Объектом исследования явилось отношение к смерти. Предметом исследования – связь отношения к смерти с личностными характеристиками и смысложизненными ориентациями людей разного возраста. Магистерская диссертация состоит из введения, двух глав, заключения, списка литературы (60 источников) и приложений, включающих в себя бланки применявшихся методик, а также результаты описательной статистики Объем магистерской диссертации 87 страниц, на которых размещены 2 рисунка и 12 таблиц. Во введении раскрывается актуальность проблемы исследования, разработанность проблематики, ставятся цель и задачи исследования, определяются объект и предмет исследования, формулируются основная и дополнительные гипотезы, указываются методы и эмпирическая база, а также этапы проведения исследования, научная новизна, теоретическая и практическая значимость работы. Первый раздел включает в себя обзор иностранной и отечественной литературы по теме отношения к смерти. Представлены разделы, посвященные отношению к смерти в разные возрастные периоды, а также подходы к понятиям личностные характеристики и смысложизненных ориентации. Выводы по первому разделу представляют собой итоги по изучению теоретического материала. Второй раздел посвящен эмпирической части исследования. В ней представлено описание организации и методов проведенного исследования и результатов, полученных по всем использованным методикам: 1. Пятифакторный личностный опросник» Р. МакКрае – П. Коста. 2. Опросник «Профиль аттитьюдов по отношению к смерти – переработанный» (DAP-R) П. Т. П. Вонга, Г. Т. Рикера и Дж. Гессера. 3. Тест «Отношение к смерти И. Ю. Кулагиной и Л. В. Сенкевич. 4. Тест смысложизненных ориентаций Д. А. Леонтьева. Также в главе представлен корреляционный анализ результатов исследования. Выводы по разделу 2 включают в себя основные результаты эмпирического исследования. В заключении в обобщенном виде изложены результаты теоретической и эмпирической частей работы, а также выводы по выдвинутым гипотезам, обоснована практическая значимость исследования и описаны возможные перспективы дальнейшей разработки данной проблематики. / The object of the study was the attitude to death. The subject of the study is the relationship of attitudes to death with personal characteristics and life–meaning orientations of people of different ages. The master's thesis consists of an introduction, two chapters, a conclusion, a list of references (60 sources) and appendices, including forms of the methods used, as well as the results of descriptive statistics. The volume of the master's thesis is 87pages, which contain 2 figures and 12 tables. The introduction reveals the relevance of the research problem, the elaboration of the problem, sets the purpose and objectives of the study, defines the object and subject of the study, formulates the main and additional hypotheses, specifies the methods and empirical base, as well as the stages of research, scientific novelty, theoretical and practical significance of the work. The first section includes a review of foreign and domestic literature on the topic of attitudes to death. The sections devoted to the attitude to death in different age periods, as well as approaches to the concepts of personal characteristics and life orientations are presented. The conclusions of the first section are the results of the study of theoretical material. The second section is devoted to the empirical part of the study. It provides a description of the organization and methods of the study and the results obtained by all the methods used: 1. Five-factor personality questionnaire" R. McCrae – P. Costa. 2. Questionnaire "Attitudes profile in relation to death – revised" (DAP-R) by P. T. P. Wong, G. T. Riker and J. Gessera. 3. Test "Attitude to the death of I. Y. Kulagina and L. V. Senkevich. 4. Test of life orientations by D. A. Leontiev. The chapter also presents a correlation analysis of the results of the study. The conclusions of section 2 include the main results of the empirical study. In conclusion, the results of the theoretical and empirical parts of the work are summarized, as well as conclusions on the hypotheses put forward, the practical significance of the study is substantiated and possible prospects for further development of this problem are described.

No / Palliative care in the UK has been developed to meet the needs of predominantly middle aged and younger old people with cancer. Few data are available regarding the extent to which services respond to the specific needs of an older group of people with other illnesses. This paper draws on in-depth interviews conducted with 40 people (median age 77) with advanced heart failure and poor prognosis to explore the extent to which older people's views and concerns about dying are consistent with the prevalent model of the 'good death' underpinning palliative care delivery. That prevalent model is identified as the "revivalist" good death. Our findings indicate that older people's views of a 'good death' often conflict with the values upon which palliative care is predicated. For example, in line with previous research, many participants did not want an open awareness of death preceded by acknowledgement of the potential imminence of dying. Similarly, concepts of autonomy and individuality appeared alien to most. Indeed, whilst there was evidence that palliative care could help improve the end of life experiences of older people, for example in initiating discussions around death and dying, the translation of other aspects of specialist palliative care philosophy appear more problematic. Ultimately, the study identified that improving the end of life experiences of older people must involve addressing the problematised nature of ageing and old age within contemporary society, whilst recognising the cohort and cultural effects that influence attitudes to death and dying.

No / Prognosis in COPD is poor and many patients perceive shortcomings in the education they receive about aspects of their condition. This study explores the experiences of patients with COPD, particularly fears surrounding death and dying. Semi-structured interviews were conducted with 21 patients with moderate or severe COPD. Findings revealed that patient understanding of COPD was poor, most patients were unaware of the progressive nature of the condition, and few were aware they could die of COPD. Despite this, patients often expressed concerns that their condition might deteriorate. Patients had particular concerns regarding the manner of their death; the overriding fear was dying of breathlessness or suffocation. None of the patients' had discussed these fears with a health care professional. Improved patient education is needed in order to improve patients understanding of their condition and prognosis. Open communication regarding death, as advocated in a palliative care approach, is also appropriate to alleviate patients fears and to allow them to make decisions regarding the management of their care at the end of life.

No / The current systems of care for dying persons, the people caring for them, and the bereaved operate in ways that frequently lack sufficient sensitivity to their needs. We describe a new model for dying, death, and loss that adopts a public health approach. Specifically, we describe a deliberative process that resulted in a charter for a public health approach to dying, death, and loss. Modeled after the World Health Organization's 1986 Ottawa Charter, our charter includes a call to action. It has the potential to bring about significant change on local, societal, and global levels as exemplified by four projects from three countries. Public health and end-of-life services and organizations need to form partnerships with the community to develop a public health approach to dying, death, and loss. Learning from each other, they will affirm and enhance community beliefs and practices that make death part of life.

