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Adecuaci&oac= ute;n del esfuerzo terapéutico: aspectos emocionales y éticos

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Adequacy of therapeutic effort: emotional and ethical aspects

1 M&oacu= te;nica Alexandra Valdiviezo May= gua &= nbsp; https://orcid.org/0000-0003-= 2002-5857 Facultad de Ciencias de la Salud, Universidad Nacional de Chimborazo, Ecuador mvaldiviezo@unach.= edu.ec

3D"Interfaz 2 &nb= sp; Valeria de los Ángeles Naranjo Peña = https://orcid.org/0009-0004-= 7106-1799

Facultad de Ciencias de la Salud, Universid= ad Nacional de Chimborazo, Ecua= dor valerianaranjo073@gmail.com= <= /span>

Mary Jessenia Silva Carrera = &nb= sp; https://orcid.org/0009-0004-= 4074-7421 Facultad de Ciencias de la Salud, Universidad Nacional de Chimborazo, Ecuador marysilva199902@gmail.com<= /span>

= 4 &nb= sp; Gabriela Elizabeth Damián Sinchiguano https://orcid.org/0009-0006-= 2697-2029

Facultad de Ciencias de la Salud, Universid= ad Nacional de Chimborazo, Ecua= dor gabriela.damian@unach.edu.ec<= /span>

Artículo de Investigación Científica y Tecnológica

Enviado: 29/10/2023 Revisado: 26/11/2023 Aceptado: 15/12/2023 Publicado:28/12/= 2023

DOI: https://doi.org/10.33262/anat= omiadigital.v6i4.3.2826

Cítes= e:

Valdiviezo= Maygua, M. A., Naranjo Peña, = V. de los Ángeles, Silva Carrera= , M. J., & Damián Sinchiguano, G. E. (2023). Adecuación del esfuerzo terapéutico: aspectos emocionales y éticos. Anatomía Digital, 6(4.3= ), 626-649.

https:= //doi.org/10.33262/anatomiadigital.v6i4.3.2826

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ANATOMÍA DIGITAL, es una Revista Electrónica, Trimestral, que se publicará en soporte electrónico tiene como misión= contribuir a la formación de profesionales competentes con visi&oac= ute;n humanística y crítica que sean capaces de exponer sus resultados investigativos y científicos en la misma medida que se<= span style=3D'letter-spacing:.05pt'> promueva mediante su intervención cambios positivos en<= span style=3D'letter-spacing:-.15pt'> la sociedad. https://anatomiadigital.org=

La revista = es editada por la Editorial Ciencia Digital (Editorial de prestigio registrada en la Cámara Ecuatoriana de Libro con No de Afiliación 663) www.cel= ibro.org.ec=

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Esta revista est&aa= cute; protegida bajo una licencia Creative Comm= ons Atribución-NoComercial-Comp= artirIgual

4.0 International. Copia de la licencia: https:/= /creativecommons.org/licenses/by-nc-sa/4.0/deed.es=

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Palabras claves: Esf= uerzo terapéutico, Procedimientos diagnósticos, Sostén emocional, P= rofesional sanitario, Salud

Resumen

Introducción: <= /span>La adecuación del esfuerzo terapéutico (AET) es una decisión clín= ica de detener actividades diagnósticas y/o de tratamiento al paciente con enfermedades terminales o al final de la vida, a fin de asegurar que la transición entre la vida y la muerte sea adecuada y humana= . Objetivo: El presente estudio se desarrolló media= nte revisión bibliográfica con el objetivo de sistematizar aspectos emocionales y éticos de l= a AET. Metodología: La búsqueda se realizó en las bases de datos Web of Science y Medline, en la plataforma ProQuest = y en la biblioteca digital SciELO.= Se usó el formato población, intervención, comparación y resultados y objetivos (PICO) para establece= r la pregunta de investigación y definir los descriptores, se evaluó la calidad metodológica aplicando la guía Critical Appraisal Ski= lls Programme Español (CASPe). Resultados: Fueron se= leccionados 19 artículos científicos, que permitieron identificar los siguientes= resultados: entre las actitudes y emociones expresadas s= obre la AET se encuentran temor,= tristeza, miedo, confusi= ón e insatisfacción. Las decisiones se basan en el Código de Étic= a Médica, en la clínica del paciente y en los principios bioéticos. Conclusión: Los profesionales de enfermería experimentan dificultades al no ser tomados en cuenta para decidir su aplicación, el estrés laboral, la falta de registros en = las historias clínicas, carencia = de insumos y protocolos y obstáculos en la comunicación con los familiares. Área de estudio general: Salud y Bienestar. Área de estudio específica: Cuidados Paliativos. Tipo de estudio: Artículo de revisi&oac= ute;n.

Keywo= rds: Therapeutic = ; effort, Diagnostic procedures,= Emotional support, Heal= thcare professional, Health

Abstract

Introduction: Adequacy of therapeutic effort (AET) is a clinical decision to stop diagnost= ic and/or treatment activities f= or patients with terminal illnesses or at the end of life, to ensure that the transition between= life and death is appropriate and humane. Aim The present stud= y was developed through a bibliogra= phic review with the objective of systematizi= ng emotional and ethical aspects of AET. Methodology: The search was conducted in the Web of Science and Medline databases, on the ProQuest platform and in<= span style=3D'letter-spacing:.1pt'> the SciELO digital

library. The population, intervention, comparison and results

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and object= ives (PICO) format was used to establish the research question and define the descriptors, the methodological quality was evaluated by applying the Critical Appraisal Skills Program Spanish<= span style=3D'letter-spacing:-.7pt'> (CASPe) guide. Results: 19 scientific articles were selected, which allowed the following results to be identified: among the attitudes and emotions expressed about= AET are fear, sadness, fear, confusi= on, and dissatisfaction. Decisions are based on the Code of Medical Ethics, the patient's clinic, and bioethical principles. Conclusion: Nursing professionals experience difficulties by not being considere= d when deciding their application, work stress, lack of records in medical records, lac= k of supplies and protocols, and obstacles = in communication with family members.<= o:p>

