EUTHANASIA FROM THE PERSPECTIVE OF NURSING UNDERGRADUATE STUDENTS : CONCEPTS AND CHALLENGES

The aim of this study is to present rounds of conversation carried out with nursing students on the issue of euthanasia before they begin the university course of “Professional Practice and Bioethics” in order to verify whether or not, before that semester, the student had in fact achieved a competence and ability to debate the topic itself. This is a descriptive and exploratory study, which follows a case-study-type qualitative approach. The sample consisted of 31 students enrolled in the course. Data collection was performed in three rounds of conversation with 10 students and one with 11 students. The discourses were analyzed using content analysis, as set forth by Lawrence Bardin. It was possible to see the reality of the students’ daily lives, which led them to seek in God the strength to face the end of life, without binding their action as a professional to the Nursing Code of Ethics or to the Brazilian Penal Code and the lack of knowledge of the living will (CFM Resolution 1995/2012) as a document of respect towards the pre-established will of terminal patients. The study helped to understand the discourse of the participants and to structure the euthanasia module within the university course of “Professional Practice and Bioethics” as well as to broaden the awareness of the rights of professionals and users in the rendering of medical services, which requires a well-founded educational work. This is due to the fact that the constitutional guarantees and legitimated codes are not enough to assure the rights of the patient in practice.


INTRODUCTION
Over time, the term euthanasia has undergone semantic evolution.Its etymological meaning comes from the Greek (eu = good + thanatos = death) meaning a good death, without pain and anguish 1 .The study of euthanasia gave rise to new words, such as orthotanasia, dysthanasia, assisted suicide, and misthanasia, created to define specific situations surrounding euthanasia. 1 Orthotanasia is the term used to define natural death, without interference from technology or Medicine, allowing for a dignified death according to the evolution of the disease.Dysthanasia is understood as prolonging the patient's suffering, which runs in direct contrast to euthanasia, a term used to abbreviate this scenario of pain and suffering.By contrast, misthanasia, also called social euthanasia, has come to denote a miserable and premature death.Moreover, the broad category of misthanasia includes three scenarios: (1) the great mass of sick and disabled people who, for political, social and economic reasons, do not receive medical services simply because they cannot effectively enter the health care system; (2) sick people who receive medical services only to then become victims of medical malpractice; and (3) those who become victims of malpractice for economic, scientific, or socio-political reasons. 1 The present study focuses on the concept of euthanasia as the shortening of life.
Euthanasia can be differentiated into two types: active euthanasia, which is the death negotiated between the patient and the professional, and passive euthanasia, which occurs when there is an interruption in medical care. 2 Euthamasia may also occur by two means: voluntarily, performed by the patient him/herself or at the patient's request, or involuntarily, performed without the consent of the patient, i.e., by someone who decides the time to end the life of another person. 2uthanasia is a controversial topic.Some countries have a defined legislation about its practice, while others refute it categorically for several reasons.In the world, Uruguay was the first country to pass legislation on the issue.The Uruguayan Penal Code, which refers to the 1930s, does not punish the individual who practices "compassionate homicide", since he/she relies on "honorable history" and that his/her practice is based on piety as well as on the victim's "repeated pleas". 3n the Netherlands and Belgium, the practice of euthanasia has been governed by laws since 2002, and the nurse participates in the decision-making process. 4Sweden authorizes medical assistance for suicides.In Switzerland, a doctor can administer a lethal dose of a drug to a terminally ill patient who wishes to die, but it is the patient him/herself who must take it.In Germany and Austria, passive euthanasia is not illegal, as long as the patient's consent is given. 5In Brazil, euthanasia is considered to be murder.According to the Brazilian Penal Code, assisting a suicide, i.e. encouraging or inducing a patient to kill him/herself, is also considered a crime. 6alking about euthanasia is talking about death, and this disturbs and challenges human and professional omnipotence, since health professionals are taught to care for life, but not for death.Proof of this is that in most disciplines formulated for the education of health professionals, no specific university course deals directly with this issue in a non-defensive and biologicist manner as does Bioethics. 5he National Curriculum Guidelines for Undergraduate Nursing (CNE / CES, Number 03, from July 11, 2001) 6 , art. 5, section XXIII, on skills and abilities of the nurse, recommends: "[…] to manage the process of nursing work based on principles of Ethics and Bioethics […]".The nursing staff, in their day-to-day work, can be faced with incurable patients with severe pain and who, showing no improvement in their medical condition, believe that death is the only solution and ask, or even beg, the professional to put an end to their suffering.Thus, it is necessary to have ethical and legal knowledge about the work of nurses regarding euthanasia. 7he justification of the present study lies in considering the fact that facing a situation like that mentioned above demands a process of judicial, legal, and ethical decisions that could trigger a wide range of feelings in the staff as well as produce difficulties associated with their beliefs and ethical and bioethical values.
The aim of this study is to present the rounds of conversation carried out with nursing students on the issue of euthanasia, before they attend the university course of "Professional Practice and Bioethics" in order to verify whether or not, before that semester, the students had in fact achieved a competence and ability to debate the topic itself.