研究背景: 居住於安老院舍的長者通常患有多種不可逆轉的慢性疾病或未期病症。相對其他組群，他們將更快面對臨終與死亡的問題。因此，了解他們對「臨終問題」的態度、臨終地方的選擇意向及其預測因素是非常重要的。研究所得資將有助提供優質的“善終“服務予這群弱勢的長者。 / 研究目的: 本研究旨在探討有關居於香港安老院舍的長者對「臨終問題」的態度、臨終地方的選擇意向、是否視安老院舍如同自己的家及其預測因素。 / 研究方法: 本研究採用橫斷面量性研究的方法，以便利抽樣方式在香港不同地區的安老院舍進行研究。研究對象為年齡65歲或以上，及簡短智能測試達6分或以上，並能以廣東話溝通的安老院舍長者。研究採用結構性問卷以面對面訪談形式進行，作者把「對臨終問題的態度調查問卷」翻譯成中文版本用作調查長者對臨終問題的態度。並採用EQ-5D和Barthel Index (20) 以評估長者的自我健康評估及日常生活自我照顧能的狀況。調查問卷亦包括探討長者對安老院視為自己的家的看法和死亡地點的選擇。收集之數據採用了二分類邏輯回歸進行各因素與結果變量之間的單因關聯分析，那些p值<0.25的因素被選定為候選自變量，然後利用逐步多因素邏輯回歸分析來劃定結果變量的獨立相關因素。 / 研究結果: 合共317名來自20間安老院舍的長者參與了此項研究，包括248名女性(78.2%)和69名男性(21.8%)，年齡介乎65至99歲，平均年齡為84歲(標準差6.6)。多因素分析顯示多種預測因素與「臨終問題」的態度有著相關性；對於有家庭財政支持的長者來說，他們較傾向不同意由醫生作出所有有關照顧上的決定；有接受教育和患有較多慢性病的長者較傾向同意訂立預前指示；那些在安老院舍居住時間較長的長者較傾向不同意使用藥物讓他們可以隨時選擇結束生命；但患有糖尿病者較傾向同意安樂死；有宗教信仰者較傾向同意靈性或宗教的支持對他們是重要的。此外，310名安老院舍長者(97.8%)認為安老院舍如同自己的家。有261名長者 (68.1%) 表示希望在目前的安老院去世。那些認為安老院舍如同自己的家、有獨立經濟支持、及同意安樂死的院舍長者，較傾向希望在目前的安老院去世。 / 研究結論: 本研究譂述了居於香港安老院舍的長者對「臨終問題」的態度及其相關因素的實證結果。研究發現幾乎所有安老院舍的長者視安老院舍如同自己的家，明顯地相當多的長者表示如果條件允許下，希望在目前的安老院舍去世。這種強烈的聲音指出我們需要發展院舍的臨終照顧以滿足院舍長者的需要及期望。而從獲悉長者對「臨終問題」的態度及臨終地方的選擇意向，可讓醫護專業人員在安老院舍裡更有效地規劃臨終照顧服務，並能讓長者善終與好死。 / Background: Older people living in residential care homes for the elderly (RCHEs) have high incidences of irreversible chronic illnesses and terminal diseases. They are the most significant group facing impending death and dying. It is vital to understand their attitudes toward end of life (EOL) issues and their preference for EOL care in order to promote their quality of life. / Objective: This study aims to examine the attitudes toward EOL issues, the preference for place of death, the perception of RCHE as a resident’s own home and their predictors amongst older RCHE residents in Hong Kong. / Method: A cross-sectional quantitative study with convenience sampling was conducted in RCHE in different regions of Hong Kong. RCHE residents aged ≥65 achieving abbreviated mental test score ≥6 and who were able to communicate in Cantonese were recruited. Face-to-face interviews were conducted with the aid of a structured questionnaire. Demographic and clinical characteristics were collected. Health and functional status were measured by Euroqol-5D and Barthel Index (20). The “Attitudes of older people to end of life issues questionnaire“ was translated from the English version into a Chinese version and employed to examine the attitudes toward EOL issues. The perception of RCHE as own home and the preference for place of death were examined. Univariate analysis on the association between the outcome variables was performed. Factors with a p value <0.25 in univariate analyses were selected for multivariable logistic regression to delineate factors independently associated with the outcome. / Results: A total of 317 participants including 248 (78.2%) women and 69 (21.8%) men from 20 RCHE participated in the study. Their mean age was 84 ± 6.6 (mean ± SD). As showed in multivariate analysis, respondents financially supported by their family were less likely to allow doctors to make all the decisions about their care. Those respondents with higher number of morbidities and had higher education were more likely to agree with making a living will. Those who lived longer in RCHE were less likely to agree to having a drug at their disposal to end their life. Respondents with diabetic mellitus were more likely to agree with euthanasia. Respondents who followed a religion were more likely to agree on the importance of spiritual or religious support. Furthermore, 310 (97.8%) respondents perceived RCHE as their own home. Two hundred and sixteen (68.1%) residents wished to die in their present RCHE. Residents with the means to support themselves financially, agreed with euthanasia and who perceived RCHE as their own home were more likely to wish to die in RCHEs. / Conclusion: Nearly all residents perceived RCHEs as their own home and a significant proportion wished to die there if conditions allowed. This asserts that EOL care in RCHE should be developed to meet the wishes of the older residents. This study delineated significant factors associated with the attitudes of older people toward EOL issues. Knowing those factors allows health care professionals to plan for quality EOL care services in RCHEs more effectively and foster good death for this vulnerable population. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Law, Po Ka. / Thesis (D.Nurs.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 160-173). / Abstracts also in Chinese; appendixes includes Chinese. / Chapter 1. --- CHAPTER ONE: INTRODUCTION AND BACKGROUND / Chapter 1.1 --- Introduction --- p.1 / Chapter 1.2 --- Epidemiology data of ageing in Hong Kong --- p.3 / Chapter 1.3 --- Impact of ageing population --- p.4 / Chapter 1.4 --- Residential care services in Hong Kong --- p.5 / Chapter 1.5 --- Quality of residential care homes for the elderly (RCHEs) in Hong Kong --- p.7 / Chapter 1.6 --- Definition of end of life care, palliative care and hospice care --- p.9 / Chapter 1.7 --- End of life care in residential care homes in Hong Kong --- p.11 / Chapter 1.8 --- Dying in place --- p.14 / Chapter 1.9 --- Perception of RCHEs as own home --- p.15 / Chapter 1.10 --- Factors influencing attitudes to end of life issues --- p.15 / Chapter 1.11 --- The proposed framework --- p.18 / Chapter 1.12 --- Aim of the study --- p.20 / Chapter 1.13 --- Operational definitions of key terms --- p.20 / Chapter 1.14 --- Significance of the study and its impact on the society and future service development --- p.22 / Chapter 1.15 --- Overview of each chapter of the thesis --- p.24 / Chapter 2. --- CHAPTER TWO: LITERATURE REVIEW / Chapter 2.1 --- Introduction --- p.25 / Chapter 2.2 --- Literature search --- p.26 / Chapter 2.3 --- Search results --- p.27 / Chapter 2.4 --- Unmet need for end of life care in RCHEs in Hong Kong --- p.28 / Chapter 2.5 --- EOL care in RCHEs of other Western and Asian countries --- p.33 / Chapter 2.6 --- Preference for place of death --- p.34 / Chapter 2.7 --- Attitudes toward end of life issues --- p.38 / Chapter 2.8 --- Factors affecting older residents when choosing to die in RCHEs --- p.41 / Chapter 2.9 --- Barriers to EOL care in RCHEs --- p.43 / Chapter 2.10 --- Conclusion --- p.45 / Chapter 3. --- CHAPTER THREE: RESEARCH DESIGN AND METHOD / Chapter 3.1 --- Introduction --- p.47 / Chapter 3.2 --- Aim of the study --- p.47 / Chapter 3.3 --- Objectives of the study --- p.47 / Chapter 3.4 --- Research questions --- p.48 / Chapter 3.5 --- Research design --- p.50 / Chapter 3.6 --- Sample size --- p.51 / Chapter 3.7 --- Study setting --- p.52 / Chapter 3.8 --- Sampling method --- p.52 / Chapter 3.9 --- Data collection --- p.54 / Chapter 3.10 --- Study instruments --- p.55 / Chapter 3.11 --- Translation process for the AEOLI questionnaire --- p.60 / Chapter 3.11.1 --- Establishing the semantic equivalence --- p.64 / Chapter 3.11.2 --- Establishing the content and face validity --- p.66 / Chapter 3.12 --- Pilot study --- p.67 / Chapter 3.12.1 --- Testing the feasibility --- p.67 / Chapter 3.12.2 --- Test-retest --- p.68 / Chapter 3.13 --- Data cleaning --- p.70 / Chapter 3.14 --- Data analysis --- p.70 / Chapter 3.15 --- issues and consent Ethical --- p.72 / Chapter 4. --- CHPATER FOUR: RESULTS / Chapter 4.1 --- Introduction --- p.74 / Chapter 4.2 --- Recruitment of participants --- p.74 / Chapter 4.3 --- Characteristics of the study sample / Chapter 4.3.1 --- Socio-demographic characteristics --- p.76 / Chapter 4.3.2 --- Clinical characteristics --- p.79 / Chapter 4.3.3 --- Functional and health status --- p.81 / Chapter 4.4 --- Descriptive statistics of AEOLI-C, preference for place of death and perception of RCHEs as residents’ own home / Chapter 4.4.1 --- Descriptive statistics of AEOLI-C --- p.83 / Chapter 4.4.1.1 --- Decision making (Attitude 1) --- p.83 / Chapter 4.4.1.2 --- Pain (Attitude 5, 9, 20) --- p.83 / Chapter 4.4.1.3 --- Care environment (Attitude 3, 6, 10, 15, 27) --- p.84 / Chapter 4.4.1.4 --- Living wills (Attitude 8, 14, 19, 24) --- p.84 / Chapter 4.4.1.5 --- Euthanasia / Physician assisted suicide (Attitude 4, 17, 18, 26) --- p.85 / Chapter 4.4.1.6 --- Ageism (Attitude 13, 16, 23) --- p.85 / Chapter 4.4.1.7 --- Psychological needs including religious/spiritual (Attitude 11, 25) --- p.85 / Chapter 4.4.1.8 --- Quality versus quantity of life (Attitude 2, 7, 21, 22) --- p.85 / Chapter 4.4.1.9 --- Societal awareness (Attitude 12) --- p.86 / Chapter 4.4.2 --- Descriptive statistics of the perception of RCHEs as residents’ own home --- p.86 / Chapter 4.4.3 --- Descriptive statistics of the preference for place of death --- p.86 / Chapter 4.5 --- Correlational and logistic regression results / Chapter 4.5.1 --- Correlational and regression results of the predictive factors associated with AEOLI-C --- p.89 / Chapter 4.5.1.1 --- Decision making (Attitude 1) --- p.89 / Chapter 4.5.1.2 --- Pain (Attitude 5, 9, 20) --- p.90 / Chapter 4.5.1.3 --- Care environment (Attitude 3, 6, 10, 15, 27) --- p.91 / Chapter 4.5.1.4 --- Living wills (Attitude 8, 14, 19, 24) --- p.93 / Chapter 4.5.1.5 --- Euthanasia / Physician assisted suicide (Attitude 4, 17, 18, 26) --- p.95 / Chapter 4.5.1.6 --- Ageism (Attitude 13, 16, 23) --- p.97 / Chapter 4.5.1.7 --- Psychological needs including religious/spiritual (Attitude 11, 25) --- p.99 / Chapter 4.5.1.8 --- Quality versus quantity of life (Attitude 2, 7, 21, 22) --- p.100 / Chapter 4.5.1.9 --- Societal awareness (Attitude 12) --- p.101 / Chapter 4.5.2 --- Correlational and regression results of the predictive factors associated with the perception of RCHEs as residents’ own home --- p.104 / Chapter 4.5.2.1 --- Relationship with socio-demographic characteristics, clinical characteristics, health and functional status --- p.104 / Chapter 4.5.2.2 --- Relationship with AEOLI-C --- p.108 / Chapter 4.5.3 --- Correlational and regression results of the predictive factors associated with preference for place of death --- p.110 / Chapter 4.5.3.1 --- Relationship with socio-demographic characteristics, clinical characteristics, functional and health status --- p.110 / Chapter 4.5.3.2 --- Relationship with AEOLI-C --- p.114 / Chapter 4.6. --- Summary of the results --- p.116 / Chapter 5. --- CHAPTER FIVE: DISCUSSION / Chapter 5.1 --- Introduction --- p.117 / Chapter 5.2 --- Characteristic of the participants --- p.118 / Chapter 5.3 --- The attitudes toward end of life issues --- p.120 / Chapter 5.3.1 --- Decision making (Attitude 1) --- p.121 / Chapter 5.3.2 --- Pain (Attitude 5, 9, 20) --- p.123 / Chapter 5.3.3 --- Care environment (Attitude 3, 6, 10, 15, 27) --- p.125 / Chapter 5.3.4 --- Living wills (Attitude 8, 14, 19, 24) --- p.128 / Chapter 5.3.5 --- Euthanasia / Physician assisted suicide (Attitude 4, 17, 18, 26) --- p.131 / Chapter 5.3.6 --- Ageism (Attitude 13, 16, 23) --- p.133 / Chapter 5.3.7 --- Psychological needs including religious/spiritual (Attitude 11, 25) --- p.135 / Chapter 5.3.8 --- Quality versus quantity of life (Attitude 2, 7, 21, 22) --- p.136 / Chapter 5.3.9 --- Societal awareness (Attitude 12) --- p.137 / Chapter 5.4 --- The perception of RCHEs as residents’ own home --- p.138 / Chapter 5.5 --- The preference for place of death --- p.140 / Chapter 5.6 --- Summary --- p.143 / Chapter 6. --- CHAPTER SIX: CONCLUSION / Chapter 6.1. --- Introduction --- p.145 / Chapter 6.2 --- Limitations of the study --- p.145 / Chapter 6.2.1 --- Generalization of the results --- p.145 / Chapter 6.2.2 --- Lack of theoretical construct of the translated questionnaire --- p.147 / Chapter 6.2.3 --- Limitations of quantitative study and cross-sectional design --- p.149 / Chapter 6.3 --- Contributions of the study --- p.150 / Chapter 6.4 --- Recommendations and implications to nursing practice --- p.152 / Chapter 6.5 --- Implications to the EOL Care Practice in Residential Care Setting --- p.154 / Chapter 6.6 --- Implications to residential care policy --- p.155 / Chapter 6.7 --- Recommendations for further studies --- p.156 / Chapter 6.8 --- Conclusion --- p.158 / Chapter 7. --- REFERENCES --- p.160 / Chapter 8. --- APPENDICES --- p.174