Introducción

La Adecua= ción del Esfuerzo Terapéutico (AET), es una decisión basada en el conocimiento del estado del paciente de no aplicar, no iniciar o de retirar medidas de soporte vital. Esta decisión debe ser debatida por los profesionales de= la salud, considerando si estas medidas result= an en un bien para la vida del paciente, cuando no existe esperanza de recuperación biológica compatible = con la vida. Por lo tanto, se adaptarán los procedimientos médicos, diagnósticos y los cuidados enfermeros a la situación clínica, evi= tando acciones innecesarias que no mejoran su evolución (1), con la AET, la opción de “curar” se transforma en “cuidar y acompañar”= ; al paciente hasta su fallecimiento= , no se trata de limitar un tratamiento si no de reorientar los objetivos, adecuando de este modo los cuidados a las necesidades y la clínica del paciente (2).=

Actualmente, la medicina está estrechamente relacionada con el desarrollo tecnológico, que ofrece posibilidades sin precedentes para la prolongación de la vida, la eficacia y la calidad de los servicios de salud, lo cual conlleva nuevos conflictos de carácter ético y legal para la decisión de la AET, que requieren de la reflexión clínica en respuesta a la demanda de la comunidad científica y de la sociedad (= 3). Por lo tanto, las personas a qu= ienes se aplica la AET serán totalmente dependientes, con compromiso serio= de una o varias de sus funciones vitales, esto incluye: pacientes terminales, en estado vegetativo permanente, con daño neurológico grave, crónico o irreversible o que su recuperación se encuen= tra fuera de alcance (4).

Para atender las necesidades de las personas, en el m= arco de la AET es fundamental la tom= a de decisiones, que no se reduce a una decisión única en la cual = se resuelve hacer o no hacer, sino a un conjunto de decisiones meditadas que responden a las condiciones y

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evolución clínica, razón por la = cual los criterios a considerar deben ser analizados desde el punto de vista clínico, ético y legal, además de ser una deliberación participativa, es decir, con todos los actores implica= dos: paciente (si su condición lo permite), familiares y el equipo de<= span style=3D'letter-spacing:-.05pt'> profesionales involucrados en su atención (4-10).

Cuando la decisión es tomada solo por una part= e del equipo multidisciplinario, los profesionales que aplican la AET, li= mita su función al cumplimiento de una orden, situación que en unos casos puede desencadenar disyuntivas mora= les, angustia, sensación de sen= tirse “verdugos” e incluso responsables de la muerte del paciente. No obstante, en ocasiones, son l= os mismos profesionales quienes consideran que esta función no les compete y no reconocen la importa= ncia de su participación (11).

Los crite= rios para aplicar la AET deben ser individualizados y justificados en el beneficio para el paciente, sus caracter&i= acute;sticas y su evolución clínica, también se asocia a la decisión, el agotamiento de las intervenciones tecnológicas, el fracaso de los sistemas orgánicos del paciente, el uso de medidas muy costosas o dudosamente efectivas y procedimientos excesivos con medios artificiales, que prolongan<= span style=3D'letter-spacing:-.45pt'> la vida, pero al mismo tiempo extienden la agonía y el sufrimiento, que pone al ser humano en un ento= rno incompatible con el respeto a la dignidad. Las modalidades más utilizadas de la AET son la retirada d= el soporte respiratorio, la no reanimación cardiopulmonar, ventilación mecánica, diálisis, fármaco= s vasoactivos, antibióticos, hidratación, alimentación tanto enteral como parenteral y pruebas diagnósticas (12).

Tras la supresión de estas terapias, la muerte= del paciente puede acaecer en cualquier instante, horas o días, evidentemente, con la implementación de la AET modifican las situaciones, modo= y momento de la muerte, con una transición entre la vida y la muerte lo más natural, adecuada y humanizada posible (13). Al realizar un análisis de los últimos días de= vida sin la aplicación de la AET, se observa que los pacientes son sometidos a una serie de procedimientos invasivos, temidos y dolorosos, hospitalizaciones prolongadas y muerte hospitalaria (14). La implementación de la AET, puede ser considerada como un cambio de enfoque que se centra en la implantación de medidas y cuidados que garanticen el bienestar y el confort del pacie= nte y su familia, en donde el personal de enfermería desempeña un rol independiente, en la confecció= ;n de la AET, ejerciendo su rol como principal cuidador.

En este contexto, se han identificado l= imitaciones en la AET por parte de los profesionales de la salud, entre estos se encuent= ran dudas clínicas, éticas o legales que afectan la toma de decisiones, generan dilemas éticos hacia el paciente y la familia que dificulta la delimitación de responsabilid= ades de los participantes. De hecho, se describen algunas dificultades como: la falta de registros en la historia clínica, la angustia de los familiares quienes solicitan “hacer todo”, diferencias en el criter= io del equipo de salud, entre otras. Ante lo cual, es recomendable el acceso a material de lectura, discusión de casos clínicos,

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charlas informativas, cursos sobre cuidados paliativo= s, encuentro con especialistas en = bioética, médicos legistas, entre otros (15). Incluso es importante la aprobación de una ley que garantice una atención integral a las necesidades del= ser humano al final de la vida (6, 15).

