Palliative care to the cancer patient: reflections according to Paterson and Zderad's view

Abstracts

Trata-se de um estudo reflexivo que apresenta a abordagem do Cuidado Paliativo de Enfermagem ao portador de câncer, fora de possibilidade terapêutica, sob o olhar dos pressupostos da Teoria Humanística de Enfermagem de Paterson e Zderad. O Cuidado Paliativo tem por finalidade proporcionar ao paciente e sua família melhor qualidade de vida. Quando o enfermeiro, ao cuidar do paciente portador de câncer fora de possibilidade terapêutica, aplica o referencial da Teoria Humanística em combinação com a terapêutica do Cuidado Paliativo, é possível reconhecer cada ser como existência singular em sua situação. Desse modo, propicia entender seu significado e compeendê-lo no processo de sua doença.

neoplasias; cuidados paliativos

Se trata de un estudio reflexivo que presenta un enfoque del Cuidado Paliativo de Enfermería para aquel portador de cáncer sin posibilidad terapéutica, de acuerdo con los supuestos de la Teoría Humanística de Enfermería de Paterson y Zderad. El Cuidado Paliativo tiene como finalidad proporcionar al paciente y a su familia una mejor calidad de vida. Cuando el enfermero, al cuidar del paciente portador de cáncer sin posibilidad terapéutica, aplica el referencial de la Teoría Humanística en combinación con la terapia del Cuidado Paliativo, le es posible reconocer la existencia singular de cada ser. De este modo es posible entender su significado y comprenderlo dentro del proceso de su enfermedad.

neoplasias; cuidados paliativos

REVIEW ARTICLE

Palliative care to the cancer patient: reflections according to Paterson and Zderad's view

Míria Conceição Lavinas Santos^I; Lorita Marlena Freitag Pagliuca^II; Ana Fátima Carvalho Fernandes^III

^INursing Doctoral student, RN at the National Institute of Cancer, e-mail: [e-mail]

^IIPhD, RN, Full Professor, e-mail: [e-mail]

^IIIPhD, RN, Professor, e-mail: [e-mail]. Federal University of Ceará

ABSTRACT

This reflective study presents the approach of the Nursing Palliative Care to the cancer patient without therapeutic possibility according to the Paterson and Zderad's Humanistic Nursing Theory. The palliative care aims to provide the patient without therapeutic possibility and his family better quality of life. When the nurse, in addition to delivering palliative care to the cancer patient, uses the Humanistic Theory, (s)he starts to recognize each person as a singular existence. This recognition permits one to understand the person's meaning in the process of his(er) disease.

Descriptors: neoplasms; hospice care

INTRODUCTION

In 1990, the World Health Organization (WHO) conceptualized Palliative Care as "measures that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual"⁽¹⁾.

Palliative Care constitutes an integrated and multidisciplinary therapeutic modality for advanced cancer patients without any therapeutic possibility of cure. This possibility, described as low-technology and high-contact, aims to avoid the patients' last days from turning into lost days, offering a type of care that is appropriate to their needs⁽²⁾.

In the Palliative Care team, nurses play a singular role, whose care covers a humanistic view that considers not only the physical dimension, but also the patient's psychological, social and spiritual concerns.

The impossibility of cure does not mean that the nurse-patient relation deteriorates but, on the opposite, that it is tightened, which will certainly offer benefits to both. Actively taking part in their treatment, the patients can participate in decision processes and in the care they receive.

In the case of cancer patients without therapeutic possibility, it is important to maintain health with quality. However, to guarantee it, cancer nurses face one difficulty: develop means to offer a sensitive care that allows for health maintenance and, at the same time, confronts the terminal nature of the disease.

Most of the times, terminal cancer patients are seen as dependent on the family, incapable of making decisions and taking initiatives with respect to the destiny of their existence, and normally find themselves impeded from participating in the questions of the society they are inserted in. For these human beings, in general, a special place is reserved, whether in the family or in hospital, which is justified by protection.

