Relationship between characteristics of health professionals and the respect for the autonomy of cancer patients at the end of life
Authors: de Camargo Júlia Drummond , Forte Daniel Neves 
Published: April 2022

Abstract
Introduction: One of the conflicts that is frequent in oncology, bioethics, and palliative care is determining, together with the patients at advanced stages of cancer and their families, the moment when to prioritize symptom control and allow the natural progression of the disease or continue treatments in an attempt to control or reverse the disease, despite the worsening of symptoms. Among the bioethical principles and the professionals’ ability to recognize their decision-making capacity, there are factors and characteristics that contribute to this ability to acknowledge and respect patient autonomy. Objective: To assess the characteristics of health professionals that are associated with the respect for the autonomy of cancer patients at the end of life. Methods: This was a quantitative, prospective, and cross-sectional cohort study conducted through an anonymous questionnaire with hypothetical clinical cases based on real-life cases, in which the characteristics of the care professionals associated with the respect for the autonomy of terminal cancer patients were evaluated. Results: The study included 151 professionals (94.37% of the oncology care team). Of these, 57 (37.8%) showed a paternalistic decision-making pattern, 58 (38.4%) had a shared decision-making approach, 16 (10.6%) had an obstinate approach, and 20 (13.2%) showed a consumerist pattern. The analysis according to profession showed the following distribution of decision-making profiles: paternalistic - 17 (29.8%) nurses, obstinate - 10 (62.5%) nurses, shared - 20 (34.5%) clinicians, and consumerist - nine (45%) nursing technicians. The majority of the participants who reported having very good contact with patients at the end of life were in the obstinate group (n = 8, 50%), while the minority were in the paternalistic group (n = 16, 28.1%). Among those who reported never having participated in an end-of-life class, seven (35%) had a consumerist profile and five (8.6%) were in the shared decision-making group. Among the individuals who had never taken a class in ethics, 20 (35.1%) had a paternalistic approach, seven (35%) were in the consumerist group, four (25%) had an obstinate approach, and 11 (19%) were in the shared decision-making group. Among the professionals who had never trained in palliative care, six (30%) were in the consumerist group and five (31.2%) were in the obstinate group, whereas the participants who had previously participated in more than six training sessions were those with a shared-decision making approach (13, 22.4%). There was no significant difference between the profiles regarding knowledge and experience in palliative care or the Burnout index. Among the participants who believed that it is a priority that patients are able to share their preferences, 48 (82.7%) had a shared decision-making approach, 45 (78.9%) were in the paternalistic group, 14 (70%) had a consumerist profile, and seven (43.8%) were obstinate. Thus, 100% of obstinate participants and 95% of consumerist participants exhibited cognitive dissonance regarding their attitude versus their justification of the chosen attitude (p<0.000).Conclusion: Most professionals in the oncology team had either a shared or paternalistic approach to decision-making. Although the difference was not significant, there was a coherent pattern of lower participation in educational activities related to palliative care or bioethics among the professionals with an obstinate and consumerist profile, probably a type II error. Moreover, there was a high frequency of cognitive dissonance between what the professionals would do and the justification for their actions in the answers of the participants with obstinate and consumerist profiles (100% and 95%, respectively). We concluded that future discussions about therapeutic obstination, patient autonomy, and cognitive dissonance in particular are necessary to contribute to reducing the financial and therapeutic costs associated with the suffering of patients, their families, and health professionals.