Actualmente, la comunidad científica intern= acional considera a la AET como una práctica éticamente adecuada y acepta= ble en pacientes que cumplen criterios que aseguran la irreversibilidad de su situación patológica y = los cuidados de enfermería sirven como primera línea de atención, donde la analgesia, la sedación y el apoyo emocional son imprescindi= bles (3, 15), este personal desempeña un rol coordinador y asistencial al estar en contacto directo y permanente co= n la persona y su familia; su atención al final de la vida se basa en criterios como: alivio de los síntomas físicos, = soporte psicosocial, respeto de deseos, costumbres, creencias y religiones;<= span style=3D'letter-spacing:-.75pt'> la cooperación y colaboración en el proceso de toma de decisiones junto con el equipo médico; la comunicaci&= oacute;n efectiva y la atención continuada junto con el apoyo familiar, creando la mejor experiencia en el afrontamiento de la transición de la vida a la muerte (9, 15).

Es ciert= o que la AET toma en cuenta a la familia, sin embargo, esta es una responsabilidad que a veces no se asume, por temor= a la falta de comprensión, problemas legales o conflictos entre= ellos. Frecuentemente, los familiares intentan proteger y ocultar la gravedad de la enfermedad, pero el paciente tiene derecho a recibir información verdadera para= que pueda tomar decisiones con su propia y libre voluntad (15-2= 0). Sin embargo, un cambio en el pronóstico del paciente implica un giro emocional que requiere tiempo e información para asimilar las nuevas circunstancias (20). De acuerdo con el principio de autonomía, los pacientes pu= eden comprender, aceptar o rechazar el someterse a una prueba diagn&oac= ute;stica o recibir un tratamiento de soporte vital que a la larga puede convertirse en una medida<= span style=3D'letter-spacing:-.05pt'> que prolongue el sufrimiento (21).

Otro esc= enario frecuente se recrea cuando un paciente se encuentra física o emocionalmente vulnerable, con una condición de salud grave que afecte la capacidad= para ejercer su autonomía, da= r su consentimiento o expresar sus elecciones personales. En estas situaciones, la familia es quien representa al paciente y el equipo médico son los responsables de orientar en la decisión de qué acción es mejor (22). En estos casos, = el acompañamiento y la participación de la familia hace posible disminuir el impacto del sufrimiento físico-emocional y asegurar un transitar tranquilo y en paz (23).

Dada la preocupación consciente por los dilemas éticos que plantea la toma de decisiones<= span style=3D'letter-spacing:-2.9pt'> en la práctica médica diaria y de los potenciales conflictos psicológicos que podrí= an suscitarse, se lleva a cabo un debate reflexivo sobre los aspectos fundamentales a fin de lograr un acerca= miento teórico a este tema pol&eacut= e;mico y contencioso de permanente relevancia, en el que intervienen as= pectos religiosos, filosóficos, morales, culturales y éticos; e= n este sentido, las cuestiones clínicas y éticas surgen cuando modifica la

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planificación de la AET, por lo tanto, para qu= e el equipo de salud tome decisiones acertadas, los autores creen que este= tema requiere madurez y cautela (24).

En el mismo orden de ideas, para promover decisiones acertadas, cada<= span style=3D'letter-spacing:-.45pt'> país debe disponer de una legislación clara con= forme su autonomía, por ejemplo, en Uruguay el Código de Ética Médica manifiesta “En etapas terminales de la enfermedad no es ético que el <= /span>médico indique procedimientos diagnósticos o terapéuticos que sean innecesarios y eventualmente perjudiciales para su calidad de vida”. El derecho a una muerte d= igna se encuentra contenido en el artículo 2 Numeral D de la Ley 18.335 de Derechos y Obligaciones de los Pacientes y Usuarios de los Servicios de Salud, estipula “morir en forma natural, en paz, sin dolor, evitando prolongar artificialmente la vida del paciente cuando no existan razonables expectativas de mejoría (futilidad terapéutica)” (15, 24).

Cabe reca= lcar que, con base en lo descrito en el párrafo anterior, un documento de registro de AET permite realizar un mapa de ruta para momentos de incertidumbre. Además, con relación a la atención recibida, todo paciente tiene derecho a un trato digno y respetuoso; al respecto, la misma Ley 18.335, incluye la preservación de la dignidad al final de la vida, entendiendo que este concepto implica el morir naturalmente, en paz, sin dolor, evitando en toda circunstancia anticipar la muerte por cualquier medio utilizado para tal fin (eutanasia) o prolongar artificialmente la vida del paciente cuando no existen expectativas realistas de mejora (inutilidad terapéutica) (15, 24).

Así también, en el artículo 3 refiere que “en situaciones donde la ciencia médica haya agotado las posibilidades terapéuticas de mejorí= a o curación, esta situación esté claramente consignada <= /span>en la historia clínica, constatando a continuación la orden médica `No reanimar&ac= ute; impartida por el médico tr= atante, decisión que será= ; comunicada a la familia d= irecta del paciente”. Estas declaraciones legales sirven como marco de derechos de los pacientes y de referencia para los profesionales médicos, garantizando la orientación para una decisión clínica = adecuada (12, 25). En el mismo contexto, el sistema de salud cubano contempla regulaciones relacionadas con= la muerte encefálica, pero hace falta más disposiciones legales que establezca los lími= tes de las acciones terapéuticas; po= r lo tanto, la AET no se encuentra reconocida expresamente por el ordenamiento jurídico en ese país (25).=

En tanto que, en Ecuador, los estudios y la información encontrada sobre la AET son escasos y desactualizados, sin embargo, la aplicación de criterios éticos en cuidados paliativos y la AET, se encuentran consignados bre= vemente en la Guía de Práct= ica Clínica de Cuidados Paliativos del Ministerio de Salud Públi= ca del Ecuador 2014 (MSP), en la q= ue señala que el mencionado documento “= ;contribuirá para proveer información práctica y de fácil lectura que capacite tanto= a los profesionales de la salud como a los familiares de personas que presentan una enfermedad incurable avanzada y de pronóstico de vida limitado, acerca de los cuidados paliativos para que tengan mejores

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condiciones, aliviando sus necesidades físicas, psicológicas y sociales.R= 21; (Acuerdo Ministerial 4862, del 7= de mayo del 2014) (26).

