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Nursing faculty and terminality with dignity Júlio César Basta Santana 1 , Andréa Vaz dos Santos 2 , Bruna Reis da Silva 3 , Denísia Crisane dos Anjos Oliveira 4 , Eberth

Mesquita Caminha 5 , Flávia Soares Peres 6 , Cynthia Carolina Duarte Andrade 7 , Maria Bernadete de Oliveira Viana 8

Resumo

Este estudo teve como objevo compreender o signicado atribuído por um grupo de docentes enfermeirossobre o fenômeno da ortotanásia. Trata-se de pesquisa qualitava, com inspiração fenomenológica. Do es-

tudo parciparam cinco enfermeiros de uma universidade privada do Estado de Minas Gerais e emergiramquatro categorias: despreparo da equipe em situações que remetem à nitude humana; enfrentamento dosfamiliares no processo da nitude; prolongamento do sofrimento humano nas unidades de tratamento in-tensivo; perspecva dos cuidados paliavos nas unidades de tratamento intensivo. Conclui que a reexãoacerca da terminalidade vem aumentando, mas ainda é insuciente no tocante à práca dos prossionais daenfermagem. Percebe-se que a diculdade em lidar com a morte é um problema comum aos prossionais desaúde. Novas pesquisas são necessárias à exploração das diculdades e do conhecimento dos enfermeiros,englobando a ortotanásia e a assistência humanizada na terminalidade.Palavras-chave: Doente terminal. Cuidados paliavos. Direito a morrer. Cuidados de enfermagem. Pesquisa.

Resumem

Docentes de enfermería y terminalidad en condiciones dignas

Este estudio tuvo como objevo comprender el signicado asignado por un grupo de profesores enfermerossobre el fenómeno de la ortotanasia. Se trata de un estudio cualitavo con la inspiración fenomenológica.Asiseron a este estudio cinco enfermeros de una universidad privada en el Estado de Minas Gerais. Emer-gieron cuatro categorías: falta de preparación del equipo en situaciones que hacen referencia a la nitudhumana; enfrentamiento de la familia en el proceso de la nitud; prolongación del sufrimiento humano enlas unidades de cuidados intensivos; perspecva de los cuidados paliavos en las unidades de cuidados inten-sivos. Se llega a la conclusión de que la reexión acerca de la terminalidad es creciente, pero siguen siendoinsucientes en lo que considera la prácca de los profesionales de enfermería. Se observa que la dicultadde tratar con la muerte es un problema común para los profesionales de la salud. Se necesitan más inves-gaciones para explorar las dicultades y los conocimientos de los enfermeros, que abarca la ortotanasia y laatención humanizada en la fase terminal.Palabras-clave: Enfermo terminal. Cuidados paliavos. Derecho a morir. Atención de enfermería. Invesgación.

Abstract

Nursing professors and the terminality in condions of dignity

This study aimed to understand the meaning assigned by a group of nursing professors on orthotanasia. Thisis a qualitave study with a phenomenological perspecve. The study included ve nurses from a privateuniversity of Minas Gerais State. Four categories emerged: Unpreparedness team in situaons that refer tohuman nitude; Confronng the family in the process of nitude; Extension of human suering in intensivecare units; the perspecve of palliave care in intensive care units. It may be concluded that reecons onthe nality has been increasing but are sll insucient in contemplang the pracce of professional nursing.It is observed that the diculty in dealing with death is a common problem for health professionals. Furtherresearch is necessary to explore the dicules and knowledge of nurses, encompassing orthotanasia and

humanized in terminality.Key words: Terminally ill. Palliave care. Right to die. Nursing care. Research. Approval CAAE no 0201.0.213.000-11

1. Doctoral candidate [email protected] – Centro Universitário São Camilo, São Paulo 2. Graduate [email protected] 3.

Graduate [email protected]. Graduate [email protected]. Graduate [email protected]. Graduate

[email protected]. Expert [email protected]. Master [email protected] – Poncia Universidade

Católica de Minas Gerais, Belo Horizonte/MG, Brasil.

Mailing address

Escola de Enfermagem – Av. Dom José Gaspar, 500, Prédio 25 Coração Eucarísco CEP 30535-610. Belo Horizonte/MG, Brasil.

All declare no conict of interest.



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acvely as possible, unl the moment of death; ithelps the family to deal with the paent’s illness andwith mourning; it demands a team approach; andseeks to improve quality of life 10.

