Luciana Bento

Conheça os fundamentos dos Cuidados Paliativos

Durante uma aula sobre aspectos éticos, na pós-graduação em Unidade de Terapia Intensiva (UTI), os alunos iniciaram uma discussão com opiniões muito divergentes a respeito desse tema.

Mesmo com os avanços da medicina para o tratamento de pacientes críticos e da tecnologia moderna disponível, muitas vezes o profissional da Unidade de Terapia Intensiva é obrigado a adotar os cuidados paliativos, principalmente quando todas as possibilidades terapêuticas foram aplicadas sem sucesso e a evolução é rodeada de dor e sofrimento.

E isso representa uma dificuldade a ser enfrentada, uma vez que na formação do enfermeiro existe uma lacuna em relação aos cuidados prestados à pacientes fora da possibilidade terapêutica e ao tema luto e fim da vida.

A distanásia, conceituada como a morte lenta, sofrida, aliada a uma “obstinação terapêutica” representa, ainda, a maior parte do cenário das unidades de atendimento ao paciente crítico.

Definição

Cuidados Paliativos, segundo a Organização Mundial da Saúde (OMS), 2002, consistem na “assistência promovida por uma equipe multidisciplinar, que objetiva a melhoria da qualidade de vida do paciente e seus familiares, diante de uma doença que ameace a vida, por meio da prevenção e alívio do sofrimento, da identificação precoce, avaliação impecável e tratamento de dor e demais sintomas físicos, sociais, psicológicos e espirituais”.

O foco do cuidado paliativo deve ser as necessidades do paciente e seus familiares. Os cuidados devem ser realizados por todos os profissionais da equipe multidisciplinar, cada um com a sua importância, já que o objetivo é diminuir o sofrimento.

Para isso, o paciente deverá ter sua dor amenizada, seu bem-estar priorizado e suas crenças consideradas, a fim de que possa aceitar sua condição como um processo natural da finitude, e as ações terapêuticas devem ser planejadas com a participação de todos os envolvidos: paciente, família e equipe. (Barros et al)

E a equipe de enfermagem com as suas ações, além de ter papel importante nos cuidados paliativos, respeita o fundamento do Código de Ética de Enfermagem que diz: “o profissional de enfermagem respeita a vida, a dignidade e os direitos humanos, em todas as suas dimensões”.

Pré-requisitos no processo decisório por cuidados paliativos em UTI (Laselva e Junior)

  • A decisão de iniciar os cuidados paliativos em UTI é um processo que envolve o paciente, a família e a equipe. Para que o enfermeiro atue na orientação e suporte técnico, ele deve estar seguro e conhecer os regulamentos da instituição no processo de decisão por cuidados paliativos, bem como, deve contar com o auxílio do Comitê de Ética do hospital
  • A bioética tem como ponto fundamental “o equilíbrio entre o humano e o técnico, diante dos problemas éticos, decorrentes dos avanços tecnológicos na área da saúde”
  • No ambiente da UTI, as pessoas ficam mais vulneráveis e sensibilizadas diante da pressão que envolve a tomada de decisão. Questões como capacidade de julgamento, crenças, juízos de valor devem ser baseadas nos aspectos: comunicação direta, clareza das informações fornecidas e certeza das intenções.

Escolha por cuidados paliativos – medidas de suporte de vida

Segundo o manual Critérios de Qualidade para os Cuidados Paliativos no Brasil elaborado pela Academia Nacional de Cuidados Paliativos, os pacientes se caracterizam por um padrão de múltiplas necessidades e alta demanda, de acordo com a natureza da doença de base e apresentam como perfil:

  • Enfermidade avançada e progressiva
  • Poucas possibilidades de resposta à terapêutica curativa
  • Evolução clínica oscilante, caracterizada pelo surgimento de várias crises de necessidades
  • Grande impacto emocional para o doente e sua família
  • Impacto social para o doente e sua família
  • Prognóstico de vida limitado
  • Necessidade de adequação terapêutica

