what the directives are facilitates the process of deliberation with the patient, with knowledge of bioethics being fundamental to support the decision of professionals when choosing the best conduct to be adopted.
G	Cecconello, Erbs, Geisler; 2022 ⁵	Revista Bioética	“Condutas éticas e o cuidado ao paciente terminal”	Analyze the approach aimed at terminally ill patients since ethics and care need to be present in a cautious relationship, which raises discussions and different interpretations in the medical environment.	Integrative bibliographic review based on the analysis and integration of works found in multiple online databases, such as SciELO, PubMed, the Federal Council of Medicine (CFM) portal, and the Code of Medical Ethics (CEM), in addition to journals, platforms and printed works. The search included publications from 2001 to 2020, and 23 articles were selected.	The approach to conducting and caring for terminally ill patients is critical, given the possibilities and disagreements that these can cause. The article concludes that a multidisciplinary team must provide palliative care to promote comprehensive care for patients and their families while respecting biopsychosocial and spiritual aspects.
H	Espíndola and collaborators; 2018 ²⁰	Revista Bioética	“Relações familiares no contexto dos cuidados paliativos”	Narrative literature review, i.e., a non-systematic survey that does not specify keywords, descriptors, sources, and publication period.	The article aims to explore possible implications for family relationships at the end of life through a narrative literature review.	The article concludes that changes and losses in the illness process affect the patient and their family members. This justifies the need for assistance that offers care to these individuals and supports the physical, psychosocial, and spiritual suffering to which they are subject.
I	Souza and collaborators; 2022 ²¹	Revista Bioética	“Dilemas éticos no direito de acesso aos cuidados paliativos na pandemia da covid-19”	List some ethical dilemmas related to the right to access palliative care in the context of the COVID-19 pandemic and encourage discussion, aiming to allocate resources equitably, according to doctrinal assumptions of the Unified Health System legislation.	This theoretical reflection references Norman Daniels’ approach to accountability for reasonableness.	The article makes it clear that it is essential to discuss the dilemmas highlighted so that the deliberation process in the allocation of health resources is done fairly, as directed by the principle of equity, and bioethical references can be used to provide greater transparency to decisions, the so that the population can understand them as fair and justified.
J	Campos, Silva , Silva; 2019 ²²	Revista Bioética	“Comunicação em cuidados paliativos: equipe, paciente e família”	Evaluate communication in palliative care and its influence on the team, patient, and family relationship.	Qualitative, descriptive, and exploratory research involving six participants at a public health hospital institution in Suzano, in the state of São Paulo. Data were collected in semi-structured interviews and evaluated using the content analysis technique.	The article establishes that a good relationship between the three parties through dialogue is fundamental. However, it is necessary to identify other phenomena beyond professionals’ communicative skills. From a bioethics perspective, communication stands out in assistance and creates a bond that enables shared decisions.

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