Bellato, Araújo, Ferreira and Rodrigues high-light that, during nursing training, there is great

emphasis in the subjects that capacitate profes-sionals in caring for health maintenance and cure ofdiseases, but lile or none support is provided forthe nurse to learn to aend a dying person 11. Suchcontradicon in the process of nursing training,associated to the increase in chronic degeneravediseases, due to the increase in fostered human sur-vival, among other aspects, because of the adventof increasingly advanced technologies in the eldof health 12, brings about the forceful quesoning:what is the nurse faculty’s contribuon in the diu-sion of knowledge to future professionals, when it

comes to orthothanasia, in order to ensure dignityto a terminal paent?

This queson guides the presented study,which is jused by the relevance of the theme n-itude in nursing training, considering especially theunpreparedness and lack of knowledge on the sub-

ject, of professionals already in the labor market, butalso seeking to extend the discussion to professionaltraining. Thus, this research aims to understand themeaning aributed by a nursing faculty group to thephenomenon of orthothanasia, seeking to contrib-ute to the pracce of the orthothanasia and the pal-liave care to terminal paents.

Method

It is a qualitave research performed with pro-fessors from the nursing undergraduate course ofPonca Universidade Católica de Minas Gerais (PUC/MG). The goal was to invesgate the faculty’s inter-pretaons about dignied death in the intensive in-paent units of the instuon. The technique applied

was the phenomenological research, which, comingfrom subjecvity, leans toward the parcular collec-on and interpretaon of the phenomenon itself 13.The phenomenological resource seeks to interpretthe phenomenon from each person’s subjecvity 14.

To be successful, a phenomenological study de-mands three fundamental stages: phenomenologicaldescripon, reducon and comprehension. Coltro 13

argues that during the process of descripon, the re-search subject elaborates their speech and reportson how he/she sees themselves facing such situaonin the world. From this subjecvity, the researcher

intends to reach the descritpive objecvity 13. It isworth nong that intersubjecvity can be found inthe speeches, i.e., the intercession of experiences.The reducon is the stage in which the researcherseeks in the speeches of their interviewees to ndthe meaning to their guiding quesons.

The subject’s ideas shall sustain their speech,and oenmes the reecon of the respondentsreaches new possibilies, not thought of or studied atrst. Lastly, the reducon aims to elucidate the phe-nomenon, but it does not deny or limit the world ofexperiences of the respondent. The comprehension

approaches how to understand the manners of oth-ers, na aspect full of possibilies. It is about under-standing others in order to interpret them. To reachcomprehension, it is necessary to accept the reduc-on stage, looking for the soul of the respondent. So,the three stages interconnect and are reversible 14.

It becomes clear to understand that the phe-nomenological inspiraon will not result in concreteanswers, but in the reecon on dignied death.The research was performed with ve nursing fac-ulty members from PUC/MG. The subjects wereinvited to parcipate in this study whose exclusioncriteria was professors who did not provide nursingassistance to terminal paents, or refused to parc-ipate for private reasons.

The data collecon was performed in themonths of February and March of 2012, by record-

ed semi-structured interview, contemplang the fol-lowing guiding quesons:

• What is the meaning of the process of dignieddeath (orthothanasia) aributed to terminal pa-ents?

• What are your thoughts on the health care pro-vided to terminal paents nowadays?

• what changes in nursing training do you considerimportant concerning the implementaon of hu-manized care for dying paents?

The term “free, prior and informed consent”

was presented to the interviewees, in order to ex-plain the ground of the research and its relevancein the context of care in life terminality situaons.Aer the subjects’ consent, the interviews were re-corded in MP3 and transcript for the analysis of thespeeches. The interviews will be stored in a secretspot for ve years, for future evaluaons, and de-stroyed aerwards. For the anonymity of the sub-

jects, the speeches were idened by pseudonymsas a tribute to the caregivers: Florence Nighngale,Anna Nery, Callis-ta Roy, Wanda Horta and SaintFrancis of Assisi.



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The project was submied and approved bythe Ethics Commiee of Poncia UniversidadeCatólica de Minas Gerais concerning the guidelinesand rules for research involving human beings. Fromthe speeches, the following analycal categorieswere built: unpreparedness of the team in situa-

ons related to human nitude; extension of humansuering in intensive care units; perspecve of thepalliave care in the intensive treatment units.

