Brazilian Health Professionals ’ Perception about Death : an Integrative Review

Results: The evaluation of the work made possible the detection of five perceptions towards death: life stage, technicist conception, move to a better place, liberation from suffering and unexpected interruption of life. It was noticed that nurses are the professionals who have more comprehensive understanding of death as multifaceted event. Moreover, most doctors have a vision centered on the technicists and biological ideals.


Introduction
As born and grow, death is part of the development of human life, being characterized as a natural fact and expected.Some experiments experienced by every human being give an analogy of the idea of death with separation and disease, making man's view on the subject somewhat negative [1].
Death can be divided into clinical, biological, obvious, brain, psychic, legal and brain [2].Death, whether insidiously or preceded by foreshadowing, enables the presence of reflexive posture and the review of concepts by closer to this process, family members and healthcare professionals.
The development of medicine has allowed a profound improvement in human health, with direct implications in improving the quality of life of people, particularly in developed countries, whose direct consequences are the reduction of mortality and increased life expectancy.Improvements that have brought up the dilemma surrounding death, mainly which related to artificially prolonging the life of terminal patients, incurring on the patient's autonomy concepts and human dignity facing discussions on the practices of euthanasia, dysthanasia and orthotanasia seeking a dignified death [3].
Confirmation of the difficulty of professionals to deal with the theme recurs in the published studies on the subject, showing that even this death is still faced as strange fact and not well-liked by health workers [4].
Aiming the knowledge about the subject is critical to the correct practice of good care; this research is fostered by the need to know the perception of Brazilian health professionals, so that such work shows the importance of expanding discussions on death and dying.The objective is to analyzing the perception of Brazilian health professionals about the terminal illness of life, from the review of scientific production.