Princípios fundamentais do cuidado paliativo na UTI (Moritz et al)

  • Aceitar a morte como um processo natural do fim da vida
  • Priorizar sempre o melhor interesse do paciente
  • Repudiar futilidades: diagnóstica e terapêutica
  • Não encurtar a vida nem prolongar o processo de morte
  • Garantir a qualidade da vida e do morrer
  • Aliviar a dor e outros sintomas associados
  • Cuidar dos aspectos clínicos, psicológicos, sociais, espirituais dos pacientes e de seus familiares
  • Respeitar a autonomia do doente e de seus representantes legais
  • Avaliar o custo-benefício a cada atitude médica assumida
  • Estimular a interdisciplinaridade como prática assistencial

Existe um imenso desgaste emocional da equipe que conduz o tratamento desse tipo de paciente. Portanto, essa equipe deve ser preparada para oferecer a assistência adequada e, também, deve ser vista como objeto de atenção, principalmente no que diz respeito a oferta de apoio psicológico com oportunidade de discutir questões conflitantes, sentimentos vivenciados.

Algumas ações no cuidado paliativo

  • Realizar o diagnóstico de enfermagem de acordo com as necessidades
  • Planejar ações de enfermagem segundo a prioridade do paciente e avaliar os resultados
  • Avaliar a dor e os sintomas que causam sofrimento e oferecer a terapêutica necessária
  • Administrar medidas de tratamento farmacológico e não-farmacológico
  • Encorajar o paciente a enfrentar a situação de doença
  • Esclarecer as opções de cuidados a serem implementados e suas possíveis consequências
  • Solicitar consentimento para qualquer manobra ou procedimento
  • Realizar cuidados básicos de higiene e conforto, alimentação, eliminação
  • Prevenir complicações e situações de risco, e evitar danos previsíveis decorrentes do estado de doença
  • Agregar apoio espiritual na assistência ao paciente
  • Apoiar os familiares para fortalecê-los a suportar a doença e se prepararem para o luto
  • Criar um ambiente favorável a comunicação
  • Permitir a presença de amigos e familiares, sempre que possível

A reflexão sobre a prática vivenciada e os valores considerados na escolha das terapêuticas utilizadas é fundamental na medida em que possibilita mudanças na maneira de atender esses pacientes.

Segundo Carvalho e Lunardi, “não implementar tratamentos de cura não significa deixar o paciente morrer, mas, sim, aceitar o processo de morte, que não tem como ser evitado”.

O foco da assistência deve ser a manutenção da qualidade de vida, (diminuição da dor e do sofrimento emocional) e o atendimento aos desejos do paciente, permitindo maior proximidade com familiares e amigos.

Referências

  • Barros et al. Cuidados paliativos na UTI: compreensão, limites e possibilidades por enfermeiros. Ver. Enferm. UFSM, 2012, Set/Dez;2(3):630-640
  • Critérios de qualidade para os cuidados paliativos no Brasil / documento elaborado pela Academia Nacional de Cuidados Paliativos; Maria Goretti Sales Maciel… [et al.]. – Rio de Janeiro: Diagraphic, 2006 60p.
  • Moritz et al. Terminalidade e cuidados paliativos na unidade de terapia intensiva. Rev. bras. ter. intensiva vol.20 no.4 São Paulo Oct./Dec. 2008.
  • Knobel E, Junior DFM, Laselva CR. Terapia Intensiva: enfermagem. São Paulo: Editora Atheneu, 2009.

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Prof. Dra. Elizabeth Galvão

Doutora em Ciências (EEUSP), pós-graduada em Administração Hospitalar (UNAERP) e Saúde do Adulto Institucionalizado (EEUSP), especialista em Terapia Intensiva (SOBETI) e em Gerenciamento em Enfermagem (SOBRAGEN). É professora titular da Universidade Paulista no Curso de Enfermagem, e professora do Programa de Especialização Lato-sensu em Enfermagem em Terapia Intensiva e Enfermagem do Trabalho na Universidade Paulista.

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