Directives of Patient ’ s Will : a Study Among Resident Physicians

Results: It was found that about 98% of the participants fully or partly agree to respect the wishes of the patients or their representatives, if they are unable to express themselves. However, 73% of participants reported to disregard the wishes of the patient if they contravene the Medical Ethics Code and 76.9% of physicians agree that advance directives should be recorded in the medical record. It is noteworthy that expressed favorable that the wishes of the patient prevails over the wishes of the family.


Introduction
The end of life is a moment that is too complex, permeated by a multiplicity of feelings and fears.The explanatory juxtaposition to live and the awareness that death is a stranger to the individual have the potential to cause a significant amount of distress.Therefore, it is natural to understand that many individuals, after the diagnosis of an imminent death, present the aspiration of a finitude free of suffering among their wishes and desires, promoting the improvement of their self-esteem and, consequently, increasing its quality of life [1].
Although, structural and organizational characteristics, attitudes of the professionals and the decisions made by family members may adversely affect the patient's well-being, and are therefore considered harmful to the dignity of the patients that have no cure prognostic [2].Still, the lack of practical clinical protocols related to the terminal period of life makes the standardization of care procedures impossible, turning it improvised and difficult to assist these patients.[2].
Inserted in this scenario there are the advance directives of the patients will (AD), a tool that prioritizes the will, intention and the discernment of the patient built in a form of a document that expresses the types of treatments that the individual wishes to receive in the instant he or she are not able to make their own decisions anymore.This document must be recorded even when the patient still has mental clarity and complete autonomy to decide for themselves [3].
The AD are already secured as legal in countries such as United States, Spain, Portugal, Germany and Uruguay.However, in Brazil is still required regulation and it is a subject of profound debate.The Federal Council of Medicine of Brazil (CFM) has committed to regulate it in the Medical Ethics, by Resolution 1995/2012, that features about the AD.This decision fills an important gap in this approach as it motivates and encourages discussion and the interest around the issue in a national level [4,5].
It is necessary to point out that the CFM Resolution 1995/2012 provides that doctors should consider the AD in the care of patients, however fewer of them reported using it, in fact, because they believe that the impact of this type of document is not clear under the palliatives care [5,6], in another words, care for the prevention and relief of suffering through the identification and early treatment of physical and psychosocial symptoms throughout the disease process, even if the result is the patient's death.[7].It notes that the aforementioned registration does not guarantee that the patient's desire will be respected, since this is not considered an official document with legitimacy, requiring larger theoretical basement on the subject.
Considering the reality that was exposed before presents itself, on a daily basis, in the medical routine and in view of the importance of the fulfillment of the patient's wishes in their last moments of life, it is relevant to investigate the level of agreement of the resident physicians in a public hospital located in the city of João Pessoa-PB, related to the CFM tion 1995/2012 of the Federal Council of Medicine of Brazil, which guides as the Advance Directives, considering it adequate and appropriate to direct medical action against dilemmas and conflictive situations that commonly arise in the management of patients in terminal condition.
Resolution 1995/2012 which deals with the AD, in order to better understand whether there is any impediment, from the perspective of the medical profession for the implementation this policy into routine health services.