Method
For the organization of work, a study was developed along the lines of integrative review, which are selected, evaluated and condensed studies about the same subject, enabling then the formation of critical thinking and the development of protocols and procedures to be incorporated into daily practice.The preparation of this type of study consists of six steps, summarized below [5].
Step 1: Definition of the theme The beginning of the work was due to the issue of definition to be discussed.We chose to addressing and analyzing in this study, a subject that is relevant to clinical practice and hardly discussed in hospital environments and academic training.This difficulty can be explained by the fact of the matter being a peculiar issue involving ethical and legal aspects, making it different.In view of the problems addressed, the central question of this study was: 'What is the perception of Brazilian health professionals about terminally life?' Step 2: Screening in literature The research on the subject was held at the International Medical Published-database service of the US National Library of Medicine (PubMed) and the index of Latin American Literature in Health Sciences (LILACS) on November 4 th , 2014.
It was used to carry out the screening, the descriptors in Portuguese: nursing, perception, euthanasia, medical, death and attitude towards death in the survey conducted in LILACS.The same descriptors were used, but in English, for the search carried out in PubMed.Articles on human beings were included, published in the period 2005-2014, in Portuguese, English and Spanish, with summary and text published in full, characterized as exploratory qualitative research/descriptive and performed in Brazil.It was only computed once the articles that appeared in duplicate and excluded those who did not discuss primarily the theme proposed in this study, as well as those who did not meet the inclusion criteria mentioned above.In LILACS, the survey was conducted initially with the placement of the descriptors: nursing, perception, euthanasia, medical, death and attitude towards death, joined by the Boolean operator OR.
They found 956 articles, after the application of filters article and summary available in full work of the last 10 years, about human beings and in English, Spanish and Portuguese, totaled 245 items.After reading the title of the work, it was found 57 articles on the subject, of which 18 were preselected.
Subsequently, we carried out a new search, even in LILACS, by combining descriptors.The first association was made "Nursing AND Euthanasia", and found a related article; the second search was conducted with the union "AND Doctors Euthanasia", with the presence of nine works, but only two met the criteria adopted; the third survey was conducted with the terms "Perception AND Nursing AND Death", being found 26 articles, five of which met the inclusion and exclusion criteria; the fourth combination was performed "Doctors AND Perception AND Death", being five articles related to the topic, leaving one, after the application of the criteria; the fifth arrangement was made with the words "Attitude death AND Nursing, " resulting in 16 articles, with only 6 pre-selected; It was last searched "Attitude death AND Doctors", and found two articles, one after leaving suitability criteria of this work, totaling 13 articles at the end.
In PubMed, the search was conducted with the descriptors: nursing, euthanasia, death, perception, doctors and attitude to death united by the Boolean operator OR.There were no articles related to focus on death, proposed in this paper, which can be explained by the fact that such a database be set up, for the most part, Clinical Trials, methodology not applied the theme focused on this research.PubMed has the feature to provide bibliographic indexing services, genetic and genomic sequence, sequences and three-dimensional structure of proteins, taxonomic database of human genetic information, etc. [6].Thus, the theme of research addressed becomes limited in this database.
Step 3: Data collection After preselection, there was the extraction of data from 31 articles by a collection instrument, validated and adapted, which included data for evaluation as work identification and realization of main institution headquarters, methodology, objective, sample, interventions, results and conclusion [7].It is sought; therefore, ensure that the relevant data for the research were taken, minimizing failures and performing a deep checking of the information.
Step 4: Analysis of included studies This phase is characterized by the evaluation of methodological rigor and peculiarity of each study, using the evidence-based practice -PBE to propose a hierarchy of evidence.This practice in qualitative studies is not well defined.
It is worth mentioning the premises of qualitative research are different from quantitative, having therefore other ways to interpret and evaluate scientific methods of that type of study [8].Based on this characteristic of qualitative research, we sought at this stage to correlate studies, juxtaposing the results according to the central theme of this research.After analyzing the 31 pre-selected articles remained 15 works of LILACS.
The articles were organized into categories, according to the perception of death observed in studies: life stage, technicist conception, and moving to a better place, suffering and liberation unexpected interruption of life.
Step 5: Discussion and summary of results At this stage, we tried to identify biases and possible faults in the construction of knowledge from the critical analysis of each article, outlining the conclusion and drafting new statements and inferences on the subject, which gives it the construction of a new knowledge.The presentation of the results took place in the form of tables, created according to the division proposal for the items, explaining the form and content of each work.
Step 6: Building knowledge It is the presentation of integrative review complete and explicit.Hand throwing tool already described for data analysis and, after following the steps abo-ve this, it was possible to more detailed assessment of each study researched, with evaluation of each conclusion as to limitations.It attempted to, thereby, achieve the reduction, exposure and comparing the findings to data analysis in qualitative research [5].

Characterization of the articles
Table 1 shows the year of publication, the federal state where the surveys were conducted, as well as the journals in which the papers were published.We realize that the largest number of studies was published in 2009 and 2013.The state that best researched on the subject was that of São Paulo, with five articles [11,15,[17][18]21].
Table 2 shows the characterization of selected articles, according to the authors, title, journal, volume, number and year of publication.

Perceptions of brazilian health professionals about the completion of life
In response to the main question of this integrative review, "the perception of Brazilian health professionals about the terminally life", Table 3 summarizes the results found in the analyzed articles.Then the discussions will be exposed.

Discussions Characterization of the articles found
It is noticed that the theme is prevalent among nurses, this fact can be explained by these have guided their training in comprehensive care for human beings in every stage of life, including the death process.In addition, nurses are staying next to the terminal patient continuously and are considered key elements for the thematic discussion.
The practice of nursing is to care for the essence, racing this professional approach a physical, mental and spiritual patient who fostered by moral and ethics, makes the professional able to cover a multidimensional human, through scientific practice association with humanitarian [23].
The articles that analyze the perception of the multidisciplinary team [10,13,21] have limited results, considering the unclear details of the opinion of each respondent, prioritizing the analysis of the health team concept at the expense of individual perception of the professional.