METHODOLOGICAL APPROACH
The present work is an exploratory and descriptive study, whcih follows a case-study-type qualitative approach.
Our field of study was the undergraduate course in Nursing from the Catholic University of Brasília (UCB).This study was developed in the second half of 2012, and the participants included students enrolled in the university course of "Professional Practice and Bioethics", at the evening classes.This course is offered in the los participantes y estructurar el modulo de la eutanasia dentro de la disciplina "Ejercicio profesional y Bioética" y, asimismo, para aumentar la conciencia de los derechos de los profesionales y de los usuarios en la práctica de los servicios, lo cual requiere un trabajo educativo fundamentado.Esto se debe a que la garantía constitucional y los códigos legitimados no son suficientes para consolidar los derechos del paciente en la práctica.Palabras clave: Eutanasia; Enfermería; Muerte con Dignidad; Bioética.
minutes.With the consent of the groups, entries were recorded for transcription.The material from these transcripts was systematized into a document, which is the main foundational basis of this article.The transcripts were organized, and their results were ordered according to Bardin's Content Analysis technique. 10hematic category analysis was used as the content analysis technique, as it allows for the break-up of the text into units, which are then placed into categories according to analogical regroupings, 10 using the thematic categorization criterion.The reading and rereading of each group report was performed in an attempt to identify the structural elements of the discourses on euthanasia delivered by the groups so that they could be divided into categories and subcategories, in turn providing the axis for their analysis.This study's design was approved by the UCB Ethics Committee on Human Research, according to the requirements established by Resolution 466/2012, under protocol number 25101.

RESULTS AND DISCUSSION
Of 31 young adult students, 30 agreed to participate in the research (25 female and 5 male), all of whom were attending the fifth semester of the nursing program.The survey was carried out in the third week of classes in the university course of "Professional Practice and Bioethics".The rounds of conversation analyzed conceptions of euthanasia related to a more general understanding of the students on the topic.
The recorded reports were analyzed and then structured into categories, searching for the formation of meaning systems that, taken together, revealed the collective representations of euthanasia.
This study began with the systematization of six categories that represent the axis around which the product of the performed dynamics is articulated: a. nurses' perceptions of euthanasia; b. their actions concerning the termination of life; c. the feeling of being prepared for dealing with euthanasia and the expectation that college will prepare them; d. their attitudes towards euthanasia; e. euthanasia itself, divided into subcategories of pain and physical appearance.

