Palliative doctors report prejudice after Covid’s CPI

An employee of Instituto Paliar answered the phone and was asked about the price of the palliative care course. He questioned whether the person on the other end of the line was interested in the classes, but heard an unusual response: “I want to know how much you guys sell this certificate for, because that bunch of hack doctors from Prevent Senior must have bought one of you.”

Dalva Yukie Matsumoto, an oncologist at the Public Servant Hospital and director of the institute, says that the person was very angry, cursed, screamed. The outrage is a kind of distrust that has been hanging over palliative care since the treatment was mentioned in Covid’s CPI.

In September, amidst sessions in the Senate, Prevent was the target of complaints about unethical and unscientific conduct. The operator was also accused of reducing oxygen and recommending palliative care for patients who still had a chance of surviving.

Matsumoto says that the prejudice with care has always existed and that Covid’s CPI only made the situation worse.

The way the CPI approached palliative care provoked criticism. At the time, someone compared the treatment with euthanasia, such as senator Otto Alencar (PSD). After the negative repercussions, Alencar stated that he expressed himself badly and that his speech referred exclusively to cases involving Prevent.

Douglas Henrique Crispim, president of ANCP (National Academy of Palliative Care), says that mistakes in the CPI were a disservice to the area, but that, at the same time, the senators’ positions are a symptom of general misinformation related to the topic in Brazil , where the practice is not yet widely adopted.

Matsumoto laments the senators’ speeches. “I have students who work with palliative care at Prevent Senior and they were very shaken because the patients started to throw stones at them.”

She explains that palliative care is indicated for any patient with a serious, progressive, chronic and potentially fatal disease. It is not just for those at the end of life, but for anyone with a condition that can lead to death and bring suffering.

“Palliative care must be done in conjunction with other measures and goes hand in hand with other specialties. It is not an imposition, but a right that the patient must demand, as it emphasizes the right to a dignified life. If the individual has a disease that this time of life decreases, that this time is dignified. And if that includes death, that death is also dignified,” he says.

Physician André Cerqueira Comune, who works at the Premier hospital, claims that the noise surrounding the subject caused unnecessary discomfort for one of his patients, who became suspicious of the care received. “I think it generates in people an anxiety like ‘did they do everything possible for me?”

And then another question comes in: even with all the current knowledge of medicine, in some situations there is really nothing to be done — and insistence can cause harm.

Crispim, from ANCP, says: “The same senator who was criticizing the use of treatments that do not work, such as chloroquine, did not understand that palliative care is the art of not using what does not work.”

“Why am I going to send a dying patient to an ICU, away from his family, if that won’t work? This is on the same level as chloroquine. You took the person’s dignity at the last moment. And it won’t. be able to defend herself, because she’s going to die later,” he says.

For Luciana Dadalto, bioethicist and lawyer, the fear is that any misunderstanding will lead to an increase in dysthanasia, the use of futile medical resources that only add suffering to a patient in a serious and irreversible clinical condition.

Dadalto considers it dangerous to create a dichotomy between medical care aimed at cure and palliative care.

“If we tell the public that every time a doctor says that there is no indication for a treatment, that doctor is doing ‘what Prevent did’, we are going to increase dysthanasia”, he says.

Misguided approaches to palliative care have not only affected patients, but their families as well—which are also part of palliative care concerns. And, again, this is a problem that already existed.

It is part of the daily life of Carolina Sarmento, an intensive care physician and palliative care practitioner, to listen to families who say they do not want to hear about palliative care. “It is a very prevalent prejudice in the population. People think that it is taking care of death, taking care of those in their 48 second period, of those who have no cure. This is not true,” he says.

Ana Carolina Capuano, coordinator of the palliative care service at Hospital Brasil, says that her area of ​​expertise is relatively recent. In its modern form, it emerged in the 1960s in the UK. Here in Brazil, the movement only started in the 1990s.

“Sometimes, even health professionals restrict themselves to an end-of-life approach, when there is nothing to be done, as if it were a death sentence”, says Capuano. “But it is a treatment that aims to promote quality of life”, he explains.

She says that it is not a question of doing nothing, but of changing the proposal for the procedure. For example, in the case of a patient with metastatic cancer, what is feasible?

“I’m not treating cancer anymore. I’m treating Mr. João, who is married to Maria, who wants to see her grandson get married, but who, within this context, being intubated or resuscitated is a context that is out of his biography, because it won’t solve the basic problem”, he says.

“Nothing is imposed,” he says. “If the patient has autonomy and is aware, he is the main source of consultation. Now, if he does not have it, it is the family that will be consulted.”

Capuano explains that palliative care is not synonymous with euthanasia, that is, the treatment does not accelerate death and is also the opposite of dysthanasia.

In Brazil, euthanasia is considered a crime. Dysthanasia, according to the Medical Code of Ethics, is unethical. And between the two ends is the palliative. “Palliative care understands that death is a natural process. Death is part of life, and treatment is a movement that rescues this naturalness and understanding of our finitude”, he says.

The ANCP president says there is evidence that patients treated with palliative care have longer survival, with higher quality.

“Not having palliative care means, scientifically, dying sooner and dying worse,” says Crispim. “The person who lives comfortably lives longer.”