About the ideas of the authors about the completion of life
Category 1. Death as a stage of life Among the categories of perceptions, it stands out that death is considered a stage of life of every human being.Even health professionals comprising death naturally, there are several challenges faced by them.
The reports analysis of a group of pediatric intensive care unit nurses is list a difficulty on the issue of early death [9].Notes also that, even with the inherent sadness of death, the perception that it makes up a stage of life that provides attitudes alleviate the suffering of everyone involved.
This can be evidenced by the following statement: "It is inevitable and sometimes it is best for the child, when its condition cannot improve and there is great suffering.When this happens suddenly, it is very sad " [9].
In a study of group of nurses in an oncology unit, noted the view of death as a natural process of life, highlighting the importance of this in relation to the deaths of pediatric patients [11].After this realization, the professional is able to see death from a positive angle, providing the patient, grant to a dignified death.
In research conducted with nurses in an intensive care unit (ICU), report that respondents understand death as inherent to life [16].Despite this perception, nurses find it difficult to accept the death of newborns, comparing the findings of the study conducted with nurses in an oncology unit previously mentioned [11].In this way, the loss imposed suffering overrides the fact that death be understood as something natural for these professionals.
In the same perspective, there is evidence that, despite having a proper understanding of the finitude of life, health professionals dealing with terminal patients are full of negative feelings resulting from the unpreparedness to support the entire process surrounding the death [20][21].
Therefore, understanding of death as a stage of life, and not as a disease, is the first step in its proper acceptance in order to change the mentality against death rooted in today's culture.After studies with nurses of Paraná ICU, highlighted the need also for greater training of professionals, since graduation, so they are able to bear this burden [19].

Categories of perception Articles Professionals Abstractions/Comments
Stage of life [9] Nurses Nurses define death as a natural event, a part of the cycle of life of human beings.
[10] Dietitian/Doctor/Nurse/ Nursing technician The team sees the death of the elderly in a calm way thus is defined as something expected of the natural cycle of life.
[11] Nurses Nurses interpret human finiteness as a stage of life, although this happened early.
[15] Doctors The doctors realize the completion of life naturally, as something intrinsic to the fact of being alive, allowing a practice based on orthotanasia.
[16] Nurses The nurses have the perception that death is part of life, but have difficulty in accepting it as such when it comes to the death of newborns.
[18] Nurses The nurses' perception about death is that she is a natural stage of life, being the dysthanasia prolongation of pain and suffering, while the orthotanasia is the ideal death.
[19] Nurses The nursing staff understands death as something that is part of life, being thus realizes that his dysthanasia is slow death, anxious and suffering.
[20] Nurses The death of the elderly is seen as a natural step in life.
[21] Doctors/ Nurses Health professionals realize, in its entirety, death as stage of life, but it is surrounded by numerous difficulties of understanding in daily practice.
Technicist conception [4] Doctors Within healthcare, the completion of life is almost always reduced to technical rationality.
[12] Doctors The understanding of physicians about the completion of life anchor the definition based on biology, the death as permanent cessation of biological activities necessary to maintain life.
[13] Nutritionist/Nurses/ Doctors Some professionals present a technical perception of death.
[17] Doctors Doctors understand death as cessation of biological activities.
Euthanasia is perceived as a method of reducing the suffering.
Moving to a better place [13] Nutritionist/Nurses/ Doctors Some health care professionals use religious ideals to define death as a ticket to a better place.