Category: "Nurses' perceptions of euthanasia"
The following excerpts have been identified within the nurses' discourses: Euthanasia is the shutdown of machines that keep a person artificially alive, or it is the interruption of a life when a terminally ill person asks to die or some family member asks for this interruption in order to end the suf-fifth semester, i.e., halfway through the Nursing program, before the students begin their Nursing practice in hospitals.The course is worth four credits and includes a workload of 60 hours.
The sample consisted of 31 students enrolled in the aforementioned course; one student refused to participate in the research.To collect data, rounds of conversation were performed, with euthanasia as the central theme.Students were divided into three groups of 10 and one group of 11.
The rounds of conversation are an educational and communicative strategy intended to meet the basic needs of learning, understanding, and empowerment.The technique, in this study, was based on the proposition developed in the studies of the "Wheel Method", developed by Campos 8 , who "understands the constitution of the subject and the collective groups, based on plans situated between their inner world and their circumstances -external world."Campos also based his findings on the thoughts from Freire 9 regarding the instilling of the sense that "those who teach, learn while teaching, and those who learn, teach while learning" (our translation).In the context of the study, the intellectual and affective formulation of euthanasia was applied to both hospital environment and the self.As a pedagogical strategy, it was able to promote reflection and the sharing of experiences.
The logic based on the respect for the knowledge and experiences of the participants focused on the evaluation of the subject and conversation, providing an exchange of ideas among students so that they could all grasp the reasons and theories behind each concept of euthanasia.This strategy was supported by the recognition of previous learning and values, which were the basis for the creation of new learning and decision-making so as to adapt the existing reality to the health professional and patient's rights as well as to euthanasia itself.
Thus, the present study sought to develop the concept of euthanasia by following a script.The researchers conducted the process and played the role of facilitators and participants in a dialog originated from the experience and knowledge of each individual, promoting questioning and searching for information on reflections and judgments related to the nursing practice.Among the three rounds of conversation, a debate took place, which lasted approximately 150 Depending on the case, I believe it is a relief to a prolonged suffering with no chance of cure.
Euthanasia is the wish to die under incurable health circumstances.
It is the person him/herself who decides for the right to die.

It is killing someone who is very weak or in comatose condition.
The concepts expressed above deal with active euthanasia, in which an action is generated from the intention of performing euthanasia.None of the nurses' discourses made reference to passive euthanasia, in which there is an omission, i.e., the interruption of the therapeutic action indicated for a given scenario 4 .However, some statements associate euthanasia with murder: "Anticipating the death of a patient without the expectation of healing is a kind of murder." Euthanasia is considered murder in Brazil, according to the Brazilian Penal Code, which states that if the offender acted out of compassion, at the request of the victim, to shorten his/her unbearable physical suffering, because of serious illness, than a penalty of imprisonment of three to six years shall be applied.Practicing assisted suicide, as well as encouraging or inducing the patient to kill him/herself, is also a crime according to the Brazilian Penal Code. 3 The only situation in which Brazilian law does not apply punishment is when the patient kills him/herself, upon his/her own initiative and will.Paragraph 4 states: Stopping the artificial maintenance of one's life is not a crime if death is previously certified by two doctors as imminent and inevitable and if the consent is given by the patient or, if the patient is not in condition to do so, the consent is given by the ascendant, descendant, spouse, or sibling.In Brazil, the constitutional impediment also weighs against euthanasia, enshrining, among the essential rights, the right to life. 11 2011, a new version of the Brazilian Penal Code was approved with regard to euthanasia, predicting more lenient sentences than murder in general, guided by that set forth in international laws in which euthanasia deemed legal 12 .This core issue lies in Art.121, Paragraph 1, of the Brazilian Penal Code, according to which the act of taking the life of another person who is in great suffering may be considered a cause of relevant moral value, in which case the person who commits the offense may have his/ her sentence reduced 13 .

