Análise bioética da relação médico-paciente na perícia médica da Previdência Social

Esta dissertação apresenta e discute resultados de pesquisa desenvolvida como pré-requisito parcial para obtenção do grau de mestre em Bioética, Ética Aplicada e Saúde Coletiva junto ao Programa de Pós-graduação em Bioética, Ética Aplicada e Saúde Coletiva da Universidade do Estado do Rio de Janeiro, em regime de associação com a Universidade Federal do Rio de Janeiro, a Fundação Oswaldo Cruz e a Universidade Federal Fluminense. A pesquisa de metodologia qualitativa analisou material empírico composto por amostra de registros da Ouvidoria da Previdência Social contendo reclamações sobre o atendimento médico-pericial. A Previdência integra o campo da seguridade social e tem a vida e suas intercorrências na população de segurados como seu objeto de cuidados e controles. O benefício auxílio-doença é o mais frequentemente concedido entre todos os benefícios da Previdência sendo devido somente a seus segurados em dupla condição de vulnerabilidade, doentes e incapazes para o trabalho. A verificação da condição de incapacidade para o trabalho é realizada pelos médicos peritos da Previdência Social como pré-requisito para acesso ao benefício e funciona como mecanismo de controle de custos. Os resultados do estudo evidenciam que a tarefa de controle de acesso, realizada na interface com o segurado, exige um deslocamento da atividade médica da função assistencial para a pericial em decorrência da natureza da tarefa médico-pericial, onde o lugar do controle é o da exceção beneficente. Tal atribuição condiciona um risco da atividade médico-pericial que entendemos ser de ordem moral. As reclamações sobre o atendimento médico na perícia previdenciária foram compreendidas como índices de disfunções nesta interface, assim como os registros de violência em torno desta atividade. Resultantes da prática de limites de acesso ao benefício, na forma em que estes limites estão colocados. A análise desta interface coloca em relevo o paradoxo da proteção securitária que funciona retirando da proteção partes de sua população e caracteriza a relação médico-paciente na perícia médica da Previdência Social como moralmente conflituosa. A pesquisa na linha de uma bioética crítica, que enfatiza as políticas públicas que afetam a vida, entendeu Previdência Social como biopolítica e a atividade médico-pericial como expressão de biopoder, nos termos da filosofia política de Michel Foucault. Cabe à sociedade refletir seriamente sobre essas práticas de controle e definir o alcance e a forma da proteção securitária tendo em vista que esta proteção tensiona necessidades individuais e coletivas. Cabe a todos e a cada um ter em mente a dimensão ética da política previdenciária.

A legitimação bioética e jurídica das diretivas antecipadas sobre a terminalidade da vida no Brasil.

Este trabalho volta-se ao estudo das diretivas antecipadas sobre o fim da vida na relação médica no Brasil. Pretende-se verificar a legitimidade bioética e a legitimidade e possibilidade jurídicas da prática das diretivas antecipadas sobre o fim da vida como objetivo central. Busca-se aferir a adequação, bioética e jurídica, das diretivas antecipadas como veículo próprio de autodeterminação da pessoa diante de suas possibilidades existenciais e da formulação de seu projeto de vida e de morte digna. Ademais, especificamente, procura-se determinar a possibilidade jurídica das diretivas antecipadas no Ordenamento brasileiro: a coerência com as garantias constitucionais e a existência de institutos aptos a tal prática. Propõe-se sustentar a legitimação jurídica das diretivas antecipadas no Brasil, indicando possíveis caminhos às soluções interpretativas no plano jurídico, e os efeitos na relação médica a partir, também, das considerações bioéticas. Com essa finalidade, pretende-se averiguar a compatibilidade entre as normas deontológicas de origem bioética e as normas jurídicas de status constitucional de proteção à pessoa humana. A tese também propõe a análise do contexto em que as diretivas antecipadas são utilizadas para (i) problematizar as ideias de capacidade e competência para a prática desse ato de autonomia pessoal, (ii) problematizar sobre como a perspectiva familiar, a perspectiva técnica dos profissionais da saúde e a perspectiva do Poder Judiciário contingenciam a liberdade desse ato e (iii) aferir a eficácia desses atos no espaço clínico e familiar. Para tanto, será empreendido estudo teórico mediante pesquisa bibliográfica e de referências, que levantará as publicações, nacionais e internacionais, sobre os temas da tese. O levantamento bibliográfico compreenderá, preferencialmente, obras sobre filosofia, ética, bioética e direito, que permitam a análise das questões teóricas envolvidas no estudo. O desenvolvimento do trabalho estrutura-se em três capítulos. O primeiro pretende estabelecer as bases conceituais e os fundamentos legais das diretivas antecipadas. O segundo capítulo apresentará a sistematização entre os valores bioéticos e jurídicos que se relacionam a tal prática. O capítulo três apresentará as questões fundamentais pertinentes à validade e eficácia da prática das diretivas antecipadas no Brasil. A partir das premissas construídas ao longo do desenvolvimento, o desfecho da pesquisa pretende reforçar seu argumento central demonstrando, então, a legitimação bioética e a legitimidade e a possibilidade jurídicas das diretivas antecipadas sobre o fim da vida no atual contexto brasileiro.