This philosophy, associated with the ethical and care premises, turns Palliative Care into a valuable instrument to improve the living conditions of cancer patients and their families. The goal is to offer them humanized care, guaranteeing a quality of life that is adequate to their needs, base don the sharing of knowledge and respect among health professionals, patients and family members. Thinking of these human beings, we deepened our reflections about the humanistic form of care.

Thus, the study aims to reflect on the Humanistic Theory by Paterson and Zderad⁽³⁾, evidencing some of its premises applied to cancer patients without therapeutic possibilities, and to project nurses' participation in the Palliative Care Model. Therefore, a conscious practice is used, related to the Humanistic Nursing Theory.

METHODOLOGY

We carried out a reflexive study. To obtain further theoretical foundations, we realized a comprehensive reading of the Humanistic Nursing Theory, in its original language English⁽⁴⁾, as well as in a version translated to Spanish⁽³⁾. Next, we looked for the elements attributed to the concept of Palliative Care for Cancer Patients without therapeutic possibilities in literature, in order to outline the connections with the Humanistic Nursing Theory.

HUMANISTIC NURSING THEORY AND PALLIATIVE CARE TO TERMINAL CANCER PATIENTS

The Humanistic Nursing Theory⁽³⁾ was developed in 1976 by Public and Mental Health nurses, amidst a discussion in society about the form and contents of human existence, whose bases were appointed by phenomenology and by existentialism.

In existentialism, individuals have possibilities to choose which determine the direction and meaning of each person's life. It is a philosophical approach to understand life and the dimension of the human being, with existence as the primary dimension.

In theory, existentialism emerges as an existential experience that allows for human knowledge of the being and the quality of the other person's being. Theory identifies the individual as a being with self-perception abilities, with freedom and responsibility, fighting to find his/her own identity and at the same time relating with other beings, who are actually involved in a search for the meaning of life. Both phenomenology and existentialism value experience, man's abilities for surprise, knowledge and opening to what is new⁽¹⁾.

The Palliative Care Model emerged from the movement originated by Cecily Saunders, in 1984, when the palliative medicine process started. This model, in turn, introduced a care concept focused on care and not on the patient's definitive cure. Palliative medicine associates this philosophy with the work of the multidisciplinary health team to control pain and relieve symptoms⁽⁵⁾.

This care model uses a multidisciplinary approach that includes the patient, the family and the community with a view to reducing suffering and offering total care. It is conceptualized as a care philosophy and aims to provide individual and family support to people who are living with the advanced phase of chronic-terminal diseases⁽¹⁾.

The focus of these three concepts is to achieve the relief of pain and symptoms and to attend to biopsychosocial and spiritual needs, understanding the patient's individual beliefs, values and needs and family support. Caregivers are responsible for defending the patients' rights to receive adequate care indistinctly.

The Palliative Care Model covers two important aspects for care: the holistic approach and an interdisciplinary professional practice. Thus, associating Palliative Care with the Humanistic Nursing Theory is quite favorable, because it involves the valuation of the human being in the health-disease process, with a view to always benefiting the patients, preserving their autonomy and decision-making ability. Therefore, nurses should not only focus on the persons' well-being, but on their full existence, helping human beings at this particular moment in their lives.

In this perspective, being human is considered in the Humanistic Nursing Theory⁽³⁾ on the basis of an existential structure of becoming through choices, with the ability to open up for options, with value and with the single manifestation of one's past, present and future. Although the person's individuality is respected, it should be related with other human beings in time and space.

Based on these concepts, humanistic nursing goes beyond a unilateral, theoretically competent and creative subject-object relation, and is guided by a nursing practice that benefits the other person. According to the relationship process, nurses should get to know each human being as a singular existence, individually, with his/her particular history, with his/her experiences, accepting the way (s)he lives and his/her world, with a view to delivering help.