Category: "Their actions concerning the termination of life"
From the ethical point of view, can the nurse contribute to accelerating the death of a patient with no chance of recovery?
During the group discussions, a conflict of value emerged in the considerations about the professional practice, as it is an ethical process of decision-making, overcoming of problems or referrals, given that, on one hand, nurses can effectively contribute to the autonomy of both the patient and the family, while on the other hand, they can prioritize their wishes, disagreeing with professional ethics, as expressed by a student: "I would not be so selfish as to watch a person dying every day and do nothing; I would perform euthanasia on this person".
In the Brazilian Nursing Code of Ethics, Article 29, which concerns the relationship with the individual, family, and community, promoting euthanasia or participating in the practice designed to anticipate the death of the client is strictly prohibited.In the fundamental principles, Article 3 respects the life, dignity, and rights of human beings throughout their life cycle, with no discrimination whatsoever.Article 12 states that it is the responsibility of Nursing to ensure the patient a nursing care free of damages resulting from malpractice, negligence, or recklessness.The authors of this article observed that one of the duties of Nursing, as set forth in Article 19, is to respect the modesty, privacy, and intimacy of human beings throughout their entire life cycle, including death and postmortem scenarios. 14n the discourses of the students against the action of interrupting life, the following excerpts can be highlighted:

Category: "The feeling of being prepared to deal with euthanasia and the expectation that college will prepare them"
Gave rise to the third category: I still don't feel prepared, and I think that college does not prepare anyone to deal with this situation; only the day-to-day professional life does it.

Not completely, I think it's always good to have a greater knowledge, especially on such a sensitive issue, I
thus bringing representations of spiritual beliefs and convictions of the human being. 5would be totally against it, because God created life and only He has the right to take it.
I'm against it, because only God has the gift to give and take life.
Religious institutions create moral authorities that produce legitimacy based on the values imposed by the institution.Thus, Buddhism sees the moment of death as fundamental.According to their values, rebirth occurs by consciousness and learning at the time of death.In the Buddhist tradition, the personal decision on the time and way of dying is highly valued.According to Judaism, death cannot be rushed, and the dying individual should receive the necessary treatments.The decision on the patient's death is not for him/her to decide, but for the rabbis who interpret the Torah to apply their knowledge to everyday life.In Christianity, letting someone die does not mean killing. 18Pope Pius XII, speaking on the issue of the termination of life, said that "the termination of life is a medical issue and not a religious one, and that reasonable criteria should be applied in this case." 19eople internalize these traditions and when they do not to act according to the given dogmas, they begin to feel the moral suffering.Therefore, the religious institutions, like other social institutions, are ways of controlling individual and social behaviors according to parameters set by society in general.Such a controlling pattern serves to maintain a certain unity amidst such plurality, as is the reality of the human being.
Regarding euthanasia as a crime, one nurse gave the following statement:

I am against it, because I think it is a crime against life, because as I had already mentioned, no one has the right to take the life of anyone. If the patient had a chance to give an opinion, would he/she really want to die? I don't think so.
The Nursing Code of Ethics, in the section concerning the relationship with the individual, family, and community, as set forth in Article 18, which describes the responsibilities and duties, states that nurses must respect, recognize, and perform actions that guarantee the right of the person or of his/her legal representative to make decisions about his/her health, treatment, comfort, and well-being. 13egarding orthotanasia, defined as the patient's decision to refuse treatment in order to die naturally, the Brazilian Federal Council of Medicine (CFM) issued Resolution 1.995/2012, which addresses the advance directives on the patients' will.This resolu-think college has an obligation to address the topic and to prepare future nurses.
Another aspect that stood out is the concern of the students regarding the preparation for coping with situations involving experiences with death during the undergraduate Nursing program.
There is a lack of information during the educational studies of the nurse regarding this issue, although educational experiences are recommended. 4ince the beginning of the formation process, the nursing student has the idea that, as a health professional, he/she will struggle, trying to preserve life, as opposed to the possibility of death 5 .From their training, professionals will feel committed to life, and they will feel qualified to preserve it.Their academic training is based on healing, and it is their greatest reward.Therefore, when in their daily routine, nurses need to deal with situations involving death and dying; in general, they feel unprepared and tend to move away from them. 15feel prepared, I do, but in college we are not prepared for these situations, at least not entirely.We will be really prepared when practice and clinical experience are real.

I feel prepared, because I'm already working in the area, but college did not prepare me for this.
Therefore, the nursing staff should be trained to deal with the situation of terminal illness and the dying process which comprises existence itself and death. 16,17 niversity extension courses and post-graduate courses on death are available to ensure quality care for terminally ill patients and their families.