The spirit of palliative practice:A qualitative inquiry into the spiritual journey of palliative care physicians

Objective: Much is known about the important role of spirituality in the delivery of multidimensional care for patients at the end of life. Establishing a strong physician-patient relationship in a palliative context requires physicians to have the self-awareness essential to establishing shared meaning and relationships with their patients. However, little is known about this phenomenon and therefore, this study seeks a greater understanding of physician spirituality and how caring for the terminally ill influences this inner aspect. Method: A qualitative descriptive study was used involving face-to-face interviews with six practicing palliative care physicians. Results: Conceptualized as a separate entity from religion, spirituality was described by participants as a notion relating to meaning, personal discovery, self-reflection, support, connectedness, and guidance. Spirituality and the delivery of care for the terminally ill appeared to be interrelated in a dynamic relationship where a physician's spiritual growth occurred as a result of patient interaction and that spiritual growth, in turn, was essential for providing compassionate care for the palliative patient. Spirituality also served as an influential force for physicians to engage in self-care practices. Significance of results: With spirituality as a pervasive force not only in the lives of palliative care patients, but also in those of healthcare providers, it may prove to be beneficial to use this information to guide future practice in training and education for palliative physicians in both the spiritual care of patients and in practitioner self care. Copyright © Cambridge University Press 2010.

Does vicarious traumatisation affect oncology nurses?:A literature review

It is widely documented that nurses experience work-related stress [Quine, L., 1998. Effects of stress in an NHS trust: a study. Nursing Standard 13 (3), 36-41; Charnley, E., 1999. Occupational stress in the newly qualified staff nurse. Nursing Standard 13 (29), 32-37; McGrath, A., Reid, N., Boore, J., 2003. Occupational stress in nursing. International Journal of Nursing Studies 40, 555-565; McVicar, A., 2003. Workplace stress in nursing: a literature review. Journal of Advanced Nursing 44 (6), 633-642; Bruneau, B., Ellison, G., 2004. Palliative care stress in a UK community hospital: evaluation of a stress-reduction programme. International Journal of Palliative Nursing 10 (6), 296-304; Jenkins, R., Elliott, P., 2004. Stressors, burnout and social support: nurses in acute mental health settings. Journal of Advanced Nursing 48 (6), 622-631], with cancer nursing being identified as a particularly stressful occupation [Hinds, P.S., Sanders, C.B., Srivastava, D.K., Hickey, S., Jayawardene, D., Milligan, M., Olsen, M.S., Puckett, P., Quargnenti, A., Randall, E.A., Tyc, V., 1998. Testing the stress-response sequence model in paediatric oncology nursing. Journal of Advanced Nursing 28 (5), 1146-1157; Barnard, D., Street, A., Love, A.W., 2006. Relationships between stressors, work supports and burnout among cancer nurses. Cancer Nursing 29 (4), 338-345]. Terminologies used to capture this stress are burnout [Pines, A.M., and Aronson, E., 1988. Career Burnout: Causes and Cures. Free Press, New York], compassion stress [Figley, C.R., 1995. Compassion Fatigue. Brunner/Mazel, New York], emotional contagion [Miller, K.I., Stiff, J.B., Ellis, B.H., 1988. Communication and empathy as precursors to burnout among human service workers. Communication Monographs 55 (9), 336-341] or simply the cost of caring (Figley, 1995). However, in the mental health field such as psychology and counselling, there is terminology used to captivate this impact, vicarious traumatisation. Vicarious traumatisation is a process through which the therapist's inner experience is negatively transformed through empathic engagement with client's traumatic material [Pearlman, L.A., Saakvitne, K.W., 1995a. Treating therapists with vicarious traumatization and secondary traumatic stress disorders. In: Figley, C.R. (Ed.), Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. Brunner/Mazel, New York, pp. 150-177]. Trauma not only affects individuals who are primarily present, but also those with whom they discuss their experience. If an individual has been traumatised as a result of a cancer diagnosis and shares this impact with oncology nurses, there could be a risk of vicarious traumatisation in this population. However, although Thompson [2003. Vicarious traumatisation: do we adequately support traumatised staff? The Journal of Cognitive Rehabilitation 24-25] suggests that vicarious traumatisation is a broad term used for workers from any profession, it has not yet been empirically determined if oncology nurses experience vicarious traumatisation. This purpose of this paper is to introduce the concept of vicarious traumatisation and argue that it should be explored in oncology nursing. The review will highlight that empirical research in vicarious traumatisation is largely limited to the mental health professions, with a strong recommendation for the need to empirically determine whether this concept exists in oncology nursing.

