ABSTRACT

OBJECTIVE:

To understand the relations between autonomy and health-disease-care processes of older adults in the daily life of primary health care.

METHODS:

Qualitative research developed in 2019, in a primary health unit in the central region of the city of São Paulo, using participant observation and in-depth interviews with 16 health professionals and 8 older adults. The construction and interpretation of the narratives produced in the study were guided by the perspective of Gadamer’s philosophical hermeneutics and Ricoeur’s theory of interpretation. The theoretical framework of vulnerability/Care^ᵃaThe use of the term Care beginning with a capital letter aims to differentiate a concept, developed by the second author, in relation to the use of the term in ordinary language., as proposed by Ayres, guided the definition of the study and interpretative categories.

RESULTS:

Closely related to the difficulties, facilities and strategies to cope with the daily challenges in the health care of older adults, autonomy was an important marker of vulnerability (interpersonal, social and programmatic), indicating areas that require special attention, such as drug dispensing, urban mobility, social isolation, financial frailties and adequacy of service routines.

CONCLUSION:

Distinctly from an individual attribute, autonomy has proved to be the expression of relational characteristics, requiring plural and flexible practical-moral strategies, techniques and horizons, although always guided by the same ethical commitment to respect the singular needs of individuals.

DESCRIPTORS:
Older Adult; Personal Autonomy; Health Vulnerability; Health-Disease Process; Aging; Primary Health Care

INTRODUCTION

Population aging is one of the biggest events in modern society. Due to the fall in fertility and mortality, and the consequent increase in life expectancy, virtually all regions of the globe, including Brazil, have experienced the gradual growth of the older adult population. It is estimated that, by 2050, about 1.5 billion people in the world will be 65 years of age or older, corresponding to approximately 16% of the population¹1. United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2019: highlights. New York: UN; 2019 [cited 2020 Jun 20]. (ST/ESA/SER.A/430). Available from: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/worldpopulationageing2019-highlights.pdf
https://www.un.org/development/desa/pd/s... ^–33. Veras R. Envelhecimento populacional contemporâneo: demandas, desafios e inovações. Rev Saude Publica. 2009;43(3):548-54. https://doi.org/10.1590/S0034-89102009005000025
https://doi.org/10.1590/S0034-8910200900... .

From this perspective, since the 1980s, interest in older adults has grown, with worldwide encouragement to healthy or active aging, which has the autonomy of older adults among its premises⁴4. World Health Organization. Relatório Mundial de Envelhecimento e Saúde: resumo. Genebra: WHO; 2015 [cited 2018 Aug 20]. Available from: http://apps.who.int/iris/bitstream/handle/10665/186468/WHO?sequence=6
http://apps.who.int/iris/bitstream/handl... .

The first known publications that used the term “autonomy” date back to 1693. Derived from alto (self) and nomia (law or rule), the word was translated literally as “own rules.” However, despite the historical use, its meaning has no consensus in the context of health care⁵5. Welford C, Murphy K, Rodgers V, Frauenlob T. Autonomy for older people in residential care: a selective literature review. Int J Older People Nurs. 2012;7(1):65-9. https://doi.org/10.1111/j.1748-3743.2012.00311.x
https://doi.org/10.1111/j.1748-3743.2012... . It is currently recognized that autonomy involves dimensions that can be understood under the approaches of politics, sciences, powers or of individuals themselves, among others. Therefore, it is possible to speak of several autonomies⁶6. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Ações Programáticas e Estratégicas. Orientações técnicas para a implementação de Linha de Cuidado para Atenção Integral à Saúde da Pessoa Idosa no Sistema Único de Saúde - SUS. Brasília, DF; 2018 [cited 2020 Jun 20]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
https://bvsms.saude.gov.br/bvs/publicaco... .