Category: "Their attitudes towards euthanasia"
Groups for euthanasia said: I'm for euthanasia, because it would be a way to lessen the suffering of a person who is in a critical condition and with no prospect of healing, giving the patient the right to end his/her own life.

Depending on the situation, I'm for euthanasia. I believe no one should live a life of suffering and pain.
Students against euthanasia expressed themselves in three different ways: with elements of spiritual conception, considering euthanasia as a crime, and by the biological determinism of pro-life advocates.
The answer demonstrates a spiritual conception, reveals the interference of the belief and faith that only God can take a life,

Category: "Euthanasia itself, divided into subcategories of pain and physical appear ance"
When asked about what they would do if they were in the terminal phase of life suffering from pain or if they suffered from a face deforming tumor, the answers were divided into two subcategories: pain and physical appearance.
In the subcategory of pain, the most relevant opinions, whose issues concern spirituality, were highlighted and are transcribed below: I would live normally until God called me to meet Him.Human perspective is limited in several aspects, but the spiritual perspective is broad.I would stay there until the end.And if someone turned off the life support devices, I would ask God to apply divine justice on that person's life.
In the first discourse, it is possible to see that the ethical conflict lies in the issue of divine authority and the possibility of the human being's self-determination; therefore, the dialog between ethics and religion is essential. 19In the second discourse, it is possible to see that the imposing ethical foundation of necessary care for a terminally ill patient is the predisposition of the best conditions for this patient to deal with his/her disease and, eventually, with his/her death.The sense of injustice and denial are also present in this discourse.If death is denied and if the person refuses to get in touch with his/her own feelings, this grief will be poorly handled. 5n the subcategory of physical appearance, the answers were surprising in that they did not spell out the fear of rejection, which is common in cases of illnesses that cause deformation, bad smell, or marked change in the physical appearance, resulting in an isolation behavior that turns the patient into a lonely and depressive individual. 5n the modern Western culture, the human body establishes the border of personal identity.According to David Le Breton, the gaze is an instance that removes or gives value.It necessarily takes into account the expression of the other, confirming (or not) the mutual identification.In the relationship between people, the gaze is perceived as an emotional experience, which can be felt as an aspect of self-recognition or as a separation from the individual's own personal and body identity. 21mong the main reasons for not committing euthanasia, students cited: I would live; I would not want to die because I had a deformed face.There are several examples of deformed people who live and overcome their own biases, challenges, and so on.
tion establishes the criteria for patients to set, together with their doctor, the therapeutic boundaries in the terminal phase. 20The living will, as that resolution became known, intends to grant patient's autonomy, drastically changing the conduct of Brazilian doctors, in giving the patient the power to choose how he/she wishes to be treated when on the brink of death.
Biological Determinism: in this approach, death is seen as a biological aspect, as if all living beings had an exact time to live and no one can interfere in this cycle.Thus, the following answers were given by the nurses: I'm against euthanasia, because the patient must live, even in this situation.I'm against euthanasia, because each individual has a determined period to live.Some students have expressed undecided judgments regarding the situation (against or for euthanasia).The most interesting answers are as follows: It depends on the case, if the patient has no chance of surviving and this causes distress to the family, then euthanasia should be performed.However, there are medical cases in which a patient came back from coma, so we should try until the final moment, fighting for the life of the patient.
In my point of view, it varies a lot from case to case.It is very hard.In the case of this clinical case, not yet, because it seems that the patient can still talk, but there are many other situations that I think I would be for euthanasia.But, performing euthanasia, the act itself, I think I couldn't… If I were a patient in a vegetative state or hospitalized in a coma that was impossible to be reversed, if I could, I would express my wish for euthanasia.
As for those nurses who give undecided answers, it is possible to see an individual and personal concern that involves the passive agent and the relatives.This requires that the legislation provide a unique position for each case, because life is quite unique, and nurses should respect the will of the person who would rather die than live a life that is no longer worth the struggle.Furthermore, considering that the requestor cannot perform the action, the legalization of euthanasia directly requires the exclusion of unlawfulness regarding the performing agent, rendering him/her immune to prosecution.