Objetivos: Este estudo investigou as associações entre características dos médicos e a variabilidade de condutas em fim de vida em UTI. Métodos: Um questionário foi aplicado aos médicos das 11 UTIs do HC-FMUSP, apresentando dois casos clínicos. O primeiro apresentava uma paciente em estado vegetativo persistente, sem familiares ou diretivas antecipadas de vontade, com um choque séptico. O segundo, uma paciente de 88 anos, com disfunção de múltiplos órgãos decorrente de uma pneumonia. Investigou-se através do questionário a associação entre condutas e características pessoais, profissionais e educacionais dos médicos. Resultados: Foram analisados 105 questionários (taxa de resposta 89%). A media de idade foi de 38±8 anos, com 14±7 anos de graduação em medicina. A maioria das decisões envolveu exclusivamente médicos (66%), 21% envolveram também enfermeiros. Na análise multivariada, especialistas em Medicina Intensiva (17/22 vs. 46/83, OR=0,205[0,058-0,716], P=0,013) e médicos mais jovens (38±7 vs. 40±8; OR=0,926[0,858-0,998], P=0,045) mais frequentemente envolveram enfermeiros no processo de decisão. Ordem de não reanimação (ONR) foi estabelecida por 89% dos participantes, sendo 44% exclusivamente verbais. Médicos que atribuíram a si mesmo notas mais altas em relação ao conhecimento sobre cuidados paliativos mais frequentemente estabeleceriam uma ONR na análise multivariada (6±2 vs. 3±2, OR=2,167[1,062-4,420], P=0,034). A maior parte dos participantes (60%) respondeu que limitaria de alguma forma o suporte artificial de vida (SAV) para a primeira paciente, enquanto 21% respondeu que não limitaria nenhum suporte e 19% retiraria o SAV. Na análise de regressão logística, o interesse em discutir sobre fim de vida em UTI permaneceu como variável de associação independente para retirada ou limitação de SAV (20/20 vs. 61/63 vs. 17/22, OR=0,129[0,019-0,894], P=0,038). Quarenta e seis dos 105 médicos avaliados (44%) apresentavam respostas discordantes para as questões sobre a conduta mais provável e a conduta acreditada como a melhor para a primeira paciente. Dentre estes, 45 (98%) acreditavam que a melhor conduta envolveria o uso de menos SAV do que provavelmente fariam. Motivos relacionados a aspectos jurídicos ou legais foram os mais frequentemente apontados como os motivos para a divergência entre estas condutas. A maioria das decisões (58%) envolvendo uma paciente octagenária lúcida na UTI com alto risco de morte ou de baixa funcionalidade em caso de sobrevivência foram decisões paternalistas, e não ofereceram qualquer autonomia à paciente ou a sua família. A análise multivariada observou que médicos mais jovens (39±8 vs. 41±8, OR=0,966[0,9390,994], P=0,016) e que leram mais artigos sobre fim de vida ou cuidados paliativos em UTI (15/44 vs. 12/61, OR=2,404[1,0185,673], P=0,045) estavam associadas de forma independente ao compartilhamento da decisão com a paciente e/ou sua família, provendo assim algum grau de autonomia. Conclusão: Características dos médicos que trabalham em UTIs como idade, interesse e educação em cuidados paliativos em UTI se associam a variabilidade de condutas em fim de vida em UTI. Quarenta e quatro por cento dos médicos investigados não agiriam conforme o que julgam melhor para a paciente, utilizando-se de mais SAV do que julgam melhor. Motivos legais foram os mais citados como a causa desta discrepância de condutas / Purpose: To investigate associations between physician education in end-of-life (EOL) care and variability in EOL practice in the ICU, and differences between actual EOL practice and what physicians believe is best for the patient. Methods: Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, and physicians personal, professional and EOL educational characteristics. Results: One-hundred-and-five questionnaires were analyzed (response rate 89%). Respondents mean age was 38±8 years, with a mean of 14±7 years post-graduation. Physicians who applied written do-not-resuscitate (DNR) orders had more often attended EOL classes than those who did not apply DNR orders (31/47 vs. 0/7, OR=1.818[1.456-2.159], P=0.001). Younger physicians (38±7 vs. 40±8 years, OR=0.926[0.858-0.998], P=0.045) and ICU specialists (17/22 vs. 46/83, OR=0.205[0.058-0.716], P=0.013) more often involved nurses in EOL decision-making than did other physicians. Physicians who would withdraw lifesustaining therapies had more often read about EOL (11/20 vs. 3/22, OR=1.306[1.0011.547], P=0.012) and had more interest in discussing EOL (20/20 vs. 17/22, OR=4.717[2.0487.381], P<0.001), than physicians who would apply full code. Forty-four percent of respondents would not do what they believed was best for their patient: 98% of them believed a less aggressive attitude was preferable with legal concerns the leading cited cause for this dichotomy. Conclusions: Physician education about EOL issues is associated with variability in EOL decisions in the ICU. Actual practice may differ from what physicians believe is best for the patient

