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Revista Bioética

Print version ISSN 1983-8042On-line version ISSN 1983-8034

Rev. Bioét. vol.27 no.4 Brasília Oct./Dec. 2019  Epub Jan 10, 2020

https://doi.org/10.1590/1983-80422019274342 

UPDATE

Comforting practice for the hospitalized elderly in light of bioethics

Rosane Barreto Cardoso1 
http://orcid.org/0000-0001-8052-8697

Sandra Teixeira de Araújo Pacheco1 
http://orcid.org/0000-0002-4612-889X

Célia Pereira Caldas1 
http://orcid.org/0000-0001-6903-1778

Priscilla Alfradique de Souza2 
http://orcid.org/0000-0002-4625-7552

Patrícia Lima Pereira Peres3 
http://orcid.org/0000-0001-7086-8970

Michelle Darezzo Rodrigues Nunes3 
http://orcid.org/0000-0001-7685-342X

1. Programa de Pós-Graduação em Enfermagem, Faculdade de Enfermagem, Universidade do Estado do Rio de Janeiro (Uerj), Rio de Janeiro/RJ, Brasil.

2. Departamento de Enfermagem Médico-Cirúrgica, Universidade Federal do Estado do Rio de Janeiro (Unirio), Rio de Janeiro/RJ, Brasil.

3. Departamento de Enfermagem Materno-Infantil, Faculdade de Enfermagem, Universidade do Estado do Rio de Janeiro (Uerj), Rio de Janeiro/RJ, Brasil.


Abstract

Bioethics raises discussions of great relevance regarding the values and moral principles that are present in the daily practice of nursing in hospital gerontology. Hospitalization emphasizes the fragility of the elderly, leaving them susceptible to suffering, vulnerability and discomfort. This fact can hinder their recovery, entailing the adjustment of the care provided. The objective of this article is to reflect on the promotion of well-being for the hospitalized elderly, based on the Theory of Comfort and the principles of bioethics. Thus, it is essential for health professionals to offer holistic and humanized care that addresses patients’ physical, psycho-spiritual, sociocultural and environmental needs, taking into account the comfort of the hospitalized elderly and the principles of bioethics.

Key words: Population dynamics; Health of the elderly; Bioethics; Patient comfort

Resumo

A bioética traz discussões de grande relevância sobre valores e princípios morais presentes no cotidiano da prática de enfermagem em gerontologia hospitalar. A internação acentua a fragilidade do idoso, deixando-o suscetível ao sofrimento, à vulnerabilidade e ao desconforto, o que pode prejudicar sua recuperação, implicando adequação dos cuidados prestados. O objetivo deste artigo é refletir sobre a promoção do bem-e=star do idoso hospitalizado a partir da teoria do conforto e dos princípios da bioética. É imprescindível que os profissionais de saúde ofereçam cuidado holístico e humanizado que contemple as necessidades físicas, psicoespirituais, socioculturais e ambientais dos pacientes, tendo em vista o conforto do idoso hospitalizado e os pressupostos da bioética.

Palavras-Chave: Dinâmica populacional; Saúde do idoso; Bioética; Conforto do paciente

Resumen

La bioética trae discusiones de gran relevancia relacionadas con los valores y principios morales que están presentes en el cotidiano de la práctica de enfermería en gerontología hospitalaria. La internación acentúa la fragilidad del anciano, dejándolo susceptible al sufrimiento, a la vulnerabilidad y a la incomodidad, lo que perjudica su recuperación, implicando una adecuación de los cuidados brindados. El objetivo de este artículo es reflexionar acerca de la promoción del bienestar para el anciano hospitalizado, a partir de la teoría del confort y de los principios de la bioética. Es imprescindible que los profesionales de salud ofrezcan un cuidado holístico y humanizado que contemple las necesidades físicas, psicoespirituales, socioculturales y ambientales de los pacientes, teniendo como meta el confort del anciano hospitalizado y los presupuestos de la bioética.

Palabras-clave: Dinámica poblacional; Salud del anciano; Bioética; Comodidad del paciente

With technological and scientific advances in the field of health, longevity and increased life expectancy have become a significant reality in society. Population aging is a phenomenon characterized by an increase in the proportion of elderly people in relation to other age groups, leading to social and health service changes1 , 2 . Aging is a natural and progressive process that occurs throughout life, resulting in biopsychosocial changes. Old age predisposes the individual to chronic diseases, dependence, functional decline, falls, hospitalization, institutionalization, and death3 - 5 .

Although old age does not mean disease but a stage of life with its peculiarities and values, the elderly end up consuming more health services. Hospitalization of the elderly is representative and more frequent than that of people in other age groups, and it also takes longer bed occupancy, which requires professionals prepared to meet the needs of this growing population group5 , 6 .