In a document from the Ministry of Health⁶6. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Ações Programáticas e Estratégicas. Orientações técnicas para a implementação de Linha de Cuidado para Atenção Integral à Saúde da Pessoa Idosa no Sistema Único de Saúde - SUS. Brasília, DF; 2018 [cited 2020 Jun 20]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
https://bvsms.saude.gov.br/bvs/publicaco... focused on the care of older adults, the meaning of autonomy is considered as “the individual’s ability to decide and command over their own actions, establishing and following their own convictions” (p. 80). Autonomy considered as the principle of bioethics, as shown by Beauchamp and Childress — that is, as part of a conception of self-government that considers the existence of an individual free of control, interference or any limitation that prevents them from making informed choices — has been criticized by some authors for being insufficient to address the practical issues of daily life⁷7. Paranhos DG, Albuquerque A. A autonomia do paciente idoso no contexto dos cuidados em saúde e seu aspecto relacional. Rev Direito Sanit. 2018;19(1):32-49. https://doi.org/10.11606/issn.2316-9044.v19i1p32-49
https://doi.org/10.11606/issn.2316-9044.... . According to Cohen and Gobbetti⁸8. Cohen C, Gobbetti G. Bioética da vida cotidiana. Cienc Cult. 2004;56(4):47-9., the limit of an individual’s freedom occurs in the context of relations between their inner and outer world, so no one is fully autonomous. Campos and Campos⁹9. Campos RTO, Campos GWS. Co-construção de autonomia: o sujeito em questão. In: Campos GWS, Minayo MCS, Akerman M, Drumond Júnior M, Carvalho YM, organizadores. Rio de Janeiro: Fiocruz; 2009. p.669-88., in addition to stating that autonomy is not absolute, add that the relation between autonomy and health is a dynamic process, which implies gradual losses or acquisitions, “as if they were coefficients relative to a standard of the subject themselves or to established social and historical standards” (p. 670)⁹9. Campos RTO, Campos GWS. Co-construção de autonomia: o sujeito em questão. In: Campos GWS, Minayo MCS, Akerman M, Drumond Júnior M, Carvalho YM, organizadores. Rio de Janeiro: Fiocruz; 2009. p.669-88.. The exercise of autonomy is therefore close to an ethics because it is always in a situation and involves some value judgment. As a consequence, there is no autonomy a priori, for all, nor for any situation, which makes it even more complex to understand autonomy and its preservation⁹9. Campos RTO, Campos GWS. Co-construção de autonomia: o sujeito em questão. In: Campos GWS, Minayo MCS, Akerman M, Drumond Júnior M, Carvalho YM, organizadores. Rio de Janeiro: Fiocruz; 2009. p.669-88.^,1010. Soares JCRS, Camargo Junior KR. Patient autonomy in the therapeutic process as a value for health. Interface (Botucatu). 2007;11(21):65-78. https://doi.org/10.1590/S1414-32832007000100007
https://doi.org/10.1590/S1414-3283200700... .

Despite the recognition of the value of autonomy for well-being and the encouragement in global policies to preserve the autonomy of the elderly, Lothian and Philip¹¹11. Lothian K, Philp I. Maintaining the dignity and autonomy of older people in the healthcare setting. BMJ. 2001;322(7287):668-70. https://doi.org/10.1136/bmj.322.7287.668 PMID:11250856
https://doi.org/10.1136/bmj.322.7287.668... , in a review study, state that although health services should have as priorities preserving dignity and autonomy and minimizing the suffering of patients, in many circumstances these goals are not achieved.

Considering the challenges mentioned, this study seeks to understand the relations between autonomy as a value and the challenges of health care for the elderly in the daily work of primary health care.

METHODS

The aspects discussed here are part of a qualitative investigation developed in 2019 in a basic health unit (BHU) in the central region of the city of São Paulo, which used as tools participant observation in the service and in-depth interviews with professionals and patients¹²12. Kvale S. InterViews: an introduction to qualitative research interviewing. Thousand Oaks, CA: Sage; 1996..

Individuals aged 60 years or older were considered older adults. To obtain greater heterogeneity and plurality of experiences, we sought to interview older adults with varying age, sex, functionality (independent and partially or totally dependent for daily living activities), income, family composition, race, religion, housing situation and relationship with the public service (exclusive use or concomitant with supplementary health). Older adults with these profiles were selected based on the indication of health teams or identification during participant observation. As for the professionals, the selection favored variation of age and team (capturing participants from all family health teams), time of service, sex and nationality. Considering the selection criteria, the invitation was made by the first author of this study directly to professionals. Once the invitation was accepted by professionals and older adults, an interview was scheduled at the place and time of the interviewee’s choice. Before the interview, the participants were oriented about the objectives of the study, reading and signing the informed consent form.

The final composition of the subjects of the study was determined by the saturation criterion¹²12. Kvale S. InterViews: an introduction to qualitative research interviewing. Thousand Oaks, CA: Sage; 1996., that is, the 24 participants were defined by the researchers’ assessment achieving a diversity of respondents, which was capable of capturing the main profiles of interest to the research, and with sufficient empirical justification to respond consistently to the objectives of the study.