En la revista ecuatoriana Metrociencia se publicó = un estudio realizado por Montenegro CD y Maldonado FM, titulado “Adecuación del esfuerzo terapéu= tico orientado al buen morir” = que valida la realidad de la AET que se vive en el Ecuador, mencionando “= La adecuación de esfuerzo terapéutico se trata de conceptos avalados por Ét= ica y Bioética que pocos países han legalizado y llevado a la práctica, mientras en nuestro país no está claro el abordaje y la ejecución de este tema, quizás por las condiciones socio culturales= y religiosas que determinan nuestra conduct= a” (18, 26).

Desde la perspectiva de la respuesta emocional por pa= rte del personal de salud, la toma = de decisiones implica una importante carga emocional= y altos niveles de ansiedad para el personal de enfermería, situación que depende de varios factores, uno de ellos son las experiencias dolorosas en torno a la muerte, la inexperiencia que afecta el desarrollo de habilidades, disminuye la capacidad resolutiva e incrementa = el grado de estrés. Otros f= actores, que causan conflictos emocionales son: el tiempo que pasa el personal de enfermería con el paciente y familia y la naturaleza de sus funciones. Por lo tanto, se requiere desarrollar la capacidad de análisis ético, reflexivo con herramientas más obj= etivas que orienten la toma de decisiones, así como la capacidad de expresión emocional, las habilidades de atención al paciente y de establecer una relación con el paciente y la familia que genere confianza dentro del equipo multidisciplinario priorizando el beneficio del paciente (27).

Ante los= conflictos emocionales es= fundamental la actitud de los profesionales frente a la AET, de esta dependerá el desarrollo o no de respuestas patológicas que desencadenan problemas de salud. Al respecto, la actitud no es homogénea y varía<= span style=3D'letter-spacing:-.7pt'> según la especialida= d, la experiencia y las creencias. Al considerar la especialidad, en servicios de atención primaria el personal tiene mayores oportunidades de acercarse a la vida y a los valores de los pacientes y familiares y no solo a la enfermedad, lo que hace que sea el lugar adecuado para orientar y asesorar sobre la preparación y registro del documento de últimas voluntades (28).

Por su parte, la experiencia laboral se convierte en una guía y regula el accionar profesional en la UCI a fin de lograr cuidados de calidad garantizan= do una muerte digna en lo posterior. Con el tiempo de experiencia el personal enfermero va comprendiendo la finalidad de la AET que es evitar el sufrimiento, así enfermería proporciona una experiencia de bienestar al paciente crítico planificando sus cuidados para satisfacer las necesidades en la fase terminal y fortalecer el buen morir mediante el alivio de molestias, comunicación, compañía y apoyo emocional (9, 28).=

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Las creencias de los profesionales al estar en contac= to directo con el paciente, compartir creencias y costumbres religiosas, brindan al paciente la oportunidad de tener un fin= al tranquilo, cerca de los familiares, = para expresar sus últimos sentimientos, despedirse e incluso pedir disculpas por errores cometidos, experimentar un= a muerte en la que se haya mitigado o eliminado el temor y las preocupaciones por lo que queda. Así mismo, el personal de enfermería puede coordinar con los famili= ares la práctica de ciertas acciones dirigidas a una autonomía en las decisiones al final de la vida como traer un sacerdote para que el paciente reciba la unción de los enfermos, la colocación de lociones preferidas, música relajante, terapias para disminuir el estrés, temas agradables como el amor y las experiencias ag= radables, entre otros (9, 28).

Los procedimientos de la Planificación Avanzad= a del Cuidado (PAC) y la AET se han c= onvertido en partes importantes del sistema de salud, estas incluyen: buena comunicación entre los profesionales de la salud, el paciente= y su familia sobre la condici&oac= ute;n clínica y el pronóstico, definición conjunta de objetivos y planificación asistenciales del paciente para alca= nzar los objetivos. La PAC, al considerar y combinar la realidad clínica con la personalidad y los deseos = del paciente o su familia, les permite adaptarse mejor a la realidad de la enfermedad y mejorar la vida del paciente a lo la= rgo del tratamiento (12, 28).

Un mejor y profundo registro sobre la evolución o condicio= nes clínicas en las historias clínicas de los pacientes ayuda a identificar situaciones y analizar las causas, facilitando la comprensió= ;n de cómo se realizan las intervenciones, lo que permite identificar e implementar medidas clínico-éticas conforme a la enfermedad (29). En el hospital = es imprescindible tener un comité= ; de ética el cual ayude al equipo el médico, al paciente y su familia a analizar y tomar una decisión adecuada sobre el diagnóstico o tratamiento a fin de lograr siempre el bienestar de este (10, 29).

Entre las principales dificultades asociadas a la aplicación de la AET en UCI se incluye expectativas poco realistas de los padres de menores de edad, diferencias entre personal de s= alud y pacientes, poca comprensión de la enfermedad por parte del paciente = y de los familiares, falta de preparación profesional con<= span style=3D'letter-spacing:.05pt'> respecto al afrontamiento y a la comunicación de la AET, la incertidumbre, la dificultad en las dinámicas familiar= es y reconocer el sufrimiento y la difícil tarea en la toma de decisiones, son acciones que cau= san un alto desequilibrio a la hora de aplicar la AET (15,<= span style=3D'letter-spacing:-.05pt'> 29).