The becoming of patients who need palliative care is related with the preservation of their autonomy to participate and make decisions about care itself, based on their perspective. Patients are seen in their individuality, sharing care with health professionals and relatives. Palliative care aims to value the ethos, the set of feelings experienced and expressed by the human being, as opposed to the traditional method, whose absolute truth is cure.

The ethos of cure includes the virtues of combat, i.e. not giving up and always persisting. The central value of the care ethos, in turn, is human dignity, emphasizing the solidarity between patients and health professionals, an attitude that results in actual compassion⁽⁵⁾.

In Humanistic Nursing Theory⁽³⁾, nursing is seen in the human context, a comforting response from one person to another at a moment of need with a view to the development of well-being and becoming. In this context, presence is the quality of being open, receptive, ready and available for the other person in a reciprocal way.

It is a type of special encounter, that is, an intentional encounter, because it has a goal. Nurses themselves are a particular form of human dialogue, as humanistic nursing passes through the potential of humanity. It implies in one human being helping the other. This is about an action in response to a person who needs help, about effective decision practice, about being and doing with the patient.

Nursing practice is described phenomenologically, as nurses' capacity to work with other human beings in their experiences of maximum intensity does not only focus on the person's well-being, but on his/her existence in its fullest sense, helping the human being at that particular moment in his/her life.

Based on this view, humanistic nursing departs from the premises of human beings (patients and nurses) joined in an inter-subjective transaction (being and happening) with a specific goal (feeding well-being and being-better) that occurs in time and space (delimitation that patients and nurses live in), within a universe of men and things.

In the health-disease process of cancer patients, nurses are present in all different phases, ranging from prevention to diagnosis and prolonged treatments. When delivering palliative care, they participate in support to patients and families in order to cope with the terminal phase. This participation not only involves managing the pain, respiratory failure, anxiety and depression, but also sharing care decisions with patients and their relatives^(2-6).

Nursing is a continuous care means aimed at welcoming, preserving, caressing and providing physical, mental, spiritual conditions for a free and serene detachment. Thus, nurses are constantly valuing the patient's abilities and needs and stimulating their utmost participation in their recovery program.

In the philosophy of the Humanistic Care Theory as well as in Palliative Care, nurses feed the potential of jointly experiencing and supporting the process lived by the patient. Nurses and patients are humanized in making responsible choices in the inter-subjective and transactional situation of care, leading to humanistic nursing.

Therefore, in delivering Palliative Care, nurses should respect the other person and be supportive, that is, be compassionate with that person's pain and, mainly, maintain his/her individuality, because one can only be-with the patient by visualizing his/her uniqueness, as each individual is a singular being. Thus, formal caregivers (nurses) should know how to discover the sick person's time⁽⁶⁾.

In Humanistic Theory, the environment is something conceived subjectively, transcendent and located beyond the physical space. It is characterized by the nurse's relationship process with the patient in an inter-subjective transaction. As an inter-subjective transaction, it contains the possibility of both participants influencing and enriching one another; it is a live dialogue⁽⁷⁾.

Humanized care involves the true and legitimate presence, the live and authentic dialogue between people. In fact, being with or being there is a type of relationship that implies the nurse's active presence, that is, being on the alert for an opening here and now in the situation of communicating the availability. This involves being present, which constitutes a call and an answer. This relationship is part of the environment concept.

Thus, the environment allows for the development of an atmosphere that facilitates the quality of the encounter that can occur in a privative or collective space, and which is not only restricted to the physical care action, but includes much more, i.e. the becoming. The therapeutic model of Palliative Care, on the other hand, demands that nurses and patients move together, as the involvement with both participants' world will be constructed in the time and space they cover, establishing an adequate harmony with a view to helping the patients with their needs.

In this perspective, when delivering Palliative Care, nurses should single out their action and adapt to the other persons' temporality in order to offer a better quality of life in their experience of the disease. This requires treating patients in their individuality. At the same time, in communicating with the patients, nursing should take into account that what is transmitted is important, but that the way it is transmitted is as vital as the what⁽⁸⁾.