For participant observation, we used a script and a field diary in which observations, personal impressions and conversations in the field were recorded. Observing the interactions between older adults, family and professionals (among themselves and with patients) was privileged during individual visits, home visits, groups, team meetings and in the territory in which older adults and BHU were inserted.

Participant observation always carries the risk of interference arising from the presence of the researcher in the observed activities. Although it is impossible to definitively rule out this risk, we sought to avoid interpretative misconceptions arising from this situation. The progressive “dilution” of the observer’s interference by the constant and non-intrusive presence in the studied environment and, especially, the comparison of the observations with the content of the interviews and the analytical triangulation between the authors were relevant to obtain greater interpretative accuracy.

The comprehensive-interpretive process¹³13. Gadamer HG. Verdade e método: traços fundamentais de uma hermenêutica filosófica. Bragança Paulista, SP: Editora Universitária São Francisco; 2015., which supports the validity claim of this study, was based on the following steps: comprehensive reading of the interviews and the records of direct observation, objective-impregnation, insight, and understanding of the characteristics, identification, and analysis of the elements that are highlighted in the speeches, and the ideas in them, exploring the meanings that were seized at when the concerns of the researchers and the narratives that are produced met in relation to the autonomy of older adults and their implications for health care from the perspective of vulnerability.

The construction of the narratives of the interviews, the recording of field observations and the production of interpretative syntheses followed the movement of the so-called “hermeneutic arc.” The result of the study was produced by a progressive and dialectical movement between comprehensive totalizations, references that guided the interpretation of the findings and thorough analysis of the empirical material, which, with the help of the literature already produced, enriched understanding, configuring the “virtuous circularity” between whole and part, proper to the hermeneutic perspective¹⁴14. Ricoeur P. Del texto a la acción: ensayos de hermenéutica II. 2. ed. Ciudad de México: Fondo de Cultura Económica; 2002..

The empirical material was constructed from two thematic axes guided by the theoretical framework of vulnerability/care: 1) recognizing the meanings of autonomy for the deponents; and 2) understanding the main difficulties found in care in relation to the autonomy of older adults.

The concept of vulnerability, as developed by Ayres¹⁵15. Ayres JRCM. Prevenção de agravos, promoção da saúde e redução de vulnerabilidade. In: Martins MA, Carrilho FJ, Alves VAF. Castilho EA, Cerri GG, Wen CL. Clínica médica. Vol. 1. Barueri, SP: Manole; 2009. p.436-55. based on the original proposition of Mann and Tarantola¹⁶16. Mann J, Tarantola D. From epidemiology to vulnerability to human rights. In: Mann J, Tarantola D, editors. Aids in the world II. New York: Oxford University Press; 1996. p. 427-76., establishes a set of individual and collective characteristics related to the greater susceptibility of individuals and communities to an event and, in association, less availability of resources for their protection. Ayres shows three interconnected dimensions within the framework of vulnerability: individual, social and programmatic. The individual dimension concerns the individual’s own factors and their interpersonal interactions, ranging from the health condition to values and way of life of that person. The social concerns inseparable contextual aspects of the previous dimension, such as gender relations, race relations, access to health, education, justice and profession, among others. Finally, the programmatic dimension of vulnerability analyses highlights how institutions act as elements that reduce, reproduce or increase the vulnerability of individuals in given social circumstances.

As a correspondent, in the action plan, thus integrating the apprehension of health conditions through vulnerability, the concept of health Care points to the need to articulate the dimension of technical efficacy (instrumental sense of actions based on health technosciences) with that of practical success (sense of the purposes and means of actions in front of the values and interests of patients in the concrete contexts of their daily lives). The effectiveness of such articulation depends on considering as a normative reference of health actions, in addition to morphofunctional normality, the so-called “happiness project” of people, what moves them and gives meaning to their existences¹⁷17. Ayres JRCM. Cuidado: trabalho e interação nas práticas de saúde. Rio de Janeiro: Cepesc, UERJ/IMS; Abrasco; 2009..

The study was approved by the Research Ethics Committee of the institutions involved, and the certificates of presentation for ethical appreciation (CAAE) in the Plataforma Brasil are, respectively, 90497018.1.0000.0065 and 90497018.1.3001.5479.

RESULTS AND DISCUSSION

The health unit studied had 13,786 registered patients, of whom 9,708 were linked to three family health teams. Approximately 19.7% of the total population in the service was over 60 years old.