Por lo descrito, se desarrolla el presente estudio co= n el objetivo de sistematizar aspectos emocionales y éticos de la adecuación del esfuerzo terapéutico, pa= ra dar respuesta a las siguientes<= span style=3D'letter-spacing:-.2pt'> preguntas: ¿Qué dificultades se pueden encontrar en la aplicación de la AET?,

¿Cuáles son las estrategias orientadas al sostén= emocional del profesional sanitario frente a la aplicación de la AET?, ¿Qué reco= mendaciones se aplicaría sobre estrategias

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orientadas al soporte emocional en profesionales= sanitarios en el entorno de la aplicación de la AET?.

Met= odología

Estrategias de búsqueda

Se realizó la búsqueda en las bases de = datos Web of Science y Medline, en la plataforma ProQuest y en la biblioteca digital SciELO. Se usó el formato PICO (30,42) (población, intervenci&o= acute;n, comparación y resultados), para establecer la pregunta de investigación y definir = los descriptores. Los descriptores utilizados fueron: enfermería, autocuidado, adecuación = del esfuerzo terapéutico, decisiones, ética, aspectos emocionales, cuidados paliativos, final de la vida; posteriormente se crearon cadenas de búsqueda que determinaron los artículos seleccionados.=

Criterios de selección

Para la selección de los artículos se utilizaron:

1. Artíc= ulos originales publicados en<= span style=3D'letter-spacing:-.05pt'> inglés y españ= ol.

2. Publicados en los últimos cinco añ= os.

3. Estudios disponibles en texto completo.

4. Artíc= ulos que den respuesta a los objetivos d= e la revisión.<= /p>

5. Se analizaron los trabajos a= través del títu= lo, resumen y lectura completa, mismos que fueron clasificados como relevantes.

6. No fueron <= span lang=3DES style=3D'font-size:12.0pt;mso-bidi-font-size:11.0pt;line-height:1= 15%; letter-spacing:-.05pt'>seleccionados artículos duplicados, estudios que no estaban disponibles a textos compl= etos o publicados fuera del intervalo de= tiempo definido.<= /p>

Criterios de exclusión

1. Artíc= ulos sin permiso de acceso al texto completo.

2. Artíc= ulos duplicados.

3. Estudios publicados fuera del intervalo de tiempo definido.

Se identi= ficaron 128 artículos, de los cuales 48 fueron eliminados por tener citas duplicadas, 22 han sido excluidos luego de la lectura del título y del resumen, quedando 58 que cumplieron con = los criterios de evaluación para su elegibilidad, de los cuales 39 se excluyeron por estar duplicados y= no estar orientados a los objetivos del tema de estudio, quedando así un compendio de 19 artículos científicos seleccionados. Se organizó la información en 4 tablas según los objetivos planteados en la revisión bibliográfica.= En la revisión de los artículos 5 fueron elaborados en España= , 4 en Colombia, 3 en Uruguay, 2 Ecuador,= 1 en Chile, 1 en Brasil, 1 en Cuba, 1 en Europa y 1 en Perú.<= /p>

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Búsqueda bibliográfica

Se realizó una revisión bibliográ= ;fica de artículos cient&iacut= e;ficos que abordan “aspectos emo= cionales y éticos de la AET”, así también las características de los profesionales encargados de tomar decisiones para aplicar la AET que permitieron identificar dificultades asociadas a esta aplicación y finalmente= se elaboraron recomendaciones sobr= e estrategias orientadas al<= span style=3D'letter-spacing:-.55pt'> soporte emocional en profesionales sanitarios en el entorno de la aplicación de la AET. Tras la búsqueda (n=3D128), se descartaron los artículos que no cumplían los criterios de selección. Con los artículos seleccionados comprobando que estos aporten información rel= evante sobre el tema se procedió a un filtrado en base a la lectura completa, quedando definidos= los artículos, los mismos que dan un resultado de (n=3D 19).

Recogida y extracción de datos

Se diseñó una matriz de extracció= ;n de datos que contiene autoría del trabajo (título del artículo, autores, a&ntild= e;o de publicación, país y principales hallazgos).

Evaluación crítica=

Luego de<= span style=3D'letter-spacing:-.1pt'> la lectura completa de los artículos seleccionados, se realizó una evaluación de la metodología, orientándonos en la base de datos utilizada para= la revisión bibliográfica= realizada mediante la aplicación de la guía CASPe, la misma que posee preguntas de evaluación<= span style=3D'letter-spacing:.05pt'> crítica para los artículos en estudio.

Posteriormente, se pone a conocimiento la manera exac= ta de como se ha podido manejar la guía, los criterios establecidos según los estudios valorados junto a un resumen de los resul= tados de la evaluación crítica: Se inició con la lectura completa de los artículos, se <= /span>indagó la respuesta de cada una de las preguntas instauradas en el instrumento (10= preguntas de la guía CASPe), los artículos que contaban con los siguientes criterios fuer= on elegidos:

·= ; = No presentar en ninguno de los apartados de eliminación “NO CONSTA” (pregunt= as 1 a 3).

·= ; = No = presentar cuatro o más “NO CONSTA” o “DUDOSO” en los ítems restantes.