Methods
It was performed a descriptive study, cross-sectional with a quantitative approach.This type of research aims to observe, record, analyze and sort data without interference from the researcher and seeks to discover how often an event occurs, its nature, its characteristics, causes and relations with other facts [8].
The research was conducted in August 2013 in a public hospital in the city of João Pessoa -Paraíba, Brazil, associated with the Ministry of Education and founded in 1980, formed by a single unit divided into two areas: Outpatient and Inpatient.It is worth noting that the hospital network of the municipality is made up predominantly by public hospitals.
The present study had a sample of 52 resident physicians, 27 males and 25 females, aged between 20 and 40 years.For its selection, the following inclusion criteria were adopted: the professional should be working in that position and activity at the time of collection.
The sampling procedure adopted in the study was a non probabilistic and the sample was chosen by accessibility [9].This modality does not present a greater statistical rigor, being the same as the ones used in exploratory research.It is understood that, statistically, a sample over 30 already produces meaningful data for studies which the sampling process is performed by accessibility [10].
The tool used in this study was composed of two parts: the first one with questions about the professional, aiming to know your profile; and the second, with five items, answered on a Likert five-point scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree), which aimed to measure the perceptions of resident physicians of the hospital studied about the AD.These items were developed based on the CFM Resolution 1995/2012.
The study sought to understand the AD from the perspective of resident medical professionals, by the CFM Resolution 1995/2012.It was also found the level of agreement about the resolution in question, according to sex.
The data from the data collection instrument were treated quantitatively by using descriptive statistics (frequency and simple percentage) and inferential, from the adhesion test using chi-square.This test allows discovering if a set of observed frequencies differs from another set of expected frequencies.The data were analyzed by the nominal level, and each individual should frame your response in only one category.Analyses were performed using the Microsoft Office Excel and Statistics Package for Social Science programs -SPSS version 21.0.The significance level was 0.05.
The study met the ethical and legal requirements established in Resolution 466/2012 of the National Health Council of Brazil (CNS), which regulates research involving human beings in the country, which incorporates the perspective of the individual and communities, the basic principles of bioethics, such as autonomy, non-maleficence, beneficence, justice and equity, among others, and aims to ensure the rights and duties, which relate to employees of research, the scientific community and the State [11].
This research is part of the larger project entitled "Palliative care in hospitals and primary care: a bioethical approach", approved by the Ethics Committee of the University Hospital Research Lauro Wanderley, under protocol number 184/10.

Results
Among the 52 resident physicians participants of the research, the most prevalent age group was between 20 and 30 years, with average of 28 years, 51.9% were male, showing an equivalence in the participation between the genders.With regard to medical specialty, anesthesiology was the one that was more noted which were 34.6% of the participants (Table 1).
Faced with the magnitude of the implementation of the AD and considering that they constitute a type of declaration of will for medical treatment, it was found that 59.3% of male participants of this study fully agree to use it when patients are unable to communicate, while the majority of women, 56%, partially agree.It is noteworthy that 98.1% of respondents fully or partly agree to respect the will of the patient (Table 2).The value of X 2 with two degrees of freedom was 23.34, significant at the 0.05 level (p <0.001), demonstrates that there is a difference between observed and expected frequencies.With this, it is concluded that the response options do not present the same degree of preference.
It was also observed the perception of the doctor about taking into account the decision of a representative who has been appointed by the patient.The results show that there is a high concordance rate in this aspect, considering that in male participants, the total concordance rate was high (51.9%),followed of those who partially agree (48.1%).Among women, the same was true, since 98% of the participants of this kind demonstrated to agree totally or in part with this aspect.Only one participant (4%) showed partial disagreement with the statement (Table 3).It is noteworthy that the value of X 2 with two degrees of freedom, was 23.11 and had lower associated probability than 0.05 (p <0.001), suggesting that there are differences in preference of options.
In regard to the respect of the patient's will, when it is inconsistent with the ethical and health behaviors, most respondents participants (73.1%) fully agree that if the patient requests counteract to the Medical Ethics Code (CEM) of the CFM, the    professional can refuse to take any action that does not have technical and scientific support or is not legally supported.These frequencies were approximately the same in males (70.4%) and female (76.0%) (Table 4).The value of X 2 with two degrees of freedom, was 23.11 and associated probability was less than 0.05 (p <0.001), suggesting that there are differences in preference options.Also, it was questioned the degree of agreement of physicians in relation to the registration of AD directly in the chart.The results showed that most physicians agree completely (76.9%),followed by those which partially agree (15.4%) (Table 5).The value of X 2 with three degrees of freedom, was 48.51 and associated probability was less than 0.05 (p <0.001), suggesting that there are differences in preference options.
Later we analyzed the perceptions of physicians about the prevailing of the AD over another nonmedical statement, including the desire of the family.For this statement, more than a half of the participants agreed partly (53.8%), and the percentage of choosing this option was higher among women (68.0%) than among men (40.7%) (Table 6).The value of X 2 with three degrees of freedom, was 34.77 and associated probability was less than 0.05 (p <0.001), suggesting that there are differences in preference options.