Results e discussion

Unpreparedness of the, team in situaons related

to human nitude

During the training, the future nurse needs tond subsidies to face death, learning, for instance, todeal with terminal paents. As nurses, we are pre-

pared to take care of every stage of life, and death isthe last of them. The challenge in dealing with deathand the need for discussions of the process of dyingare perceived in undergraduate courses and in dailywork, as observed in the following reports:

“I didn’t learn that in college. I learnt that in life,

when I got to work.” (Nurse Florence Nighngale);

“We don’t discuss the fear of a professional. Profes-

sionals have to be prepared, too.” (Nurse Florence

Nighngale);

“Lack of a guideline, of adequate training. Training

meaning, rst of all, a discussion.” (Nurse Wanda Horta).

As can be seen, death is feared and lile dis-cussed by health professionals. Despite the curricu-lar advances of the academies and the developmentof the connuing professional educaon service,the nurses’ knowledge about palliave care to beadopted for each paent are yet insucient. Nurs-es have a diculty in managing not only signs and

symptoms, but also suspending or retaining thecare, according to the needs of paents facing theend of life 15.

The training occurs under a curave healthmodel, which makes it dicult to act before theprocess of dying. There is a struggle to prevent thesuering of others and minimize the frustraon andthe sense of failure from the non-healing:

“So there is a taboo with the word death. We say

it is certain as it is, but we generally avoid thinking

about this certainty” (Nurse Callista Roy);

“It is somewhat complicated. So it depends on that,

because I think we have to have a certain neutralism

as professionals” (Nurse Saint Francis of Assisi).

Medical and nursing students are trained forthe technical treatment, not to deal with the par-adox between life and death. Health professionalspursue the cure and grieve the death of paents un-der their care 16.

Professional unpreparedness when facingdeath and training focused on saving lives are pri-marily responsible for the frustraons and sueringof nurses before the paent in the process of death3,17. In order to change this scenery, it is necessaryfor nursing professionals to start, since the begin-ning of their training, to gradually deconstruct thetaboo around nitude. Frustraon should give riseto a new way of thinking and acng, so that nurses

can plan and provide the best possible humanizedcare to the paent. This atude should bring greatposive changes to the process, considering thatnurses are the professionals who are able to pre-scribe care.

“This concepon of humanizaon, which goes from

birth to one’s process of nitude” (Nurse Callista

Roy);

“It is taking care of them every minute, every day

is their day. Death as a stage of life” (Nurse Wanda

Horta);

“And I don’t mean treated, ok? But I think this needs

to be taken care of because the fact that they don’t

have a prognosis doesn’t mean I’m not taking proper

care of them” (Nurse Anna Nery);

“When we learn a paent is going to die, they’re ne-

glected. So we stop providing care to them. The one

they deserved” (Nurse Florence Nighngale).

Nurse Florence Nighngale’s speech also,brings the perspecve of humanized care to termi-nal paents: “In some places, people have given a

lot of thought to the human way to treat human be-

ings, which is the great duality that we oen discuss,

right? Humanizing the human being, that’s a redun-

dancy” . How to look at death is a relavely new ped-agogical proposal, the nursing faculty members lon-ger graduated lile discussed the process of nitudeduring their academic educaon, experiencing, atsome point in their professional pracce, sueringand frustraon. It is perceived in the speeches that



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nurses suer along with terminal paents and theirfamilies, and go through sadness, sense of failureand anguish facing the situaon:

“I suered a lot... I get chills when I think of it (...)

it’s a very sad scene, watching someone die, not be-

ing able to ‘do anything’, and understanding their pain...” (Nurse Florence Nighngale);

“And I’ve had a few experiences when every me I

stopped being this facilitator, I grieved much more

than the family” (Nurse Wanda Horta).

The speeches showed that in order to takecare of caregivers it is essenal to discuss the pro-cess of dying with health professionals. It is fun-damental to ensure the existence of instuonalspaces to expose fears, anxiees and frustraons

of professionals facing the process of dying. It is re-quired to have specialized environments in whichprofessionals can elaborate their daily grieving andminimize the pain and loss, also considering psy-chological support inside health instuons. It mustbe considered, moreover, that the preparaon andappreciaon of these professionals results, sll, ina decrease in cases of burnout syndrome, the nalreacon of the individual against the stressful ex-periences accumulated through their career ³.