Todo lo<= span style=3D'letter-spacing:-.3pt'> mencionado se muestran en las tablas resumen de los resultados obtenidos tras la búsqueda y en un diagrama de flujo de búsqueda que se ilustra a continuación:<= /span>

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<= /span>

Consideraciones <= span lang=3DES style=3D'font-size:12.0pt;mso-bidi-font-size:11.0pt'>ética= s

Figura 1. Diagrama de flujo de la búsqueda

La revisión bibliográfica fue realizada= en bases de datos científicas y académicas; no existe ningún conflicto de intereses, ni aspectos éticos, que originen un problema para llevar a cabo el estudio. Los result= ados encontrados se consideraron de la misma manera que se consiguieron de= los artículos científicos y se realizó la citaci&oacut= e;n de todas las fuentes.

Resultados y discusión

Para el<= span style=3D'letter-spacing:-.1pt'> personal que labora en atención a la persona al final de la vida, la posibilidad de instaurar la AET está presente desde q= ue se conoce su pronóstico o cuando ingresa a las Unidad de Cuidados Intensivos, lo cual genera un ambiente de alta responsabilidad, incertidumbre y<= span style=3D'letter-spacing:-2.6pt'> preocupación, existiendo de = esta forma, un cuestionamiento constante respecto a los alcances de las intervenciones médicas y de los procedimientos invasivos.

Los temas que surgieron del análisis de los artículos fueron: aspectos emocionales y éticos, influencia de las opiniones que tien= en los profesionales para aplicar la AET, actividades que desempeñan cada profesional, dificultades que se presentan, importancia de la implicación familiar en el cuidado y satisfacción de las necesida= des del paciente con el fin de mejorar la = calidad de vida hacia una muerte digna, correspondiendo al personal de salud el brindar cuidados mínimos, tales como: control del dolor, sedación, alimentación e hidratación (excepto en el estado vegetativo o durante el proceso de agonía), administración de ox&iac= ute;geno, entre otros. Con estas medidas se procura aliviar los síntomas, ofre= cer el mayor confort y ayudar al paciente a una transición con el mínimo sufrimiento posible.

Según Hurtado (9) y Montenegro (18), los confl= ictos emocionales desencadenados al a= plicar la AET especialmente en el personal de enfermería son: temor, tristeza, miedo

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confusión e insatisfacción cuando la mu= erte es inminente pues a pesar de los cuidados que se pueden realizar no existe una mejora, añadiendo a esto que se bas= an en la religión que cada profesional de salud, mencionando así, que Dios es el único q= ue decide cuando termina la vida= , es por eso que, en las etapas finales de la vida los cuidados solo van dirigidos hacia el buen morir. Asimismo, Bernadá (12) coincide en que los aspectos éticos de la AET se basan en la bioética junto a sus princi= pios que son la no maleficencia, jus= ticia, beneficencia y autonomía del paciente.

La Guía de Práctica Clínica de Cuidados Paliativos del Ministerio de Salud Pública del Ecuador 2014 (MSP), alude a la falta de autocontrol ante la inminencia de la muerte puede afectar las necesidades de comunicación del paciente y su familia. El nivel de comunicación brindada dependerá de las emociones que experimente el paciente y el= profesional sanitario, sin<= span style=3D'letter-spacing:-.4pt'> embargo, la tendencia actual se orienta hacia la demanda de más información, la misma que debe ser sincera, sensible y esperanzadora para lo cual es muy importante que los profesionales de la salud demuestren cierto grado de empatía y utilicen un lenguaje claro y comprensible. Conforme a ello, se debe evaluar individualmente a los pacientes para saber si cierta información se puede brindar cuando el paciente esté solo o acompañado (26).

Según Carreras (41) y Cárdenas (44), el personal de salud debe poseer características como son: experiencia en brindar cuidados paliativos a pacientes terminales, conocimiento= s, actitudes y habilidades comunicativas para hacer frente a situaciones difíciles que contienen malas noticias. Mientras que, Hurtado (9) menciona que especialmente el personal de enfermería son quienes abogan por los deseos del paciente, incluso los familia= res y el paciente los miran como una guía al momento de aceptar el tratamiento o la clínica del = mismo, por esa razón el personal de enfermería debe ser tomado en cuenta como ente principal= al momento de aplicar la AET sin embargo, en el estudio de López (30), se hace referencia a que al personal de enfermería no se le consulta esta decisión a pesar de que son pacien= tes que se encuentran bajo su cuidado.<= /p>

En este sentido, la GPC de Cuidados paliativos del MSP, Ecuador= 2014 menciona que se debe proveer al paciente y a su fa= milia de cuidados al final de la vida para así satisfacer sus necesidades físicas, emocionales y espirituales, haciendo referencia a lo siguiente, se menciona: control de dolor, valoración de síntomas, cuidados de la piel, prevenció= n de úlceras, limpieza corpora= l diaria, sedación paliativ= a, incentivar a la autonomía, referencia a un psicólogo para ayudar en la ansiedad y la depresión, hablar acerca de lo ético, emoc= ional y legal con la familia, finalmente, aplicar métodos de comunicación tanto de bu= enas como de malas noticias (26).

Las dificultades asociadas a la aplicación de = la AET según Carreño (45) y Hurtado (9), es que el personal de enfermería no es consultado al momento de establecer un juicio ético. Por otro lado, Betancourt (39) y Bernadá (12), mencionan que una de las

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dificultades es la falta de capacitación en la comunicación de malas no= ticias a los pacientes y familiares, además, de no tener una buena relación profesional. Finalment= e, una dificultad para Casagrande (38) es el estrés y la carga laboral que presentan dí= a a día el personal de salud convirtiéndolo en un trabajo monótono.

Realizando una comparación con la GPC de Cuidados paliativos del MSP, Ecuador 2014 se menciona que las dificultades para aplicar la AET son: No respetar la autonomía del paciente y= su familia, carencia en el asesoramiento por parte de expertos o escasa participación del Comit&eacut= e; de Ética Asistencial, subestimar las necesidades de informar al paciente su estado y dar por hecho q= ue conoce su situación clínica, el no registro de actividades desarrolladas durante el= turno por otros profesionales, no dominar lenguas nativas lo que dificulta la comunicación con los pueblos indígenas (26).