The disease associated with hospitalization accentuates the fragility of the elderly4 . During hospitalization, these people may lose their functional capacity due to their disease, previous clinical conditions, procedures to which they are submitted and adaptation to the hostile environment, increasing susceptibility to suffering, vulnerability, and discomfort5 - 7 .

In the hospital environment, nursing professionals must understand the aging process and be prepared to meet the specific needs of the elderly. Nursing care in gerontology should be based on scientific knowledge –biological, psychological, social, and cultural knowledge – that allow nurses to put into practice a global and bioethical approach to the elderly8 , 9 .

For integrated gerontological assistance to the hospitalized elderly and taking into account the multidimensionality of the aging process, interdisciplinarity is necessary. This requires professionals to integrate technical and scientific knowledge and actions based on bioethics, in order to restore and promote the health of the elderly. It is essential that the nursing team offers holistic and humanized care that addresses the physical, psycho-spiritual, socio-cultural and environmental needs, aiming at the well-being of the hospitalized elderly8 - 10 .

The promotion of comfort measures is intrinsic to nursing and imperative for humanized and bioethical care11 , 12 ; however, it is often minimized in the face of technologies in the hospital environment13 . Comfort is a basic human need11 , an essential result of universally desirable nursing care. Relevant to various professional taxonomies and area theories11 , 12 , 14 - 16 , welfare measures based on the principles of bioethics - beneficence, non-maleficence, justice, and autonomy - can reestablish the health of hospitalized elderly14 - 16 and even strengthen their relationship with health professionals.

Comforting is a complex act, more comprehensive than keeping patients well-positioned, warm in bed, and relieving their pain11 , 13 . It also includes the expectation and experience of the elderly to be helped and/or encouraged11 , 14 , 16 , ethical care that includes respect for autonomy and encouragement to the hospitalized elder. In this way, comfort goes beyond providing measures to mitigate suffering; it is about meeting the needs of the elderly in all human dimensions11 .

In this sense, the nursing staff, especially nurses, should provide care based on a holistic and humanized view, promoting strategies that favor comfort, respect, dignity, and relief from suffering, as well as guaranteeing principles and values of bioethics in the sphere of caring.

Considering the growing number of hospitalized elderly people, the advent of new technologies and interventionist possibilities in the hospital environment, it is essential to discuss the promotion of holistic comforting care based on the principles of bioethics. The goal is to sensitize nursing professionals to this phase of the human life cycle, understanding the ethical and moral values to care for the hospitalized elderly. This subject is entitled to the satisfaction of their biopsychosocial needs, respect, well-being, and comfort, all promoted holistically.

Therefore, this study aims to reflect on the promotion of comfort to the hospitalized elderly, based on the theory of comfort, by Katharine Kolcaba11 , and on the assumptions of principlist bioethics.

Comfort for the hospitalized elderly in light of bioethics

The term “bioethics” emerged in the 1970s through technological advances in the fields of biomedicine, establishing a method for analyzing concrete cases and ethical problems that arose in health care practice17 . The principles of autonomy, beneficence, non-maleficence, and justice underpin this approach - which is why it was called “principlism” - guiding professional conduct in decisions in the face of moral conflicts of care and contributing to care based on respect and human dignity17 - 19 .

Bioethics brings discussions of great relevance, related to the values and moral principles of nursing practice in hospital gerontology. It recognizes that every advance in the field of biomedical sciences must be at the service of humanity, paying attention to the conscious use of new technologies in the medical sciences17 - 19 . Thus, it is concerned with the care provided to the elderly, especially in the hospital environment, where sometimes technological resources are available, and it is important to reflect on bioethical issues involving this type of device.

The hospital environment is hostile, with norms, pre-established routines and technological devices imposing changes in the quality of life of the elderly. Care is increasingly dependent on technology, and humanistic practices of affection, solidarity, and even comfort for the hospitalized elderly are less valued20 . They are not always involved in decisions about their lives or communicated with in order to understand the strategies established for their assistance.

In hospitalization, the elderly become more fragile and their autonomy even more restricted. Loss of autonomy is one of the main problems faced not only by older people but by most hospitalized patients20 . This process of institutionalization entails social isolation, the imposition of different degrees of immobility, exposure to risks, adaptation to the hospital environment (with restrictions) that result in greater danger of functional decline and increased dependence4 , 5 .

Respecting autonomy presupposes that the hospitalized elderly or their family can choose comfort, and these choices must be ethically respected even in the face of the inability to manifest them. The comfort strategies promoted by nursing should be perceived and planned according to the desire of the protagonist of care, the hospitalized elderly. For humane and comforting care, it is essential that the nursing staff value communication with this vulnerable patient due to illness and hospitalization, listening to their concerns and doubts to provide clear and objective information for them and their families to understand the procedures and rules. of the institution5 , 6 .