Tomando-se como foco o cuidado de pacientes em processo de morte e morrer, a presente pesquisa teve como objetivo descortinar o interdito sobre a morte e o morrer, as percepções, os significados, os sentimentos e dificuldades atribuídos pelos profissionais da saúde sobre o cuidado de pacientes em processo de morte e morrer. Para tanto, realizou-se um estudo descritivo de cunho qualitativo. A coleta de dados foi realizada através de entrevistas e observações, e teve duração de julho a outubro de 2016. Foram entrevistados 34 profissionais médicos e enfermeiros que atuam nas unidades de clínica médica e pronto socorro em um hospital universitário do Rio Grande do Sul. Os dados obtidos foram submetidos à triangulação a partir da análise de conteúdo. Os resultados mostraram que a maioria dos profissionais significam a morte enquanto passagem, na crença de que existe algo após. A morte pode ser aceita quando esperada em pacientes idosos, com longo tempo de tratamento de alguma doença crônica. No entanto, não é aceita quando se trata de pacientes jovens e, principalmente, quando são mortes traumáticas de crianças. Na clínica médica, o vínculo prolongado com os pacientes possibilita aos profissionais diferentes formas de cuidados e é viso, na maioria das vezes, como algo positivo na relação apesar de gerar maior sofrimento quando acontece a morte ou a piora do paciente, sendo fonte de prejuízo à saúde mental. No pronto socorro, a morte gera sofrimento apenas quando traumática, não há lugar ou tempo para a morte nesta unidade, pois as intercorrências próprias da emergência e da organização do trabalho, como a superlotação, são as maiores fontes de estresse para os profissionais, sendo a saúde mental afetada por esses motivos. Os principais sentimentos destacados quando ocorre à morte de um paciente, em ambas as unidades, são: frustração, impotência, tristeza e compaixão. Apesar de lidarem com a morte no dia a dia, ela não é elaborada ou conversada entre os profissionais, havendo um forte interdito sobre o assunto, que é passado também aos pacientes e familiares. É comum a utilização de estratégias defensivas, como racionalização e distanciamento do paciente para não enfrentar a finitude do outro e, consequentemente, a sua própria. Para a maioria dos profissionais é inevitável relacionar o paciente com pessoas conhecidas, membros da família ou eles próprios, essa identificação causa maior sofrimento, principalmente quando o profissional está vivenciando uma situação familiar parecida. A maior parte dos profissionais possui como exigência própria aproveitar melhor a vida, pois vivenciam muito sofrimento no ambiente hospitalar. Concluiu-se que, o cuidado dos pacientes em processo de morte e morrer versam em cima do interdito social que a morte carrega, pois apesar de gerar sofrimento aos profissionais, não se reflete sobre a morte de pacientes. Na clínica médica a morte gera maior sofrimento devido ao tempo de convivência entre profissionais e pacientes. No pronto socorro, a morte fica subtraída diante de uma rotina marcada pelos inúmeros procedimentos que necessitam ser realizados, não permitindo espaços para elaborações individuais ou coletivas. A saúde mental dos profissionais fica sujeita e sujeitada pelas exigências do trabalho, não permitindo considerar o doente em sua integralidade, como sujeito na vida e na morte. Ademais, não se pode dizer que a morte é naturalizada pelos profissionais, se esses não se permitem olhar para ela de forma límpida, sem tantas estratégias defensivas. / Taking as a focus the care of patients in the process of death and dying, the present research had the objective to uncover the prohibition on death and dying, perceptions, meanings, feelings and difficulties attributed by health professionals about care of patients in the process of death and dying. Therefore, a descriptive study of qualitative nature was performed. Data collection was done through interviews and observations, and lasted from July to October 2016. It was interviewed 34 medical professionals and nurses who work in the medical clinic and emergency department units in a university hospital in Rio Grande do Sul. The obtained data were submitted to triangulation from the content analysis. The results showed that most professionals mean death as a passage, in the belief that there is something after. Death can be accepted when expected in elderly patients, with long time of treatment of some chronic disease. However, it is not accepted when it comes to young patients and, especially, when they are traumatic deaths of children. In the medical clinic, the long-term relationship with the patients allows the professionals different forms of care and is seen, mostly, as something positive in the relationship despite generating greater suffering when the death or worsening of the patient happens, being a source of damage to mental health. In the emergency department, death generates suffering only when traumatic, there is no place or time for death in this unit, because the intercurrences of emergency and work organization, such as overcrowding, are the major sources of stress for professionals, mental health being affected by these reasons. The main feelings highlighted when a patient dies in both units are: frustration, impotence, sadness and compassion. Although they deal with death daily, it is not elaborated or talked among professionals, there is a strong interdiction on the subject, which is passed to patients and family. It is common to use defensive strategies, such as rationalization and distancing the patient to not face the finitude of the other and, consequently, his own. For most professionals it is inevitable to relate the patient with known people, family members or themselves, this identification causes more suffering, especially when the professional is experiencing a similar family situation. Most part of the professionals has as their own requirement to enjoy life, because they experience much suffering in the hospital. It was concluded that the care of the patients in the process of death and dying are based on the social prohibition that death carries, because despite generating suffering for professionals, it is not reflected on the death of patients. In medical clinic the death generates greater suffering due to the time of coexistence between professionals and patients. In the emergency department, death is subtracted before a routine marked by numerous procedures that need to be performed, not allowing spaces for individual or collective elaborations. The mental health of professionals is subject and subjected to the demands of work, not allowing to consider the patient in its entirety, as subject in life and death. In addition, it cannot be said that death is naturalized by professionals, if they do not allow themselves to look at it in a limpid way, without many defensive strategies.