Los autores Hernández (40), Casagrande (38), S= antana (46) y Carreras (41), llegan a la conclusión en que algunas estrategias asociadas al sostén emocional de los profesionales son: realizar diversas estrategias con el fin de disminuir el estrés en el ámbito laboral, realizar= un protocolo científico que oriente a todos los profesionales de salud al momento de practicar la AET, humanizar la atención sanitaria, dar paso a la experiencia de las emociones tanto en profesionales com= o en los estudiantes y capacitar frecuentemente en el afrontamiento de situaciones difíciles.

Ante tal eventualidad es indispensable disponer una c= ita comparativa en función de los <= /span>aspectos éticos que regula los cuidados paliativos según la vigente GP= C de Cuidados paliativos del MSP, Ec= uador 2014 en la que hace mención que el personal médico es quien facilita la toma de decisiones= ante dilemas éticos en la fase final de la vida y si el paciente no está en condicion= es de autonomía decisiva se deberían considerarse las siguientes opciones: Directrices pre= vias, deseos expresados por el paciente y recogidos en su historia clínica, en caso de que los haya, representante legal familiares a cargo más <= /span>cercanos, siendo importante en toda circunstancia; documentar la toma de decisiones e= n la historia clínica e informar al equipo sobre dichas acciones (= 26).

Siguiendo con este razonamiento, es importante mencio= nar que en la actualidad no se cuen= ta con un protocolo, guía u otro documento ni en la parte médica ni terapéutica que oriente a los profesionales d= e la salud a conocer cuando es o no necesario aplicar la AET, por lo general lo que realiza el personal médico despué= ;s de agotar todos los medios y re= cursos es comunicarse con los familiares del estado general del paciente, una vez = que los familiares aceptan el mal pronóstico, si el paciente se descompensa se accede a limitar la medicación y el apoyo ventilatorio. En Ecuador si por alguna situación los familiares directos no desean que se contin&uac= ute;e con el tratamiento independientemente del estado del paciente, no es posible acceder a su petición ya que la eutanasia no se encuentra legalizada en<= span style=3D'letter-spacing:-.05pt'> nuestro país (26).

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Por esta razón, la AET se encuentra basada net= amente en los principios bioéticos ya que en el Ecuador la aplicación de los Cuidados Paliativos y de la AET se encuentran establecidos en la G= PC de Cuidados paliativos del MSP, Ecuador 2014, que menciona “contribuirá para proveer información práctica y de fácil lectura que capacite tanto a los profesionales de la salud como a los familiares de personas que presentan una enfermedad incurable avanzada y de pronó= ;stico de vida limitado, acerca de los cuidados paliativos para que tengan mejores condiciones, aliviando sus necesidad= es físicas, psicológicas y = sociales”(47,48).

En este contexto, las necesidades físicas en pacientes terminales abarcan la nutrición, hidratación, higiene, analgesia, respeto a la privaci= dad, confort y control de síntomas <= /span>como pérdida del apetito, dolor, debilidad, ansiedad, náusea, estre&nti= lde;imiento, disnea, desánimo, intranq= uilidad, cansancio, alteraciones del= sueño, entre otros. Estas necesidades deben ser cubiertas mediante tratam= ientos y cuidados humanizados, en donde el objetivo es preservar la mejor calidad de vida posible hasta el final, manteniendo la mayor autonom&i= acute;a y eliminando el sufrimiento (5,= 6).

Por otra parte, también surgen las necesidades psicológicas, puesto que el paciente experimentará: ansiedad emocional, tristeza, estrés, depresión, miedo, incertidumbre relacionada con la evolución de la enfermedad, preocupación por los cambios en l= a imagen corporal y por la muerte, sol= edad, angustia, frustración, dificultad de despedida de los pacientes en sus últimos días por parte= de la familia. Por lo tanto, los cuidados= paliativos deben cubrir estas necesidades del ser humano en el proceso de morir, cuidar y acompañar, siendo parte de la atención integral, más <= /span>allá del querer “curar” (7).<= /p>

Las otra= s necesidades para considerar= en el cuidado a la persona al final de la vida son las sociales, estas se generan por camb= ios en las relaciones personales, a consecuencia de sentirse como una carga económica, social y familiar, a verse como estorbo o problema y a la pérdida de la autonomía. Al respecto, Maslow menciona que las necesidades sociales son motivadores activos de = la conducta como: amistad, afecto e intimidad. Las intervenciones de soporte social deben ser atendidas mediant= e el cuidado con empatía, amo= r y confianza, buscando mitigar la desesperanza, la soledad, el estrés, = la ansiedad y la depresión (8).

Otra esfera de importancia para el ser humano al fina= l de la vida es la atención de sus <= /span>necesidades espirituales, en donde las creencias religiosas juegan un papel importante en el caso de ser o no creyente. Por ejemplo, la desesperanza crea inseguridades y dudas sobre existencias religio= sas que en ocasiones obligan a aferrarse a la vida, se considera que la vida es sagrada y que solo Dios puede decidir sobre ella. De tal manera que, en sus últimos días buscan un ente o fuerza superior a fin de refugiarse, perdonars= e, protegerse y creer en la salvación de su alma para la vida eterna, demandan un ambiente espiritual como una fuente de alivio y esperanza. Usualmente, solicitan la presencia de sacerdotes,

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pastores, rosarios, imágenes, hierbas, aceites= o sustancias, como un recurso de consuelo o sanación (1, 9).