Freedom from Suffering
[14] Nurses Predominates among the nurses, the perception that death is a relief and liberation from suffering.
Unexpected interruption of life [20] Nurses The death of children is taken as the unexpected interruption of the life cycle.So even with the proper understanding of death, the difficulty in accepting it is a constant in the daily lives of nurses without preparation, triggering dysthanasic practices, as evidenced by the following statement: "Because I think when we have a young patient we must make all investments, but what I see in here is that we are fighting against nature itself.I've been questioning me very well, much is he paying off, what I'm doing here?Does it is what I have to do?Is it that one is right?Am I not preventing life?Because we work a lot with older people, so I guess I would have to let these people follow the normal cycle of them."[19] In another study, nurses in an adult ICU, from the conception that death is natural and good preparation for dealing with human finitude, define dysthanasia as extending life with pain and suffering, through which patients terminals are subjected to futile treatments [18].Such understanding enables professionals bring principles of orthotanasia to their daily practice, prioritizing comfort and death at the right time.
With regard to bioethical issues, the correct conception of critical care physicians on death triggers a series of measures that seek to dignified death that ruled in reducing the suffering, the psychological, social and spiritual comfort [15].
Moreover, it could be noted that a team of professionals working on a long term care facility for the elderly faces death as something natural, prioritizing the quality of life at the expense of prolonged suffering [10].
The predominant perception of death as a stage of life for nurses is something that deserves attention.The fact that their training is focused on the care, holistically, allows a better understanding of death, making the figure of the nurse focal point for adequacy front conducts the finitude of life.

Category 2. Technicist view
In confirmation to this category, the evaluation of the meaning of death for 20 doctors from the Cli-nical Hospital Samuel Libânio allows the statement that the understanding of the dying process is the cessation of brain activity, highlighting the biological and technical vision of physicians assisting terminal patients [12].
The technique and the procedure, when evaluated, they are always prioritized the act of caring.This can be evidenced by speech, then a health professional, not determined by the study, working in a teaching hospital in Brasilia: "The doctor is a technician, who must have their ethical and balanced posture, to spend the news more quickly and directly as possible.Therefore, I would be the most frank and sincere as possible, regardless of their reaction."[13] Such speech can be explained by reductive perception of death, presented to medical students, which brings death to stop the vital functions of man, not contemplating the subjectivity of being.What is observed in work with doctors in a Marrow Transplant Unit Bone, which highlights the fact that medical training, focused on theory and techniques, does not include emotional aspects, ignoring the psychic dimension of the health professional, which explains the technicalities stance taken by the doctor when in contact with terminal life [4].
The focus on the ideal of healing power, presented by doctors, also said that he escape the inevitable human condition, death.The terminal patient is the symbol of the pursuit of health loss, and the approach of the professional to the patient who will die cause discomfort and sense of loss to the physician [12].
Thus, after an interview with a team of professionals from various fields who work with terminally ill patients, found that the technicalities design evidenced in respondents, just corroborating the position of professionals not involved with the patient, attitude which further distances the sick professional [13].The social death of the patient, then, is prior to biological death, aggravating the suffering of being careful and their families.Also, another relevant fact of the medical view is in relation to bioethical aspects, seen in survey of 30 physicians of patients with Alzheimer's disease that less than 50% of respondents are favorable in practice euthanasia, and, at the same time they pointed out that 66.6% of those respondents accept at least a variant of the duct [17].
Euthanasia is not legalized in Brazil, and the stance taken by these doctors revealed the need for further discussion on the subject, either by authorities, either by the general public as a way to establish guided conduct on ethical and legal principles in order to ensure, above all, patient autonomy and the right to die with dignity.[17] Category 3. Death as moving to a better place Based on this category, the study of a nutritionist, two doctors and two nurses, showed that through individual beliefs, professionals perform an interface between religious philosophy and secular approach to science, emerging, thus the perception that death is a passage to a better place [13].
Individual proposal to use belief as a basis to explain the death eases the pain and suffering of each professional, as seen in this speech: "I see the biological side that is the stop of the systems and the loss of what we know as life and the religious side that I think is when we go to a place better than the earth, staying here only the body that we do not need" [13].