The emerging categories reveal that the subjects of this study had experience with the family and surroundings.Conceptions of euthanasia that backed the statements of the students represent their perspectives on the notion of euthanasia, which permeated the various socio-historical formative spaces of those who participated in the study.
The current study, in seeking to understand the concepts that students have about the topic of euthanasia, found, in the participants' discourses, an attitude of weakness, since they did not bind their action as professionals to the Nursing Code of Ethics, to the Brazilian Penal Code, and to the lack of knowledge concerning the living will (CFM -Resolution 1995/2012), as a document regarding the predetermined will of terminal patients.This weakness can be justified by the fact that the research participants were mostly students of the fifth semester of the Nursing program, and they had not yet started their internships.Consequently, they had not had any prior experience with death in the learning context of professionally taking care of the patient.
The religious discourse found among participants in this study leads to a reflection on the reality of the everyday life of health professionals who provide medical services to terminally ill patients.It is inferred that their relations with God and divine powers can present itself as an opportunity to help patients and their companions or as a possible aid in the acceptance of the disease.
The present study helped to understand how participants think and, thus, to structure the euthanasia module within the university course of "Professional Practice and Bioethics".The issue of euthanasia was developed in an attempt to educate nurses who are aware of their rights/duties and who are multipliers of patients' rights, as an imperative in everyday healthcare.Without knowing how students think, professors, in the classroom, provide a totally empty ethicalphilosophical discourse which is divorced from social reality.
Increasing the awareness on the rights of professionals and users in the practice of services requires a well-founded educational work.This is due to the fact that the constitutional guarantees and legitimated codes are not enough to assure the rights of the patient in the practice.
I think that aesthetics greatly influences a person's life, but it is not the only thing that matters.In general, my action would depend on the quality of my life.
I would look for experts to try to ease the situation, and I would try to handle it the best way I could.
However, what does it mean to be beautiful or ugly?If this were a study on aesthetics, the definitions would surely have to be extended.But this is not the case.Far from naturalizing the ugliness/life/death relation, this study seeks to identify how the aesthetic standard deviation refers the subject, especially women, regarding the exclusion limbo, which can be illustrated by the case of Chantal Sébire, a 52-year-old French housewife who suffered from a very rare and incurable facial cancer, resulting in the loss of sight, smell, and taste, and causing a large facial deformation with intense and permanent pain.In the news on the case, she was renamed as the "frog-woman." 22,23ébire, who asked for the help from the Association for the Right to Die with Dignity, filed a lawsuit in French Courts requesting euthanasia.The extensive social mobilization around the issue, both in France and in other countries, as evidenced by the news and articles in the media, exemplarily demonstrates the production of distant suffering, a process analyzed by Luc Boltanski. 24According to his study, in the second half of the twentieth century the moral demands in the face of suffering converge toward the imperativeness of action.
From a process of dissemination of information about suffering scenarios, the viewer becomes affected and is required to act.Boltanski 23 considers the existence of three topics of suffering: the complaint, the feeling, and the aestheticization.These instances have two dimensions: argumentative and affective, so as to provide not only awareness of the issue, but also to evoke feelings capable of leading people to a political engagement.This led the members of the French Executive Power to express themselves in favor of introducing an item that altered the existing law, in view of the existence of extreme cases, such as this woman's case. 23he limitations of this study are related to the small sample size and to the non-random selection of the group.However, all of the discourses were analyzed according to scientific references in the field, avoiding overgeneralizations.

FINAL CONSIDER ATIONS
The proposed methodology sought to respond to the demand of knowledge production in this field, configuring itself as a laboratory in which results, in addition to directly benefiting future professionals involved in the research, allow for reflection on the issue by readers, by emans of reports and analyses of the identified categories.