Tomando-se como foco o cuidado de pacientes em processo de morte e morrer, a presente pesquisa teve como objetivo descortinar o interdito sobre a morte e o morrer, as percepções, os significados, os sentimentos e dificuldades atribuídos pelos profissionais da saúde sobre o cuidado de pacientes em processo de morte e morrer. Para tanto, realizou-se um estudo descritivo de cunho qualitativo. A coleta de dados foi realizada através de entrevistas e observações, e teve duração de julho a outubro de 2016. Foram entrevistados 34 profissionais médicos e enfermeiros que atuam nas unidades de clínica médica e pronto socorro em um hospital universitário do Rio Grande do Sul. Os dados obtidos foram submetidos à triangulação a partir da análise de conteúdo. Os resultados mostraram que a maioria dos profissionais significam a morte enquanto passagem, na crença de que existe algo após. A morte pode ser aceita quando esperada em pacientes idosos, com longo tempo de tratamento de alguma doença crônica. No entanto, não é aceita quando se trata de pacientes jovens e, principalmente, quando são mortes traumáticas de crianças. Na clínica médica, o vínculo prolongado com os pacientes possibilita aos profissionais diferentes formas de cuidados e é viso, na maioria das vezes, como algo positivo na relação apesar de gerar maior sofrimento quando acontece a morte ou a piora do paciente, sendo fonte de prejuízo à saúde mental. No pronto socorro, a morte gera sofrimento apenas quando traumática, não há lugar ou tempo para a morte nesta unidade, pois as intercorrências próprias da emergência e da organização do trabalho, como a superlotação, são as maiores fontes de estresse para os profissionais, sendo a saúde mental afetada por esses motivos. Os principais sentimentos destacados quando ocorre à morte de um paciente, em ambas as unidades, são: frustração, impotência, tristeza e compaixão. Apesar de lidarem com a morte no dia a dia, ela não é elaborada ou conversada entre os profissionais, havendo um forte interdito sobre o assunto, que é passado também aos pacientes e familiares. É comum a utilização de estratégias defensivas, como racionalização e distanciamento do paciente para não enfrentar a finitude do outro e, consequentemente, a sua própria. Para a maioria dos profissionais é inevitável relacionar o paciente com pessoas conhecidas, membros da família ou eles próprios, essa identificação causa maior sofrimento, principalmente quando o profissional está vivenciando uma situação familiar parecida. A maior parte dos profissionais possui como exigência própria aproveitar melhor a vida, pois vivenciam muito sofrimento no ambiente hospitalar. Concluiu-se que, o cuidado dos pacientes em processo de morte e morrer versam em cima do interdito social que a morte carrega, pois apesar de gerar sofrimento aos profissionais, não se reflete sobre a morte de pacientes. Na clínica médica a morte gera maior sofrimento devido ao tempo de convivência entre profissionais e pacientes. No pronto socorro, a morte fica subtraída diante de uma rotina marcada pelos inúmeros procedimentos que necessitam ser realizados, não permitindo espaços para elaborações individuais ou coletivas. A saúde mental dos profissionais fica sujeita e sujeitada pelas exigências do trabalho, não permitindo considerar o doente em sua integralidade, como sujeito na vida e na morte. Ademais, não se pode dizer que a morte é naturalizada pelos profissionais, se esses não se permitem olhar para ela de forma límpida, sem tantas estratégias defensivas. / Taking as a focus the care of patients in the process of death and dying, the present research had the objective to uncover the prohibition on death and dying, perceptions, meanings, feelings and difficulties attributed by health professionals about care of patients in the process of death and dying. Therefore, a descriptive study of qualitative nature was performed. Data collection was done through interviews and observations, and lasted from July to October 2016. It was interviewed 34 medical professionals and nurses who work in the medical clinic and emergency department units in a university hospital in Rio Grande do Sul. The obtained data were submitted to triangulation from the content analysis. The results showed that most professionals mean death as a passage, in the belief that there is something after. Death can be accepted when expected in elderly patients, with long time of treatment of some chronic disease. However, it is not accepted when it comes to young patients and, especially, when they are traumatic deaths of children. In the medical clinic, the long-term relationship with the patients allows the professionals different forms of care and is seen, mostly, as something positive in the relationship despite generating greater suffering when the death or worsening of the patient happens, being a source of damage to mental health. In the emergency department, death generates suffering only when traumatic, there is no place or time for death in this unit, because the intercurrences of emergency and work organization, such as overcrowding, are the major sources of stress for professionals, mental health being affected by these reasons. The main feelings highlighted when a patient dies in both units are: frustration, impotence, sadness and compassion. Although they deal with death daily, it is not elaborated or talked among professionals, there is a strong interdiction on the subject, which is passed to patients and family. It is common to use defensive strategies, such as rationalization and distancing the patient to not face the finitude of the other and, consequently, his own. For most professionals it is inevitable to relate the patient with known people, family members or themselves, this identification causes more suffering, especially when the professional is experiencing a similar family situation. Most part of the professionals has as their own requirement to enjoy life, because they experience much suffering in the hospital. It was concluded that the care of the patients in the process of death and dying are based on the social prohibition that death carries, because despite generating suffering for professionals, it is not reflected on the death of patients. In medical clinic the death generates greater suffering due to the time of coexistence between professionals and patients. In the emergency department, death is subtracted before a routine marked by numerous procedures that need to be performed, not allowing spaces for individual or collective elaborations. The mental health of professionals is subject and subjected to the demands of work, not allowing to consider the patient in its entirety, as subject in life and death. In addition, it cannot be said that death is naturalized by professionals, if they do not allow themselves to look at it in a limpid way, without many defensive strategies.