'Every pregnant woman needs a midwife'--the experiences of HIV affected women in maternity care

TITLE: 'Every pregnant woman needs a midwife'-the experiences of HIV affected women in Northern Ireland.

OBJECTIVE: to explore HIV positive women's experiences of pregnancy and maternity care, with a focus on their interactions with midwives.

DESIGN: a prospective qualitative study.

SETTING: regional HIV unit in Northern Ireland.

PARTICIPANTS: 22 interviews were conducted with 10 women at different stages of their reproductive trajectories.

FINDINGS: the pervasive presence of HIV related stigma threatened the women's experience of pregnancy and care. The key staff attributes that facilitated a positive experience were knowledge and experience, empathy and understanding of their unique needs and continuity of care.

KEY CONCLUSIONS: pregnancy in the context of HIV, whilst offering a much needed sense of normality, also increases woman's sense of anxiety and vulnerability and therefore the need for supportive interventions that affirm normality is intensified. A maternity team approach, with a focus on providing 'balanced care' could meet all of the woman and child's medical needs, whilst also emphasising the normalcy of pregnancy.

Feasibility and clinical outcomes when using practice guidelines for evaluation of fever in returning travelers and migrants : a validation study.

BACKGROUND: Practice guidelines for examining febrile patients presenting upon returning from the tropics were developed to assist primary care physicians in decision making. Because of the low level of evidence available in this field, there was a need to validate them and assess their feasibility in the context they have been designed for. OBJECTIVES: The objectives of the study were to (1) evaluate physicians' adherence to recommendations; (2) investigate reasons for non-adherence; and (3) ensure good clinical outcome of patients, the ultimate goal being to improve the quality of the guidelines, in particular to tailor them for the needs of the target audience and population. METHODS: Physicians consulting the guidelines on the Internet (www.fevertravel.ch) were invited to participate in the study. Navigation through the decision chart was automatically recorded, including diagnostic tests performed, initial and final diagnoses, and clinical outcomes. The reasons for non-adherence were investigated and qualitative feedback was collected. RESULTS: A total of 539 physician/patient pairs were included in this study. Full adherence to guidelines was observed in 29% of the cases. Figure-specific adherence rate was 54.8%. The main reasons for non-adherence were as follows: no repetition of malaria tests (111/352) and no presumptive antibiotic treatment for febrile diarrhea (64/153) or abdominal pain without leukocytosis (46/101). Overall, 20% of diversions from guidelines were considered reasonable because there was an alternative presumptive diagnosis or the symptoms were mild, which means that the corrected adherence rate per case was 40.6% and corrected adherence per figure was 61.7%. No death was recorded and all complications could be attributed to the underlying illness rather than to adherence to guidelines. CONCLUSIONS: These guidelines proved to be feasible, useful, and leading to good clinical outcomes. Almost one third of physicians strictly adhered to the guidelines. Other physicians used the guidelines not to forget specific diagnoses but finally diverged from the proposed attitudes. These diversions should be scrutinized for further refinement of the guidelines to better fit to physician and patient needs.

Satisfaction des patients du CHUV en 1996-1997

[Table des matières] I. Matériel et méthode. 1. Mode d'administration de l'enquête. 2. Questionnaire. - II. Résultats. - III. Enseignements à tirer et recommandations. 1. Lettres d'accompagnement. 2. Questionnaire enfant. 3. Questionnaire adulte CTR. 4. Questionnaire adulte. 5. Résultats détaillés par question. 6. Représentation graphique des résultats.

Patients who attend a private practice vs a university outpatient clinic: how do they differ?