We interviewed 8 older adults (whose main characteristics are summarized in Chart 1) and 16 health professionals aged between 29 and 67 years, who had been working in the service from 1 month to 17 years, three of them male and the rest female. One interviewee declared herself black, four brown and the others white. Fourteen of the professionals interviewed comprised the family health teams: 7 community health agents, 2 nursing technicians, 3 nurses, 2 family and community physicians (FCP). Two others — a geriatrician and a social worker — were integrated into BHU as required by management.

What autonomy are we talking about?

Even if we consider autonomy essential for care — as well as a value reinforced by legislation, national and international policies — its definition has no consensus, particularly in the field of health⁵5. Welford C, Murphy K, Rodgers V, Frauenlob T. Autonomy for older people in residential care: a selective literature review. Int J Older People Nurs. 2012;7(1):65-9. https://doi.org/10.1111/j.1748-3743.2012.00311.x
https://doi.org/10.1111/j.1748-3743.2012... ^–88. Cohen C, Gobbetti G. Bioética da vida cotidiana. Cienc Cult. 2004;56(4):47-9.. Among the health professionals interviewed, autonomy was sometimes valued in the field of functionality, such as independence for carrying out activities of daily living, sometimes as decision-making capacity.

Understanding autonomy as a decision-making capacity (or judgment) is one of the main criteria considered by health professionals (and by judges, in judicialized cases) for decision-making in the health follow-up of older adult patients. Several situations involving different perceptions of autonomy generate anxiety in the team, such as when the older adult refuses some intervention that health professionals believe is the best (when considering independence or functional capacity).

The possibility of performing tasks independently is also expressed by some older adults as autonomy and as a value for old age. Needing help for some activities is one of the main limitations faced in everyday life.

On the other hand, if physical dependence generates some possibility of exchange, if the elderly understand that they can help other people, even because of their dependence, this is accepted more easily.

The Autonomy of Older Adults in the Daily Life of Primary Health Care

When analyzed in the concrete context of relationships, the question of autonomy shows its complexity. It cannot be delimited only as functionality or decision-making capacity, because, at the interface between power and decision-making, factors inherent in personal history, culture, social environment, technology and access to programs and policies will give different meanings to these terms, with different implications on health-disease-care processes. Due to its relation to different horizons of life, in team meetings, appointments, groups and reception, the issues pertinent to autonomy and its preservation in older adults arise in several “problem situations” that acquire different colors in each context. Among the various difficulties encountered in the care of older adults in primary care, the dilemmas related to autonomy refer to vulnerabilities that extrapolate the strictly individual problem of the functional capacity of an older adult. The question becomes: incapacity or limitation, of action or decision, facing what challenges?

Non-adherence to prescriptions is considered one of the main problems in the care of the elderly in the reports of the deponents. However, factors such as illiteracy, low socioeconomic status, beliefs, ignorance or even forgetfulness are shown as involved in the difficulty of adherence, highlighting the perception that non-adherence is due to several factors, in addition to the older adult’s own will.

This perception is compatible with the current literature, which adds, in addition to these factors, that the amount of medications, weaknesses in the drug supply network, substance abuse and the presence or absence of family support also influence adherence⁶6. Ministério da Saúde (BR), Secretaria de Atenção à Saúde, Departamento de Ações Programáticas e Estratégicas. Orientações técnicas para a implementação de Linha de Cuidado para Atenção Integral à Saúde da Pessoa Idosa no Sistema Único de Saúde - SUS. Brasília, DF; 2018 [cited 2020 Jun 20]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_atencao_pessoa_idosa.pdf
https://bvsms.saude.gov.br/bvs/publicaco... ^,1818. Freitas JGA, Nielson SEO, Porto CC. Adesão ao tratamento farmacológico em idosos hipertensos: uma revisão integrativa da literatura. Rev Soc Bras Clin Med. 2015;13(1):75-84.^,1919. Marques EIW, Petuco VM, Gonçalves CBC. Motivos da não adesão ao tratamento médico prescrito entre os idosos de uma unidade de saúde da família do município de Passo Fundo - RS. RBCEH Rev Bras Cienc Envelhecimento Human. 2010;7(2):267-79. https://doi.org/10.5335/rbceh.2012.865
https://doi.org/10.5335/rbceh.2012.865... .