Según la taxonomía NANDA y NOC, basados= en las necesidades del paciente crítico se destacan etiquetas diagnósticas y resultados. En la necesidad= 11 Creencias/Valores se incluye la etiqueta diagnóstica 00124: Desesperación, atribuyéndo= se la sensación de no exper= imentar emociones positivas o una mejora en su condición de salud, asociándose con factores= como el temor, depresión, pérdida de fe, estrés, apoyo soci= al inadecuado, aislamiento, enferm= edades crónicas o terminales, para esto se desarrolla las NOC 0902: Comunicación y 1201: Esperanz= a. También se incluye la etiqueta diagnóstica 00147: Ansiedad ante la muerte, se asocia c= on factores de experiencia cercana a la muerte o el experimentar el proceso de agonía y confrontación de la realidad de la enfermedad terminal, acompañado de las NOC 1201: Esperanza, 1307: Muerte digna y 2001: Sa= lud espiritual (49, 50).

Dentro de la necesidad 09: Evitar peligros/Seguridad = se abarca a la etiqueta 00061: Ten= sión del rol del cuidador, esta se encamina en la decisión de la familia o representante legal sobre la aplicación de= la AET. Debido a factores como la resiliencia psicológica inadecuada, estrategias de afrontami= ento familiar ineficaz y enfermedad crónica, lo cual dificulta el cumplimiento con las responsabilidades, expectativas y/o comportamientos del cuidado de la familia hacia el paciente. Se aplica la NOC 2609: Apoyo famil= iar durante el tratamiento (49, 50).=

Con= clusiones

·= ; La AET consiste en la decisión de adaptar los procedimientos médicos, diagnósticos y los cuidados enfermeros a la situación clínica de los pacientes, para prevenir acciones innecesarias que no van a mejorar su condición médica.= Se hace referencia a que los m&eac= ute;dicos tienen mayor facilidad de manejo de la AET, pero si hablamos= de los profesionales de Enfermería, se ha identificado miedo al practicar la AET, consideran que se toman decisiones radicales y difíciles, por lo que, el personal de salud experimenta emociones y situaciones como: estr&eacut= e;s, confusión, tristeza, temor,= insatisfacción, perturbaciones éticas contrarias a su misión y conflictos religiosos al asociar a la AET con la decisión entre la vida y la muerte de una persona.

·= ; En cuanto a los aspectos éticos que se presentan en la AET se encuentra= la bioética junto a sus principios que son: beneficencia, no maleficencia,= autonomía y justicia. Al momento de aplicar la AET todo el equipo de salud debería estar incluido, = sin embargo, enfermería sigue sie= ndo unas de las profesiones subestimadas al momento de realizar una toma de decisión o de participar en el acto, pues como profesional posee ciertas características que constituyen una fortaleza para el equipo de salud como: empat&iac= ute;a, aboga los deseos del paciente y de la familia, posee conocimientos, actitude= s y habilidades comunicativas-relacionales aplicables en situaciones complejas,

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responsable de brindar soporte vital, ayuda a entende= r la situación clínica, entrega información veraz y facilita la aceptación de la muerte.

·= ; Entre las dificultades asociadas a la AET se identificaron que enfermer&ia= cute;a no es tomada en cuenta para decidir la aplicación de AET en pacientes terminales, en los estudios se explica esta situación en la percepción de poseer competencias insuficient= es para aplicar los cuidados y med= idas de soporte terapéutico. Los dilemas éticos, el estrés = en UCI, la falta de recursos sanitari= os y de personal especializado, ha generado una excesiva carga laboral, otras dificultades identificadas son: la falta de registros sobre la condición del paciente, la falta de protocolos sobre la AET, obstáculos en la comunicación entre el equipo = de salud con los familiares, poca comprensión de la enfermedad por parte del paciente y de los familiares, todos estos factores limitan o dificu= ltan tomar la decisión de AET.

·= ; Finalmente, entre las estrategias que permiten la participación adecuada de los profesionales d= e Enfermería en la AET se encuentran: fortalecimiento de la formación académica en el tema (manifestaciones del paciente, disminución del sufrimiento, suspensión de medidas de sopo= rte vital, cuidados y afrontamiento sobre la AET, manejo de emociones), por otra parte, es fundamental la= creación de programas, guías y protocolos que faciliten la atención multidisciplinar al final de la vida, considerando las necesidades físicas, emocionales y espirituales tanto del paciente como del personal de salud encargado de su cuidado. Ser&ia= cute;a útil recibir informa= ción o capacitación respecto a la AET en temas de la planificación anticipada del cuidado, comunicación colaborativa con pacientes y familiares, regirse a un marco bioé= ;tico y legal, comunicación asertiva entre profesionales de la salud y herramientas de discernimient= o clínico-ético.

Conflicto de intereses

Los autores declaran que no existe conflicto de inter= eses en relación con el artículo presentado.

Declaración de contribución de los autores

VMMA, NPV= A, SCMJ & DSGE: delimitaron la idea y el tema de investigación, selección de tópicos= a abordar en el artículo y búsqueda de los artículos en = las diferentes bases de datos y posterior selección de los artículos a incluir en el estudio.

VMMA, NPVA, SCMJ: Diseño del= primer borrador

VMMA, DSGE: Revisión, corrección y sugerencias del borrador inicial y posteriores

VMMA, NPVA, SCMJ & DSGE: Revisión y aprobación de la versión fin= al del artículo y envió a la revista

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El artículo que se publica es de exclusiva resp= onsabilidad de los autores y no necesariamente reflejan el pensamiento de la Revista Anatomía Digital.

El artículo queda en propiedad de la revista y, por tanto, su publicación parcial y/o total= en otro medio tiene que ser autorizado por el director de= la Revista Anatomía Digital.

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