Communication is essential to help the patients find a sense of control, capable of permitting their active participation in decision making. By establishing clear objectives, nurses and patients will create security and increase confidence. In this process, the benefit to be aimed for is to preserve the patient's functional independence.

The nurse's action is a care response to the other person in a situation of need, with a view to increasing the possibilities of responsible choices in his/her process of becoming⁽⁹⁾. Thus, the inter-subjective transaction promotes a support system that helps the patient to live as actively as possible and to feel that his/her needs are satisfied. The simple idea of doing and not just being attended to gives the patient the opportunity of being attended to, of being productive, and facilitates care delivery by the professionals involved^(10-11).

In the Humanistic Theory, health is considered a matter of survival, a quality of life or death, through the individuals' potential for well-being and being-better⁽²⁾. The elements of the reference framework established in the Humanistic Nursing Theory⁽²⁾ to promote health include the human being (patient and nurse), who are joined in an inter-subjective transaction (being and becoming) with a definite goal (promoting well-being and being-better), which occurs in time and space (as lived by the patient and nurse) in a universe of men and things. In other words, the nurse has to consider the way the patient lives, his/her world of experiences, in order to be able to attend to this patient's needs.

Nursing's interest only focuses on people's well-being in their fullest existence, and is responsible for helping them to be as human as possible at a certain time in their life⁽²⁾. Thus, in Palliative Care, although death is considered a normal process in human evolution, when it is actually manifested in a person's daily reality, it produces feelings of pain and suffering that are usually hard to accept.

In these circumstances, care for the terminally ill should always aim for the patients' benefit, preserving their autonomy and decision-making ability. Caregivers are responsible for defending the patients' rights to receive care indistinctly⁽⁶⁾.

Palliative Care is characterized by some grounds. The main ones are: relieving pain and other symptoms the patients present; helping them psychologically and spiritually to allow them to accept their own death and prepare for it as completely as possible; offering a support system that is capable of helping them lead an active and creative life until death arrives, thus promoting their autonomy, personal integrity and self-esteem; providing for a support system to help them cope with the disease and bear periods of pain as, in this therapeutic modality, the right to a dignified death is the right to live one's own death humanely^(12-13).

In the Humanistic Nursing Theory and in Palliative Care, health and disease are considered individual as well as collective processes, which are developed within a biological nucleus that is affected by physical, psychological, social and spiritual processes. These, in turn, are dimensions of reality with the patient's past and future.

FINAL CONSIDERATIONS

The Palliative Care Model emerged to attend to the needs of patients without therapeutic possibilities. Therefore, its adoption in cancer patient care is extremely important and continues being a growing need at health institutions and in the home context.

As observed, the dimension of the suffering associated with cancer has been demonstrating the urgent need to develop a scientific and humanistic care that permits health teams and institutions to give an efficient answer to the problem experienced by patients and family members.

In accordance with these reflections, care in the Humanistic Nursing Theory and in the Palliative Care Model allows for self-realization, which is how human beings live the true meaning of their existence.

However, the humanistic nursing theoreticians defend does not reject technological advances in health. On the opposite, it expands their value by considering their use in the perspective of human development. In the same way, Palliative Care values high levels of contact as a central point for human dignity, however, without overestimating it in patient care.

The care actions inserted in the humanistic perspective and in palliative therapeutic measures go beyond the performance of certain technical procedures. They involve being-with and being-there, which imply the nurse's active presence. Being-with requires attention for the being who receives care, remaining on the alert for an opening in the shared situation, as well as communicating this availability, as it is an existential commitment aimed at adding to and developing human potential.

Recebido em: 27.4.2006

Aprovado em: 13.9.2006

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Publication Dates

• Publication in this collection
  29 May 2007
• Date of issue
  Apr 2007

History

• Accepted
  13 Sept 2006
• Received
  27 Apr 2006