In the field of morphofunctionality, the most common difficulties were gait or locomotion, but urinary incontinence, decreased visual acuity and cognitive deficit or forgetfulness were also mentioned. However, once again, along with physical limitation, situations in the city context (such as violence and poor adaptation of urban spaces) appear in the reports that qualify these complaints and also set limits for the performance of care, interfering, for example, in the practice of physical activities or in the search for the BHU. Limitation of older adults or of public space? Disability of the elderly or difficulties with an unprepared environment for diversity?

According to a study based on the ELSI-Brasil database²⁰20. Giacomin KC, Duarte YAO, Camarano AA, Nunes DP, Fernandes D. Cuidado e limitações funcionais em atividades cotidianas: ELSI-Brasil. Rev Saude Publica. 2018;52 Supl 2:9s. https://doi.org/10.11606/s1518-8787.2018052000650
https://doi.org/10.11606/s1518-8787.2018... , 23.2% of individuals over 50 years of age have limitations for basic activities of daily living, especially in relation to mobility at home and to dress. Locomotion problems are common in the elderly and can result not only from alterations in the lower limbs, but also from cognitive deficits, alterations in sensoperception and environmental factors²¹21. Sirena SA, Moriguchi EH. Avaliação multidimensional do idoso. In: Duncan BB, Schmidt MI, Giugliani ERJ, Duncan MS, Giugliani C. Medicina ambulatorial: condutas de Atenção Primária baseadas em evidências. 4. ed. Vol. 1. Porto Alegre, RS: Artmed; 2013. Cap. 69, p.665-72.^,2222. Busse AL, Jacob Filho W. Envelhecimento: uma visão multidisciplinar. In: Jacob Filho W, organizador. Envelhecimento: uma visão interdisciplinar. Rio de Janeiro: Atheneu; 2015. p. 3-10.. Ferreira et al.²³23. Ferreira FR, César CC, Andrade FB, Souza Junior PRB, Lima-Costa MF. Aspectos da participação social e a percepção da vizinhança: ELSI-Brasil. Rev Saude Publica. 2018;52 Supl 2:18s. https://doi.org/10.11606/s1518-8787.2018052000647
https://doi.org/10.11606/s1518-8787.2018... also demonstrate that urban mobility is essential to facilitate or undermine social participation, in particular of older people, who are particularly sensitive to these characteristics of their surroundings and may favor social exclusion.

Among the challenges mentioned by the teams, several narratives referred to cases of social isolation of older adults, both due to their own desire (even when assessed as necessary care by other people) and by family incontinence or insufficiency.

As in the interviews, literature points out that social isolation can intervene in various ways in well-being. Social ties provide essential support in times of illness, encourage people to adopt better health habits and impact the functioning of the immune system. In addition, the absence of these ties may imply cognitive impairment and poor self-perception of health, increased mortality and reduced practice of healthy activities or ability to survive a natural disaster²⁴24. Myers L, Palmarini N. Loneliness: findings from IBM’s Institute for Business Value 2017 Study on Loneliness in the Aging Population. Public Policy Aging Rep. 2017;27(4):158-9. https://doi.org/10.1093/ppar/prx022
https://doi.org/10.1093/ppar/prx022... ^,2525. Ong AD, Uchino BN, Wethington E. Loneliness and health in older adults: a mini-review and synthesis. Gerontology. 2016;62(4):443-9. https://doi.org/10.1159/000441651
https://doi.org/10.1159/000441651... . Family availability is also considered a protective factor for aging, since loneliness, depression and poor health conditions are related to the absence of kinders²⁴24. Myers L, Palmarini N. Loneliness: findings from IBM’s Institute for Business Value 2017 Study on Loneliness in the Aging Population. Public Policy Aging Rep. 2017;27(4):158-9. https://doi.org/10.1093/ppar/prx022
https://doi.org/10.1093/ppar/prx022... .

The team and the older adults also described situations in which financial condition was decisive for care relationships. In some cases, the older adult was the main provider, so the needs of the family guided the allocation of their resources. In others, the family’s low-income condition limited the older adult’s access to the service, due to lack of transportation resources or even for fear of walking in an environment marked by violence, either to go to the service or to exercise.