Although interpersonal continuity is commonly assumed to be essential for care, some patients prefer to attend a university outpatient clinic where physicians change regularly and interpersonal continuity of care is not ensured. The aim of this exploratory study was to evaluate the differences between patients attending a university outpatient clinic and patients frequenting a private practice, explore their patterns of care-seeking and their understanding of continued care. We conducted a cross-sectional study of patients attending the university medical outpatient clinic (OC) in Lausanne, Switzerland and ten randomly selected private general practices (PP). Eligible patients were >30 years, Swiss nationals or long term residents, with one or more chronic conditions and attending the same practice for >3 years. They were asked to complete a questionnaire on sociodemographic data, use of medical resources and reasons for choosing and remaining at the same practice. Semi-structured interviews were conducted with a randomly selected subset of 26 patients to further explore their preferences. 329 patient questionnaires were completed, 219 by PP and 110 by OC patients. OC patients tended to be of lower socioeconomic status than PP patients. The main reason for choosing a PP were personal recommendation, while a higher percentage of patients chose the OC because they could obtain a first appointment quickly. A higher percentage of PP patients accorded importance to physician communication skills and trust, whereas a higher percentage of OC patients favoured investigation facilities. Qualitative data suggested that although OC and PP patients reported different reasons for consulting, their expectations on the medical and relationship level were similar. Our study suggests that the two groups of patients belong to different social backgrounds, have different patterns of care-seeking and attach importance to different aspects of care continuity. However, patients' expectations and perceptions of the physician-patient relationship are similar.

L’anomie pharmaco-médicale. Compte-rendu de La prise de décision en éthique clinique : Perspectives micro, méso et macro, sous la direction de Yanick Farmer, Marie-Ève Bouthilier et Delphine Roigt

Compte-rendu / Review

Perspective maternelle de la consultation anténatale pour travail préterme : une approche relationnelle

Une femme à risque d’un accouchement prématuré vit un enjeu de santé très éprouvant et stressant ; elle sera souvent hospitalisée pour recevoir des traitements médicaux visant à prolonger la grossesse et améliorer le pronostic du bébé. Dans ce contexte, une consultation avec un néonatalogiste est demandée. Plusieurs associations professionnelles médicales ont émis des lignes directrices sur cette consultation, insistant sur le besoin d’informer les parents au sujet des complications potentielles de la prématurité pour leur enfant. Ces recommandations s’inspirent du point de vue médical, et très peu d’études ont examiné la perspective, les attentes et les besoins des parents à risque d’un accouchement prématuré. Ce projet de thèse a pour objectif de proposer un modèle de relation médecin-patient informé de la perspective maternelle de la consultation anténatale, pour développer une approche clinique répondant à leurs besoins. Afin d’examiner cette problématique de façon complète, un travail constant de va-et-vient a été effectué entre la recension de données empiriques et une réflexion normative bioéthique féministe. Un projet de recherche empirique a d’abord permis d’explorer les attentes et le vécu de ces femmes. Les participantes espéraient recevoir plus que de l’information sur les complications de la prématurité. Elles souhaitaient que le néonatologiste soit attentif à leur situation particulière et qu’il développe une relation de confiance avec elles, leur permettant d’explorer leurs futurs rôles de mères et les encourageant à formuler leurs propres questions. Le cadre théorique féministe d’autonomie relationnelle a ensuite permis de proposer une approche de soin qui sache répondre aux besoins identifiés par les patientes, tout en adressant des enjeux de pouvoir intrinsèques à la clinique, qui influencent la santé et l’autonomie de ces femmes. Cette approche insiste sur l’importance de la relation de soin en clinique, contrastant avec un modèle encourageant une vision réductrice de l’autonomie, dans laquelle un simple transfert de données scientifiques serait équivalent au respect de la norme médicolégale du consentement éclairé. Ce modèle relationnel propose des actions concrètes et pratiques, encourageant les cliniciens à entrer en relation avec chaque patiente et à considérer l’influence qu’ils exercent sur l’autonomie relationnelle de leurs patientes.

Hur patienter med diagnosen HIV upplever bemötandet inom sjukvården : en litteraturöversikt

Syfte: Syftet med denna studie var att beskriva hur personer med HIV upplevde bemötandet inom vården i I-länder. Metod: Studien genomfördes som en litteraturöversikt. Artikelsökningarna gjordes i databaserna Cinahl och Pubmed. Både kvalitativa och kvantitativa studier hittades men författarna har enbart använt sig av de kvalitativa studierna (n=11). Studierna granskades sedan med modifierade granskningsmallar för kvalitetsbedömning. Resultat: De funna studiernas resultat granskades och utifrån detta identifierade författarna fyra teman; Att hållas på avstånd, Att bli annorlunda bemött, Att få en stämpel och Positivt bemötande. Resultatet visade att vårdpersonalen höll avstånd från patienter genom att använda sig av överdrivna hygienrutiner, och i vissa fall förekom det att patienterna blev nekade vård på grund av sin HIV diagnos. Att bli annorlunda bemött handlade i många fall om att patienterna blev utsatta för kränkande behandling. Flera patienter beskrev hur de upplevde att personalen kategoriserade dem och gav dem en stämpel på grund av sin diagnos. De upplevde även att vårdpersonalen offentliggjorde deras diagnos genom att bryta mot sekretessen. Resultatet visade att patienter upplevt positivt bemötande och att vårdpersonalen gett dem stöd. Litteraturöversikten visade också att flera patienter föredrog att söka vård på specialistkliniker. Slutsats: Många patienter kände sig kränkta och annorlunda bemötta i möte med sjukvårdspersonal. De föredrog att söka vård på speciella HIV kliniker eftersom de kände att personalen där hade bättre förståelse för sjukdomen.