Tomando-se como foco o cuidado de pacientes em processo de morte e morrer, a presente pesquisa teve como objetivo descortinar o interdito sobre a morte e o morrer, as percepções, os significados, os sentimentos e dificuldades atribuídos pelos profissionais da saúde sobre o cuidado de pacientes em processo de morte e morrer. Para tanto, realizou-se um estudo descritivo de cunho qualitativo. A coleta de dados foi realizada através de entrevistas e observações, e teve duração de julho a outubro de 2016. Foram entrevistados 34 profissionais médicos e enfermeiros que atuam nas unidades de clínica médica e pronto socorro em um hospital universitário do Rio Grande do Sul. Os dados obtidos foram submetidos à triangulação a partir da análise de conteúdo. Os resultados mostraram que a maioria dos profissionais significam a morte enquanto passagem, na crença de que existe algo após. A morte pode ser aceita quando esperada em pacientes idosos, com longo tempo de tratamento de alguma doença crônica. No entanto, não é aceita quando se trata de pacientes jovens e, principalmente, quando são mortes traumáticas de crianças. Na clínica médica, o vínculo prolongado com os pacientes possibilita aos profissionais diferentes formas de cuidados e é viso, na maioria das vezes, como algo positivo na relação apesar de gerar maior sofrimento quando acontece a morte ou a piora do paciente, sendo fonte de prejuízo à saúde mental. No pronto socorro, a morte gera sofrimento apenas quando traumática, não há lugar ou tempo para a morte nesta unidade, pois as intercorrências próprias da emergência e da organização do trabalho, como a superlotação, são as maiores fontes de estresse para os profissionais, sendo a saúde mental afetada por esses motivos. Os principais sentimentos destacados quando ocorre à morte de um paciente, em ambas as unidades, são: frustração, impotência, tristeza e compaixão. Apesar de lidarem com a morte no dia a dia, ela não é elaborada ou conversada entre os profissionais, havendo um forte interdito sobre o assunto, que é passado também aos pacientes e familiares. É comum a utilização de estratégias defensivas, como racionalização e distanciamento do paciente para não enfrentar a finitude do outro e, consequentemente, a sua própria. Para a maioria dos profissionais é inevitável relacionar o paciente com pessoas conhecidas, membros da família ou eles próprios, essa identificação causa maior sofrimento, principalmente quando o profissional está vivenciando uma situação familiar parecida. A maior parte dos profissionais possui como exigência própria aproveitar melhor a vida, pois vivenciam muito sofrimento no ambiente hospitalar. Concluiu-se que, o cuidado dos pacientes em processo de morte e morrer versam em cima do interdito social que a morte carrega, pois apesar de gerar sofrimento aos profissionais, não se reflete sobre a morte de pacientes. Na clínica médica a morte gera maior sofrimento devido ao tempo de convivência entre profissionais e pacientes. No pronto socorro, a morte fica subtraída diante de uma rotina marcada pelos inúmeros procedimentos que necessitam ser realizados, não permitindo espaços para elaborações individuais ou coletivas. A saúde mental dos profissionais fica sujeita e sujeitada pelas exigências do trabalho, não permitindo considerar o doente em sua integralidade, como sujeito na vida e na morte. Ademais, não se pode dizer que a morte é naturalizada pelos profissionais, se esses não se permitem olhar para ela de forma límpida, sem tantas estratégias defensivas. / Taking as a focus the care of patients in the process of death and dying, the present research had the objective to uncover the prohibition on death and dying, perceptions, meanings, feelings and difficulties attributed by health professionals about care of patients in the process of death and dying. Therefore, a descriptive study of qualitative nature was performed. Data collection was done through interviews and observations, and lasted from July to October 2016. It was interviewed 34 medical professionals and nurses who work in the medical clinic and emergency department units in a university hospital in Rio Grande do Sul. The obtained data were submitted to triangulation from the content analysis. The results showed that most professionals mean death as a passage, in the belief that there is something after. Death can be accepted when expected in elderly patients, with long time of treatment of some chronic disease. However, it is not accepted when it comes to young patients and, especially, when they are traumatic deaths of children. In the medical clinic, the long-term relationship with the patients allows the professionals different forms of care and is seen, mostly, as something positive in the relationship despite generating greater suffering when the death or worsening of the patient happens, being a source of damage to mental health. In the emergency department, death generates suffering only when traumatic, there is no place or time for death in this unit, because the intercurrences of emergency and work organization, such as overcrowding, are the major sources of stress for professionals, mental health being affected by these reasons. The main feelings highlighted when a patient dies in both units are: frustration, impotence, sadness and compassion. Although they deal with death daily, it is not elaborated or talked among professionals, there is a strong interdiction on the subject, which is passed to patients and family. It is common to use defensive strategies, such as rationalization and distancing the patient to not face the finitude of the other and, consequently, his own. For most professionals it is inevitable to relate the patient with known people, family members or themselves, this identification causes more suffering, especially when the professional is experiencing a similar family situation. Most part of the professionals has as their own requirement to enjoy life, because they experience much suffering in the hospital. It was concluded that the care of the patients in the process of death and dying are based on the social prohibition that death carries, because despite generating suffering for professionals, it is not reflected on the death of patients. In medical clinic the death generates greater suffering due to the time of coexistence between professionals and patients. In the emergency department, death is subtracted before a routine marked by numerous procedures that need to be performed, not allowing spaces for individual or collective elaborations. The mental health of professionals is subject and subjected to the demands of work, not allowing to consider the patient in its entirety, as subject in life and death. In addition, it cannot be said that death is naturalized by professionals, if they do not allow themselves to look at it in a limpid way, without many defensive strategies.