Having humanized care to paents in processof nitude as a perspecve, it becomes evident the

importance of extending the discussion and reec-on to academic dimensions, So that in the future,professionals can understand dying in its subjecvi-ty, thus respecng the me of the paent and theirfamily. If it is already possible to noce such changein professional educaon, which begins to contem-plate the teaching of pracces related to death anddying, the ndings of the study allow us to state thatsuch process should be built, amplied and extend-ed to all universies, to contemplate care pracce toterminal paents in consonance with the needs andprinciples of SUS:

“We need to be prepared because it isn’t easy deal -

ing with the situaon” (Nurse Florence Nighngale);

“I think it’s touching the students, showing them the

reality (…) inside the instuons and making them

(…) feel, eh? The discomfort!” (Nurse Anna Nery);

“I hope that, someme from now, the work of nurses

will improve, we are in a process of change…” (Nurse

Florence Nighngale).

Lastly, it is worth nong that in order to pro-mote a transformaon in their percepon, for theirown benet, around the phenomenon of death anddying itself, it is important for the nursing profes-sional to aggregate knowledge to the essence ofpalliave care, whose goal is to eliminate the suf-

fering caused by physical, psychic and spiritual pain.In addion, it is benecial for the professional toovercome the limitaons imposed by the hodiernalcultural paerns on human nitude in order to startfacing death as a natural consequence in every per-son’s life, without banalizing it.

Confronng the family in the process of nitude

In the speeches of the faculty members, it isperceived that the pain of the family of an individualwithout any life perspecve is oen underesmatedand forgoen by the muldisciplinary teams:

“We oen worry about the paent only, and neglect

the family that grieves for a beloved one who’s dy -

ing” (Nurse Florence Nighngale);

“They understand that there’s no prognosis, no

condions to connue treatment, but sll there’s a

human limitaon, I guess, in accepng that, right?”

(Nurse Anna Nery);

“They also confront this fear and look for someone

or something in support, and it’s oen us, nurses.

We’re there, on the front line” (Nurse Callista Roy);

“Well, this is a very private situaon, very parcu-

lar of every person involved” (Nurse Saint Francis of

Assisi).

The reality found in the inpaent units withterminal paents modies according to the families.Many accept the process of dying and some insist ondemanding investment from the team, extending thepaent’s suering. As nurses providing holisc care,the spiritual dimension of the paents and familiesshould not be le aside, because it may help themat that moment. Spirituality is a complex concept,related to the supersensible sphere, which seeks themeaning of life by the transcendence in God or ina higher power. Pessini and Bertachini nd it neces-

sary when accepng the process of nitude19.

Another aspect to be considered is the profes-sional-paent communicaon, which should reduceuncertaines and direct the paent to the situaonalreality in the process of terminality 20. Based on clear



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and relevant informaon, the communicaon shouldbe extended also to reach the family’s acceptance 20.

“They know it’s best for the paent to go, but they

don’t want to lose them because the human being is

selsh” (Nurse Florence Nighngale);

“You go through the enre situaon with them and

sll they go: I want you to do everything in your

reach to save my son” (Nurse Anna Nery).

The family plays an essenal role in the mo-ment of the decision about ceasing fule invest-ments and treatments for the execuon of the or-thothanasia and palliave care 21. In order for thereto be a conduct based on bioethical principles,respecng benecence, not malecence, autono-my and jusce, it is indispensable to introduce the

terminal paent’s family to the process of care unlthe last moment of their life. On the other hand, toGarcia 22, the principle of autonomy puts the paentas the only moral authority over their own body; so,at rst, nobody has the right to decide for them orto limit their decision.

There is no specic regulaon in Brazil regard-ing orthothanasia and therapeuc limitaon in ter-minal paents, but the refuse to medical treatmentis legally protected 23.

The constuonal principle of human dignityand the Law 10.245/99 allow terminal paents to re-fuse medical therapy 23,24. In addion, the Resoluon41/95 of the Naonal Council for the Rights of Chil-dren and Adolescents (Conanda) ensures the youngor infant paent the right to dignied death, close tofamily, when all possibilies of therapy run out 23,25.