Discussion
The results found in this study are consistent with what is found in the literature, demonstrating that medical residents have a positive perception about advance directives of patients, reinforcing the need to use them.In this sense, a research conducted in the state of Santa Catarina, with 209 respondents, comprising doctors, lawyers and students of both courses, found that 61% of participants would respect the anticipated desires of the patient, and 36% have proved favorable to orthotanasia, 1.9% dysthanasia and 1.4% euthanasia [4].
Thus, another study assessed the medical view of the patient's wishes in making decisions.The results showed that these professionals consider very important the autonomy of an ill individual, reaching an average of 8.37 on a scale from 0 to 10 points [13].The same research [13] questioned whether medical professionals would respect the patient's wishes expressed by the statement of anticipated will, getting close to average maximum score of 10 points (M = 8.26).Therefore, both this study and others performed in Brazil show that the medical team is favorable to the inclusion of the AD.
From this perspective, ensure autonomy in health is a right that must be observed by everyone, since the respect for the patient ethically substantiate the medical management.In contrast, there is evidence that doctors find it difficult to address the death and everything that surrounds it, making it difficult to insert the AD in medical practice, even with the fact that they constitute a useful tool for health professionals, especially for medical decisions [14].
The AD, presenting itself as a new approach to decision-making by the patient or by a representative, comes to prevail in health decisions when a individual, faced with a terminally prognosis, is not looking forward to intensive actions that lead to the prolongation of life through futile treatments.The advance mentioned is compared to the right of the patient to have a position in favor or not of the procedures and treatments headed for themselves during the service in any health facility.However, in this case, the patient is conscious and communicating verbally at the time of action, which differs from the AD in which the patient is in preserved neurological conditions and produces a document that gives him the autonomy over their body, on actions and procedures even when unconscious and private to communicate [3].
It is evident that during the preparation, the AD can be supplemented with the appointment of a health care attorney who will have powers of rep-resentation.Constituting person of trust of the patient shall be the depositary of his will in the event of being unable to express themselves, deciding about health care.This new paradigm aims to break the centralization of health decisions in the medical, giving more responsibility to the main interested party, the patient [15,16].In this situation, it would be through their representative, which should be linked to their desire, observing and fulfilling their aspirations.This has been reiterated in its assessment by the research participants, with high concordance rate in the question which concerns take into account the decision of a representative who has been appointed by the patient.
The dilemmas experienced by physicians to assist a patient in terminal illness, are based on distinguishing the best therapeutic conduct in cases of irreversibility and critical health condition.Understand that the best for the patient is to let the process of death occurs in its natural course, instead of using all the technology available to ensure survival through therapeutic obstinacy, is not an easy task.These challenges cut across the field of bioethics demanding professional humanization in palliative care [17].
It is worth emphasizing that the CEM guides the actions to be taken faced to the professional dilemmas, looking for the balance between what is ethical in professional practice and what is requested by the patient [18].From another perspective, the codes do not eliminate the possibility of failure, but offer the professional and the patient indication of good conduct, based on ethical principles of autonomy, beneficence, non-maleficence, justice, dignity, truth and honesty.The Medical Ethics Code carries in its heart the voluntary commitment, individually and collectively assumed, with the practice of medicine, represented in its genesis the Hippocratic Oath [5].
Recently, there was the need to upgrade the CEM, since new realities emerged in assistance.Thus, the new regulations took place by Resolu-tion 1931/2009, incorporating the importance of the respect for the patient's wishes in a terminal condition wishes prioritizing actions determined by the patient, aiming, in last case, that all therapeutic resources used minimize suffering [17].
From another point of view, completion of human life brought reflections for professional conduct.In this new perception of care, CFM Resolution 1995/2012 provides in § 2º "that the advance directives of the patient's will or legal representative may be disregarded if the analysis does not follow the precepts of CEM", corroborating the data obtained in the present research.CFM is shown fully in favor of guidelines, however, requests by the patient should not hurt the ethical principles of medicine and the professional may reject or not to consider the AD.The resolution provides the professional background to deal with everyday situations and conflict within the legal legality [5].