A sinalização do enfermeiro entre os papéis de familiares visitantes e acompanhante de adulto e idoso

Trata-se de um estudo qualitativo, utilizando-se, como referencial teórico, o Interacionismo Simbólico e, como referencial metodológico, a Grounded Theory, visando: compreender a experiência interacional de familiares visitantes e acompanhantes de adultos e idosos hospitalizados, há mais de sete dias, em um Hospital Universitário de grande porte do Estado de São Paulo, e desenvolver um modelo teórico representativo dessa experiência. As estratégias para obtenção dos dados foram a observação e a entrevista. Dos resultados, emergiram dois fenômenos: vivendo a expectativa pela internação no Hospital Universitário e assumindo o papel de familiar visitante ou de familiar acompanhante. A compreensão da experiência nos permitiu ampliar o conhecimento, referente ao movimento que eles empreenderam na vivência denominada como movendo-se perante a sinalização do enfermeiro entre os papéis de familiar visitante e familiar acompanhante: compartilhando uma experiência de poucos prazeres em solidariedade ao adulto e ao idoso hospitalizados.

A importância da comunicação durante o período de recuperação pós-operatória

Este estudo teve como objetivo conhecer a importância da comunicação durante as orientações pós-operatórias fornecidas pela equipe de enfermagem a pacientes e/ou familiares de uma instituição privada e apreender a percepção destes indivíduos acerca das orientações recebidas. Foi um estudo transversal, descritivo, com abordagem qualitativa, que utilizou o referencial teórico da Comunicação Interpessoal e o referencial metodológico da Análise de Conteúdo. Participaram do estudo 16 pacientes entrevistados no período pós-operatório mediato. Os resultados evidenciaram que a equipe de enfermagem focaliza as orientações nas técnicas instrumentais da profissão, não abordando o indivíduo de forma holística. Também foi possível perceber que, quando o profissional enfermeiro permanece afastado do paciente e/ou não presta informações adequadas gera sentimentos de ansiedade, medo, insegurança e sensação de falta de cuidado. Por outro lado, quando a equipe de enfermagem se fez presente com cuidado e informações coerentes, os clientes relataram um alto nível de satisfação e a sensação de ser bem cuidado.

Caring for organ donors: The intensive care unit nurses' view

The nursing care for patients who are pronounced brain-dead but kept alive to serve as organ donors demands technical-scientific skills and the ability to handle situations that are often in conflict with the traditional concepts of nursing care. Based on the phenomenological approach in this article, essential themes of the lived experience of caring for these patients, including the technical and specific nursing care, the relationship with organ donors and their families, and the nurses' perception of themselves in this professional situation are described. The results point to the contradictions and ambiguities of this type of nursing, especially in regards to the affective and philosophical aspects.

Behavioral evaluation during dental care in children ages 0 to 3 years

Purpose: Many studies concluded that the behavior of babies complicated dental care because of child immaturity or the difficulty of establishing acceptable communication and comprehension. Methods: The records of 696 babies were randomly selected from the baby clinic of Araçatuba in Brazil. Patient age ranged from 0 to 36 months. They were divided into 6 groups according to age: Group I-0 to 6 months; Group II-7 to 12 months; Group III-13 to 18 months; Group IV-19 to 24 months; Group V-25 to 30 months; Group VI-31 to 36 months. The behavior of the child was evaluated upon entrance in the dental office and during the first 4 clinical appointments with a clinical exam and oral physiotherapy. The baby was classified as collaborator (C) or noncollaborator (NC). Statistical analysis was performed using Pearson's chi-square method (P< .05). Results: The percentage of NC for Groups II, III, IV, and V (66%), was significantly higher than for groups I (30%) and VI (50%). Conclusions: Babies from 0 to 6 months showed a collaborative behavior; babies from 7 to 30 months showed noncollaborative behavior; and babies from 31 to 36 months showed no statistically significant difference between the percentage of C and NC.