Despite lile known in Brazil, the prior decla-raon of will of terminal paents is the documentthrough which the paent informs the family andprofessionals what treatments they would or wouldnot like to undergo, in case of terminality 8,26. In2012, the Resoluon 1.995 of the Federal Board of

medicine (CFM) considers the physician’s duty to putin the records the paent’s previous will – which,in turn, should prevail over any other non-medicalopinion, including the desire, of the family. This res-oluon also states that should be taken into accountthe informaon from legal representaves previous-ly designated by the paent 8,23.

According to the laws stated here, the Code ofEthics for Nurses highlights – on Chapter I, Secon I,arcle 18 – that it is the professional’s responsibilityand duty to respect, recognize and perform acons

that ensure the right of the person or their legal

representave, to make decisions on his/her health,

treatment, comfort and welfare 6.

Extension of human suering in intensive care units

Retrospecvely in the history of health care,the reality is understoond by technological and pro-fessional apparatuses, highly capable to deal withthe health-illness process. However, the teachers in-terviewed arm that there is a need for changes inthe qualicaon of a professional able to deal withthe acceptance of the non-connuity of investmentsin paents with guarded prognosis:

“Somemes, the pain isn’t only physical, it’s also

psychical; somemes for the lack of orthothanasia

itself” (Nurse Callista Roy);

“Even when the team noces ‘it’s beer if I just med -icate them so they won’t feel pain, and I know it’s

best for them’. But they thirst for life; you can see

that in the paent. At that point, the duality is in-

stalled” (Nurse Florence Nighngale).

it is worth nong that health professionals be-come vulnerable when taken by the anguish of lossand failure in the process of dying, when therapeu-c intervenons and responses from the technolog-ical apparatuses run out. 27. Associated to the di-culty to promote the orthothanasia, there is also the

respect to the paent’s decision, which interferes inthe process of acceptance of the human nitude. So,it is necessary to be a facilitator of the acceptance ofdeath as an end to the suering of the paent andtheir family; knowing to respect their individuality,rights and feelings.

To Nurse Callista Roy, insisng on treang ter-minal paents is contradicng the principles of or-thothanasia: “we also have dysthanasia, right? The

suering before the process of death” . At the sameme, terminal paents cannot have an early end oflife, under penalty of proceeding with the euthana-sia. So, essenal care must be provided to terminalpaents, such as adequate nutrion and hydraon,sedaon for the pain and general hygiene care, inorder to promote death in its natural course andwith dignity.

Technological improvement, besides increas-ing life expectaon, may extend the process of dy-ing. Therefore, the conducts of therapeuc eortlimitaons (TEL) and their ethical-legal implicaonshave been widely discussed 28. The promoon ofcare to TEL paents depends, primarily, on accept-



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ing human nitude and recognizing the inability ofcure by professionals 29. To these paents, it is in-dispensable to adopt palliavist therapeuc planswhich priorize the control of pain and discomfort,and the promoon of welfare 29.

Perspecve of palliave care in intensive treat -

ment units

The care provided adequately to terminal pa-ents respects the subjecvity of the individual. Atthis point, palliave care brings the best way to as-sist terminal paents:

“I understand that dignied death, for a terminal pa-

ent, is providing them with comfort” (Nurse Flor -

ence Nighngale);

“Dignied death is… I see it as taking good careof the paent at the end of their life” (Nurse Anna

Nery).

Knowing that the paent is at terminal stagedoes not mean overlooking them and denying care,according to Nurse Callista Roy: “We can’t dieren -

ate the care provided to that paent, right? Listen to

the paent, listen to the family, instruct the family,

help the family” .

The way each paent lives their terminality isrelated to the circumstances of the care provided,

the dynamics of the ethics in the relaon createdbetween the paent and the professionals assisngthem 17. So, the therapeuc focus is turned to qual-ity of life, control of the symptoms and relief of thehuman suering, based on trans, mul and interdis-ciplinary aspects of palliave care 30. Palliave ther-apy aims to the symptomac control and preserva-on of quality of life for the paent, with no curavefuncon, of extension or shortening of survival 30.

Professional work on paents in process ofnitude demands special training, including conn-uous updates on the subject, because it is by deal-

ing with this theme that professionals become moreprepared and condent about the care providedto paents under their responsibility. This way, itis highly important to treat death as a connuoustheme, including at]er academic educaon, con-sidering that acquaintanceship, observaon, inter-venons and constant updates make nurses becomeincreasingly condent in their pracce:

“It’s a friendly word, it’s standing by the paent, it’s

listening to what they’re feeling, it’s providing the

best nursing care I can” (Nurse Florence Nighngale);

“We know that a lot has been discussed about care-

giving to terminal paents, but it sll isn’t, not in my

past and present experience, it isn’t the best possi -

ble” (Nurse Florence Nighngale).