When the desires and patient's wishes are likely to be attended without hurting any jurist precept, it is essential that the professional, when considering the AD, make the proper registration for subsequent verification, allowing ensure full, especially in cases where the patient was contrary to others.In this perspective, the questioned professionals, regarding to the registration of AD in the patient's records, were favorable, which was evidenced by the high level of agreement of the same.
Also known as the patient's record, the medical record is a tool used by all health professionals involved in assisting the sick individual.Its regulation occurred at Federal Council of Medicine through Resolution 1638/2002.The chart also shows commitment to human dignity, to consolidate the previous patient's will, according to Resolution 1995/2012, § 4 "the doctor will register in the medical record, the advance directives of will that were communicated directly to them by the patient" [19].This premise, some legal experts say that the resolution makes no necessary formalization of a document.The doctor, before the exercise of his/her profession, can register in the medical records the advance wishes of the patient with public faith [20].
In contrast, the CFM, as a class apart, effectively, does not have jurisdiction to determine the requirement of AD settlement in notary's office [21].In this line of thought, non-formalization is appropriate to prejudice the autonomy of the patient, because this right is supported on the assumptions in the Constitution of the Federative Republic of Brazil 1988 [22].
Otherwise, it is clear that resident doctors had doubts when asked about the realization of the AD to the detriment of the will of family members.Thus, most agree partially (53%) not to consider the opinion of the family before the patient's desire, and yet, this was the point where there was a greater divergence between men and women.These results may suggest the existence of gender differences in medical staff dealing with the family.Nevertheless, there is evidence that there are no gender differences in relation to assertiveness [23].Anyway, this may be an important direction for future researches that seek to fill the gaps of knowledge regarding to this inquiry.
This question becomes even more pronounced when the denial of the diagnosis by the family associated with technology and advancement in medicine, generate attempts to obtain unlikely healing and intense suffering to all involved.Even considering death to be a natural phenomenon, its denotation is associated with an extremely traumatic event for both the patient and the family, so it is a common practice to seek contrary alternatives [24].
In this perspective, the Resolution 1995/2012 in and Article 2 paragraph § 3 denotes that "the anticipated patient directives take precedence over any other non-medical opinion, including on the wishes of the family" [5].It is worth noting that medical decisions should focus on the patient in detriment of the family, or the doctor.However, decision-making, whenever possible, should be shared, highlighting the relationship between the physician, the patient and his/her family.However, in case of divergence, the patient's preferences should be prioritized, even if not in a sovereign manner, since legal restrictions must be safeguarded [25].
In conclusion, most medical residents, through their positioning, show that the AD present themselves as a tool that should be considered, materializing the autonomy of the patient over any other will, including family members, since they do not violate the Medical Ethics Code and they have proper registration in the medical record.Thus, the AD is understood as the expression of the patient's autonomy, because as its implementation is ensured, the dignity of the individual is accomplished.

Conclusion
It is noticed that the doctors attending this medical research infer the AD as adequate and appropriate to direct medical action against dilemmas and conflict situations that commonly arise in the management of patients in terminal situation.
It is expected that this scientific research may contribute to a greater theoretical development for health the part of health professionals and students, focusing on improving assistance to terminally ill patients and their families.The relevance can be emphasized also by the difficulty in finding research focusing on medical professional, demanding the new studies in order to contextualize the size of the directives from the perspective of these professionals.

Table 1 .
Socio-demographic data of the resident physicians participating in the study.

Table 2 .
The agreement level of medical residents about the implementation of the advanced directives of the patient's will.

Table 3 .
The agreement level of resident physicians regarding to take into account the wishes of a representative specified by the patient.

Table 4 .
The agreement level of resident physicians in not considering the Advance Directives in the allocation of their treatments, when there is disagreement with the precepts dictated by the Medical Ethics Code.

Table 5 .
The resident physicians agreement level in regard to the registration of Advance Directives directly on the chart.

Table 6 .
The medical residents agreement level as the prevailing of the Advance Directives over another nonmedical statement, including the wishes of the family.