Barbosa, Oliveira and Fernandes²⁶26. Barbosa KTF, Oliveira FMRL, Fernandes MGM. Vulnerability of the elderly: a conceptual analysis. Rev Bras Enferm. 2019;72 Supl 2:337-44. https://doi.org/10.1590/0034-7167-2018-0728
https://doi.org/10.1590/0034-7167-2018-0... show that, in fact, a poor and deprived neighborhood is associated with worse cardiovascular health, increased incidence of infectious diseases, prevalence of depression and functional limitation, worse self-assessment of health and interference in access to health equipment and services.

Difficulties in the care of the elderly in primary care also refer to the programmatic dimension of vulnerability of older adults, related to access and accessibility (geographical issues, excess demand, short time for care, distant appointments), excess bureaucracy, lack of computerization, ignorance of the entire network of public services aimed at older adults or even incompatibility between supply and demand for these network services (such as day centers, reference units for the health of older adults, etc.).

This type of limitation is not exclusive to this BHU, and part of what is attributed as low autonomy of older adults, or an exercise of autonomy that limits the action of services, needs to be reinterpreted in light of what is actually being offered to older adults as a possibility of care. In fact, excessive demand, large population linked to the teams, delay in scheduling, bureaucracy, lack of computerization and few resources are problems pointed out in general by patients and health professionals³3. Veras R. Envelhecimento populacional contemporâneo: demandas, desafios e inovações. Rev Saude Publica. 2009;43(3):548-54. https://doi.org/10.1590/S0034-89102009005000025
https://doi.org/10.1590/S0034-8910200900... ^,2727. Campos RTO, Ferrer AL, Gama CAP, Campos GWS, Trapé TL, Dantas DV. Avaliação da qualidade do acesso na atenção primária de uma grande cidade brasileira na perspectiva dos usuários. Saude Debate. 2014;38 No Esp:252-64. https://doi.org/10.5935/0103-1104.2014S019
https://doi.org/10.5935/0103-1104.2014S0... ^,2828. Tesser CD, Norman AH, Vidal TB. Acesso ao cuidado na Atenção Primária à Saúde brasileira: situação, problemas e estratégias de superação. Saude Debate. 2018;42. No Esp:361-78. https://doi.org/10.1590/0103-11042018s125
https://doi.org/10.1590/0103-11042018s12... ^,2929. Assis MMA, Jesus WLA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cienc Saude Coletiva. 2012;17(11):2865-75. https://doi.org/10.1590/S1413-81232012001100002
https://doi.org/10.1590/S1413-8123201200... .

FINAL REMARKS

The generalization of findings of a qualitative research should be examined very carefully, because the singularization of the examined situation, necessary for interpretative deepening, competes with the extensiveness of the categories with which the study is constructed. What is expected is that the hermeneutic fecundity of the comprehensible framework produced can be useful to other comparable contexts.

The results shown here will be more easily transferable to the context of older adults living in large urban centers, in industrialized Western societies, in social segments of middle and lower-middle income, with access to primary health care services and some degree of social support via public policies. This does not mean, however, that the study is irrelevant to other contexts. The way in which the relations between autonomy and health-disease-care processes of older adults have been configured here may help to reconfigure the understanding of health care challenges for these people in different contexts. In this sense, criticism of individualizing readings of the value of autonomy and, on the contrary, emphasis on its analytical power on related social and programmatic practices may be particularly useful, not only for older adults, but also for other situations in which the issue of autonomy is relevant to care, such as in the case of people with disabilities or mental disorders.

According to the above, in the context of primary care, the difficulties found in the care of older adults permeate the autonomy embodied with the vulnerabilities to which each elderly person is exposed at a given time. Looking at the care needs of older adults through a relational and procedural perspective of their limits is a potential way to see autonomy not as an end in itself, much less as an obstacle or resistance that needs to be overcome to protect older adults from the risks brought by aging, but rather as a marker of what and how it needs to be transformed (individually, socially and programmatically) for an effective care, that is, to mobilize technical resources that enhance practical successes in terms of health.

The greater or lesser autonomy that one or another individual claims, in this or that aspect of their daily lives, actually signals regions of vulnerability, relational areas (interpersonal, social, programmatic) that require special attention so that technical efficacy and practical success may indeed interact constructively and adequately to the happiness projects of older adults.

By being constructed and understood only in the concrete contexts of the daily interaction of older adults, autonomy is gaining different features as a result of the different situations of practice, which requires thinking of it not as an individual attribute (which the older adult still has or has already lost), but as a marker of relational characteristics that demand technical strategies and plural and flexible practical-moral horizons, always from an ethical horizon of respect for the other and responsibility in relation to it.

REFERENCES

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