Category 4. Death as liberation from suffering
To understand that dying is the only way the patient stop suffering, nurses medical clinic of a southern university hospital, are, in this definition, a way to protect the patient's loss, and consequently treating human finitude in a more dignified way [14].
This view it was perceived speech this interview: "When pain is intense it seems that hurts me.I get to experience pain, suffering [cries].When death happens it is a relief for us and for them.It is sad, but it stopped suffering; then, rested."[14] Category 5. Death as unexpected interruption of life In confluence with this category, death is treated in a particular way when analyzing their perception front of the characteristics of today's society [22].Influenced by the act of worship life, and have being, people tend to distance themselves from that depart from power, thereby death ends up being overshadowed for being considered the great villain in the search for an existentialism ruled in material goods.
This understanding permeates for nurses in an adult ICU that, influenced by these issues, viewing death as an unexpected interruption of life [22].In the study, it is noted that the university graduate who had key role in this perspective, contributes to the misunderstanding of death to form the professional to fight it and not for life.
This perception is even more evident in those nurses attending the pediatric public, which filled with negative feelings after the death of a child or a youth; create more obstacles facing the natural process of life [20].The company, driven by interests and the relentless pursuit of material happiness triggers this serious ethical crisis in professionals who deal daily with terminal of life, providing the development of sadness and frustration by health workers.
The influence of these conditions on the professional can be evidenced by talks of a nurse interviewed: "I cannot deal with that reality not; the words are vain, if only because the pain of death is a pain.I usually much say, the greatest joy is a child; the greatest pain is death.There is nothing better than a son and there is nothing worse than death.No one can live with death, even you working your head for it ... [...] I think that death is not a comfort; I cannot, I cannot live with death."[22]

Synthesis of knowledge of perception of the Brazilian health professionals about death
According to the analysis of the articles, the perception of professionals led to the creation of five categories with different views about death: life stage; technicist conception; ticket to a better place; liberation from suffering and unexpected interruption of life.
The perception of death as life stage predominates in nursing professionals, who deal daily with human finitude.Despite a design deemed appropriate about death, some professionals demonstrate weakness in dealing with the subject, is a consequence of the unpreparedness and lack of training that make them able to take care of the terminally ill.
The technicist conception of the act of dying is more prevalent among physicians because biological view of human beings, rooted in technical principles of terminally life, is imposed from the undergraduate program.
Beliefs and religious principles positively influence the design of death by health professionals, especially nurses and doctors, culminating with the understanding that death is a passage to a better place.This perception makes understanding and acceptance of the finitude of life, making the vision of the holistic health professionals.
Also more prevalent among nurses, the view that death is a release from suffering is perceived as a defense mechanism for these professionals, in the midst of the process of dying.
Professionals who perceive death as the unexpected interruption of life, primarily nurses, are influenced by personal and material interests of today's society, so aloof from discussions about death because they believe that this is opposed to the ideal of power and wealth.From that design professionals are limited to understand the real basics of who is to die.Note the disparity between the number of studies conducted with doctors and nurses when compared to those performed with other health professionals.The patient approach at the last moment of life should be held as widely as possible.Therefore, it becomes necessary to understand the perception of death for other professionals in order that this be discussed and refined by the multidisciplinary team.
The few surveys conducted with health professionals from other classes as well as the limited sample used in the work, does not allow generalizing the results obtained in this study.Thus, it is necessary to carry out more researches addressing this theme.
Understanding the human terminal illness and its process influences the stance and attitudes assumed by facing health workers to die.It can only reduce the suffering of patients and consequently the human inability to deal with death, through wide discussion on the topic, especially in the hospital setting and in the academic, and providing greater contact of professionals with this issue since its training through the redesign of the education program of health courses.
[22] Nurses Nurses perceive death as unexpected interruption of the cycle of life.Source: Prepared by the authors.LILACS (2005-2014).

Table 1 .
Year of publication, the State where was carrying out the research and journals of articles selected.LILACS (2005-2014).

Table 2 .
Characterization of publications in LILACS database, according to author (s), title, journal, volume, month, year in the period 2005 to 2014.