Objetivos: Este estudo investigou as associações entre características dos médicos e a variabilidade de condutas em fim de vida em UTI. Métodos: Um questionário foi aplicado aos médicos das 11 UTIs do HC-FMUSP, apresentando dois casos clínicos. O primeiro apresentava uma paciente em estado vegetativo persistente, sem familiares ou diretivas antecipadas de vontade, com um choque séptico. O segundo, uma paciente de 88 anos, com disfunção de múltiplos órgãos decorrente de uma pneumonia. Investigou-se através do questionário a associação entre condutas e características pessoais, profissionais e educacionais dos médicos. Resultados: Foram analisados 105 questionários (taxa de resposta 89%). A media de idade foi de 38±8 anos, com 14±7 anos de graduação em medicina. A maioria das decisões envolveu exclusivamente médicos (66%), 21% envolveram também enfermeiros. Na análise multivariada, especialistas em Medicina Intensiva (17/22 vs. 46/83, OR=0,205[0,058-0,716], P=0,013) e médicos mais jovens (38±7 vs. 40±8; OR=0,926[0,858-0,998], P=0,045) mais frequentemente envolveram enfermeiros no processo de decisão. Ordem de não reanimação (ONR) foi estabelecida por 89% dos participantes, sendo 44% exclusivamente verbais. Médicos que atribuíram a si mesmo notas mais altas em relação ao conhecimento sobre cuidados paliativos mais frequentemente estabeleceriam uma ONR na análise multivariada (6±2 vs. 3±2, OR=2,167[1,062-4,420], P=0,034). A maior parte dos participantes (60%) respondeu que limitaria de alguma forma o suporte artificial de vida (SAV) para a primeira paciente, enquanto 21% respondeu que não limitaria nenhum suporte e 19% retiraria o SAV. Na análise de regressão logística, o interesse em discutir sobre fim de vida em UTI permaneceu como variável de associação independente para retirada ou limitação de SAV (20/20 vs. 61/63 vs. 17/22, OR=0,129[0,019-0,894], P=0,038). Quarenta e seis dos 105 médicos avaliados (44%) apresentavam respostas discordantes para as questões sobre a conduta mais provável e a conduta acreditada como a melhor para a primeira paciente. Dentre estes, 45 (98%) acreditavam que a melhor conduta envolveria o uso de menos SAV do que provavelmente fariam. Motivos relacionados a aspectos jurídicos ou legais foram os mais frequentemente apontados como os motivos para a divergência entre estas condutas. A maioria das decisões (58%) envolvendo uma paciente octagenária lúcida na UTI com alto risco de morte ou de baixa funcionalidade em caso de sobrevivência foram decisões paternalistas, e não ofereceram qualquer autonomia à paciente ou a sua família. A análise multivariada observou que médicos mais jovens (39±8 vs. 41±8, OR=0,966[0,9390,994], P=0,016) e que leram mais artigos sobre fim de vida ou cuidados paliativos em UTI (15/44 vs. 12/61, OR=2,404[1,0185,673], P=0,045) estavam associadas de forma independente ao compartilhamento da decisão com a paciente e/ou sua família, provendo assim algum grau de autonomia. Conclusão: Características dos médicos que trabalham em UTIs como idade, interesse e educação em cuidados paliativos em UTI se associam a variabilidade de condutas em fim de vida em UTI. Quarenta e quatro por cento dos médicos investigados não agiriam conforme o que julgam melhor para a paciente, utilizando-se de mais SAV do que julgam melhor. Motivos legais foram os mais citados como a causa desta discrepância de condutas / Purpose: To investigate associations between physician education in end-of-life (EOL) care and variability in EOL practice in the ICU, and differences between actual EOL practice and what physicians believe is best for the patient. Methods: Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, and physicians personal, professional and EOL educational characteristics. Results: One-hundred-and-five questionnaires were analyzed (response rate 89%). Respondents mean age was 38±8 years, with a mean of 14±7 years post-graduation. Physicians who applied written do-not-resuscitate (DNR) orders had more often attended EOL classes than those who did not apply DNR orders (31/47 vs. 0/7, OR=1.818[1.456-2.159], P=0.001). Younger physicians (38±7 vs. 40±8 years, OR=0.926[0.858-0.998], P=0.045) and ICU specialists (17/22 vs. 46/83, OR=0.205[0.058-0.716], P=0.013) more often involved nurses in EOL decision-making than did other physicians. Physicians who would withdraw lifesustaining therapies had more often read about EOL (11/20 vs. 3/22, OR=1.306[1.0011.547], P=0.012) and had more interest in discussing EOL (20/20 vs. 17/22, OR=4.717[2.0487.381], P<0.001), than physicians who would apply full code. Forty-four percent of respondents would not do what they believed was best for their patient: 98% of them believed a less aggressive attitude was preferable with legal concerns the leading cited cause for this dichotomy. Conclusions: Physician education about EOL issues is associated with variability in EOL decisions in the ICU. Actual practice may differ from what physicians believe is best for the patient