If nurses include the principles of autonomy, beneficence, non-maleficence, and justice in their gerontological care, considering the person and their experiences, they will indirectly offer comforting care to the elderly. For this, the patient’s decision-making capacity, as well as their beliefs and moral values, should be considered, that is, comforting care should be adjusted to the needs and singularities of the elderly11 .

For Kolcaba, comfort is the immediate experience of being strengthened by having the needs of relief, tranquility, and transcendence met in the physical, psycho-spiritual, social, and environmental contexts 21 . Relief represents the experience of the elderly having met the need for specific comfort. Tranquility, in turn, refers to the state of calm, quiet or satisfaction of the elderly in the hospital environment, promoted by the nurse. Transcendence, on the other hand, is when the elderly overcome a problem or pain, assisted by the professional, which improves the nurse-patient relationship11 , 12 , 16 . These types of comfort established in Kolcaba’s theory are interdependent, based on the principles of bioethics.

In gerontological care, beneficence refers to the act of doing good to the hospitalized elderly, promoting strategies for their comfort17 , 18 . The nursing team should share and explain to the patient and their family the need, benefits, and risks of the actions to be performed, avoiding unnecessary invasive procedures and respecting the decision, beliefs, values, identity, and privacy of those involved. The principle of beneficence encompasses another inseparable one: non-maleficence17 , which consists of the professional duty not to cause harm and minimize the risks to the patient’s quality of life22 .

Comfort actions should be chosen and discussed with the elderly and their families, based on the principles of bioethics. Respecting the will of these subjects and including them in care planning, the interaction with the professional is strengthened11 , 14 , from the perspective of holistic care.

By promoting comfort, recognizing their ethical and moral duty to act on behalf of the other, the nurse establishes a relationship of trust that can prevent invasive therapeutic actions. The principle of non-maleficence determines that the health professional commits to evaluate and avoid predictable harm to the patient. For Kolcaba, comfort can also be interpreted as the experience of being helped, supported or encouraged, a way of not causing harm 23 .

The nurse must respect the dignity of the elderly, value them and, above all, consider them in their entirety, recognizing their physical, psychological and/or social needs. Thus, the care provided will contemplate the bioethical principle of beneficence.

Based on the concepts of the holistic approach, Kolcaba defined four contexts in which comfort occurs: physical (body sensations), psycho-spiritual (internal self-awareness), explained as esteem, sexuality and meaning of life, social (social inclusion, relationships interpersonal, family and cultural or financial aspects) and environmental (light, noise, color, temperature) 24 . The author states that at the sociocultural comfort level, health professionals should promote some social and cultural aspects during hospitalization, as well as ensuring the rights of the elderly by developing the bioethical principle of justice 25 .

Such principle implies equal treatment and comfort17 , 18 , offering the older patient what is needed according to their demands and particularities. The nurse, by ensuring comfort actions - which sometimes provide maximum benefit at minimum cost - puts into practice their awareness for the fight for the rights of the elderly. The principle of justice is linked to that of charity and both should be assured to every hospitalized citizen.

Thus, holistic and comforting nursing practices constitute charitable interventions and strategies, individualized and consented by the elderly and their families. The goal is to meet the patient’s needs by valuing their preferences and life experiences with particular comfort actions. This involves listening, clarifying doubts, positive interaction/communication, touch, smile, unconditional presence, integration of the elderly and family in care, relief of discomfort and pain, actions to maintain functional abilities, respect for the decisions of those involved, care for hygiene and personal arrangement. It is about providing full support at the time of suffering and hospitalization10 .

Final considerations

Comfort based on bioethics can provide support for change in the thinking and actions in gerontological care, leading to reflection on comforting and humanized holistic practice for the hospitalized elderly. This reflection has the potential to guide society in understanding aging and the importance of respecting beliefs and ethical values in gerontological care. It is evident that bioethical principles can guide nurses to decide and act correctly, as they are the basis for assisting the elderly in their entirety.

The principlist theory is indispensable to guide the reflection and practice of gerontological care in nursing. This article is expected to provide subsidies for research on health care for the elderly, as well as on ethical conflicts in vulnerable groups in the hospital context.

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Received: January 15, 2019; Revised: May 16, 2019; Accepted: June 21, 2019

Correspondência Rosane Barreto Cardoso – Boulevard 28 de Setembro, 157, Vila Isabel CEP 20551-055. Rio de Janeiro/RJ, Brasil.

Participation of the authors

The authors participated equally in the study.

Rosane Barreto Cardoso – Doutoranda – rosane.bcardoso@gmail.com

Sandra Teixeira de Araújo Pacheco – Doutora – stapacheco@yahoo.com.br

Célia Pereira Caldas – Doutora – celpcaldas@gmail.com

Priscilla Alfradique de Souza – Doutora – prialfra@hotmail.com

Patrícia Lima Pereira Peres – Doutora – patricia.uerj@hotmail.com

Michelle Darezzo Rodrigues Nunes – Doutora – mid13@hotmail.com

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