Furthermore, it is implied in the speeches thatsome instuons do not provide adequate condi-ons for the best treatment, oen restricng mate-rials that hinder the process of dying. As exempliedby Nurse Anna Nery: “and then it’s a bedridden pa-

ent, with a request for bandage covering blocked by

the insurance company for lack of prognosis. That’s

how I see the private instuons, dehumanized! In

SUS (unied health system), on the other hand, I see

a certain exibility. If it’s prescribed, if it was evalu-

ated by the nurse, or the doctor prescribed, this cov -

ering is authorized independently of the prognosis” .

From this illustrave speech, it is understood

that the ideal of “jusce as fairness” will always bedebated in the conict between the “universaliza-

on polics” , responsible for the distribuon ofgoods for all, and the focus polics” , responsible forthe elecon of the people and goods to be distrib-uted 17.

Palliave care are a humanized complement ofthe pracces of caring and treang others, besodesproviding more comfort to caregivers in the fulll-ment of their tasks, avoiding frustraons, respond-ing to the other’s call without doing more than it’spossible, respecng the right to die with dignity.

Final remarks

Discussions about terminality have increased,but are sll not enough in regard to the pracce ofnursing professionals. To reach progress in thesediscussions, it is necessary to transversely introducethe subject in every undergraduate discipline, mak-ing it more than just an isolated topic, distant fromthe acons in nursing.

It is noceable that faculty nurses inuencethe academic point of view and are essenal tospread the importance of dignied death in thehospital scenario. The juscaon is in the fact thatnurses who experience death in their professionalpracce turn out to be mostly unprepared when ne-glecng palliave care, i.e., humanized and holisccare for terminal paents.

Regarding palliave care, the speeches of theinterviewees acknowledge considering the existenceof a niche for nursing performance that should not bedespised or unknown by the responsible profession-



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als. Considering that these professionals are primari-ly responsible by caregiving to paents, they are theones who will put orthothanasia in pracce: dignied,respecul and humanized death to terminal paents.

It is perceived that the orthothanasia isgrounded on bioethical principles, neither to short-

en nor to extend the lives of paents without ther-apeuc perspecves. On the other hand, it is alsoperceived that health professionals acknowledgethe orthothanasia, but show dicules in praccingit, whether by emoonal unpreparedness or by notactually realizing the paent’s needs. It is possiblethat professionals pracce dysthanasia because theyfeel that they have to invest once more on a paentto whom they conferred so much care. This way, thisresearch shows the need, from professional educa-on, to review quesons related to dignied death.The suggeson is to conduct quesons referring to

terminality in a more objecve, less arcial way.It is worth nong that researching, studying,

discussing or reecng on death is always very im-

portant, because it is a way of treang it as part ofthe reality of caregiving, as well as providing im-provements in the quality of the process of dying ofterminal paents. In view of this phenomenon, it isessenal to increasingly spread the ethics of care ineducaonal instuons, aiming to train profession-

als able to care for the lives of those who are dying,not only to extend the me of dying.

Promong dignity in the process of nitudeis na indispensable atude nowadays. So, the im-pressions and consideraons of professors aboutthe orthothanasia and human nitude have to beinvesgated, both because of their professional ex-perience and because they should play a referencerole in the process of training of new professionals,who hopefully will guarantee humanized care to adignied nitude. Lastly, it is considered that otherstudies are necessary to the exploitaon of the di-

cules concerning the heterogeneity of the nurses’acons and knowledge, comprising the orthothana-sia and humanized assistance in terminality.

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Authors’ parcipaon

Júlio César Basta Santana was responsible for structuring the project, analyzing the interviews andstructuring the arcle. Bruna Reis da Silva, Denísia Crisane dos Anjos Oliveira, Eberth MesquitaCaminha and Flávia Soares Peres were responsible for structuring the project, collecng data andstructuring the arcle. Cynthia Carolina Duarte Andrade was responsible for the analysis of theresults, and Maria Bernadete de Oliveira Viana, for structuring the project.

Received: 8. 9.2012

Reviewed: 8. 5.2013

Approved: 11. 6.2013

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