Scientific production in oncological palliative care with emphasis in communication

Communication is a facilitating tool in palliative care, enabling the development of a therapeutic process based on universal humanistic values, with benefits for the team, cancer patient, and family. This theme is of great importance and highlights the significant contributions to clinical practice in the context of palliative care in oncology with an emphasis on communication.


INTRODUCTION
Communication is a fundamental therapeutic modality that goes far beyond words and content, contemplating also non-verbal signs and expressed by attentive listening, eye contact, and professional posture 1 . Communication improves the bond between the patient-team-family triad. In addition, it allows patients to express their decisions and maintain social contact, thus their wishes can be met up to the end of their lives 1 .
Considering the importance of palliative care in oncology with an emphasis on communication for healthcare academia, as well as for the medical practice, it is particularly important to develop studies that seek to highlight the scientific production on this subject. Faced with this context, this research aims to: Analyze the scientific production on palliative care in oncology, with an emphasis on communication and contributions to clinical practice. previously mentioned databases, 22 publications met our criteria.
Once the study sample was identified, to facilitate the process of organization for the collection of information relevant to the objectives of the present study, we used a form previously prepared by the researchers which allowed obtaining information on the characterization of the studies, approaches to the theme investigated, and contributions for clinical practice.

RESULTS
The study sample was comprised of 22 papers on palliative care in oncology and communication. Most publications were from 2017, i.e., 18.18%. Regarding the databases, most studies were found on LILACS, with a percentage of 72.9%. With respect to journals, important health magazines were the most prominent, most in the medical area, among which the following deserve to be highlighted: Journal of Palliative Medicine, Palliative Support Care, European Journal of Cancer Care, and the Journal of Clinical Oncology,

METHODS
This is an Integrative Literature Review that aims to summarize publications systematically and rigorously, allowing to characterize and disseminate the knowledge produced. This review aimed to answer the following question: what was the scientific production on palliative care in oncology with an emphasis on communication for clinical practice between 2010 and 2017? Works published as scientific articles in the languages: Portuguese, English, and Spanish.
The selection of papers was carried out based on searches in the following databases: Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS) and Public/Publish Medline (PubMed), upon searching the Biblioteca Virtual em Saúde (BVS) of the Latin American and Caribbean Center on Health Sciences Information (BIREME). We used the following descriptors of the Database, Cinahl Headings (MeSH), and of the Health Sciences Descriptors (DeCS), all of which were associated with the boolean operator "AND". "Palliative care" "oncology" "communication" "cuidados paliativos" "oncologia" "comunicação". Thus, considering all the publications identified in People need to know the truth throughout their lives, not only in the end, out of respect, so they can develop autonomy and free-will.
Morte: o difícil desfecho a ser comunicado pelos médicos Understand, from a physicians' perspective, the process of communicating bad news.
Considering the massive denial around death and its interdiction, it is easy to understand how difficult it is to demand a dying patient to look at death and to communicate it to their loved ones.
Comunicação de más notícias pelos médicos no primeiro ano de internato: um estudo exploratório Explore the perspective of new interns regarding their preparation to communicate bad news and regarding the characteristics of medical programs curricula considered desirable for an adequate formation To improve the preparation of new interns in communicating bad news the emotional aspects of the process must be approached. which approach topics on palliative care practice and oncology. Most researchers on the subject were doctors (58%), followed by the nurses.
Regarding the approach adopted in the studies of the sample, qualitative research was the most frequently used (50%). The studies were conducted, in most cases (45%), in hospitals. All of the keywords used in the studies were indexed in the DeCs (Descritores em Ciências da Saúde) and/or the Medical Subject Headings (MeSH).
The analysis of the studies allowed us to divide them into thematic categories, namely: communication modalities were emphasized in 36% of the studies; 40% were on communication instruments and strategies; and the communication between patients and family caregivers was the focus of 24% of the publications, as presented in Tables 1, 2, and 3.

DISCUSSION
Based on the analysis of information, the studies were grouped into categories to better understand and analyze the discussion, as shown in Tables 1, 2, and 3. With the purpose of summarizing the findings, we will present a brief discussion of each category listed below.
Regarding the communication modalities (Table 1), the methods for transmitting a message using both verbal and non-verbal communication, and the effectiveness in using them when communicating bad news is a significant ability in clinical practice that should be optimized by professionals in the palliative team.
The communication of bad news causes impacts, but there are meager findings in the literature regarding the performance of nurses in this respect, particularly in publications that relate to chronic, progressive, and potentially fatal diseases 2 . The communication of bad news may involve not only the disclosure of the diagnosis, but also the disease progression, and the need for referral to palliative care and home care. Communication is understood as a means for achieving and maintaining a more solid and healthy relationship between the health team, patient, and family members. Through effective communication, the team was able to mobilize the best capabilities and potentials of human beings to face stressful situations and preserve the autonomy and dignity of individuals under their care 3. 4 .
Findings show that the difficulties and causes experienced by nurses in this context of care require emotional control in order to have therapeutic communication between professionals and patients 5 .
Research shows that communication should be understood as a resource that aims at creating environments that ensure patients' needs are met satisfactorily by sharing their experiences, anxieties, and insecurities. Thus, care should be focused on the need to communicate as a therapeutic strategy in order to connect the caregiver to the patient 6 . Thus, telling the truth is imperative in this context of care, since the learning of how to prevent a lack of sensitivity requires not only good intentions but strong communication skills 7 .
The study is about the communication of difficult news and brings suggestions for verbal and non-verbal interpersonal communication that aim to minimize the emotional suffering of patients, family members, and professionals, and the difficulties of physicians in the process of communicating bad news, in particular of recently graduated physicians 8. 9 .
When it comes to communicating difficult news, it is usual for physicians to use phrases in the first person: "I represented a huge hope and, at that moment, I felt like a failure." This feeling of failure is a barrier for physicians when communicating difficult news to family members since physicians themselves see death as a failure 10 . Research highlights that communication or lack thereof between physicians and patients is a constant problem 11 . This problem is a likely reflection of medical training, which is seen as a healing practice, causing many professionals to act mechanically in their daily practices and making them feel powerless in the face of terminality and death.
Non-verbal communication is about decoding relevant emotional information based on the various non-verbal signs, such as facial expressions, body gestures, among others 12. 13 . It is important for professionals to understand that the body speaks through words and signs. Communicational interaction should occur in an informative, sensitive, and possible manner to support patients and their family members in understanding and overcoming the difficulties and limiting situations that the disease imposes.
Research in the category of communication Communication is considered an effective element in the care of children with cancer and is of the utmost importance to promote palliative care when grounded in the Humanistic Theory of Nursing.
Cuidados paliativos à criança com câncer Understand the existential experience of nurses when caring for children with cancer without therapeutic possibilities.
Nurses acknowledge the importance of communication with children with cancer undergoing palliative care. There was an emphasis on attention to the non-verbal behavior of children, through eye contact and touch. instruments and strategies in oncology (Table 2) focused on the assessment of cancer pain in a patient with communication difficulties using the Abbey Pain Scale, which includes six items to assess pain, including vocal verbal and non-verbal complaints 14 .
Another study used the protocol for Consultation Measurement and Relational Empathy, which is a brief questionnaire designed to assess the perceptions of patients on relational empathy during consultations 15 . The research addressed the use of the Edmonton scale for the assessment of symptoms, a self-reporting tool that allows patients with advanced cancer to document the intensity of nine common symptoms 16 . Studies provided a training program with the objective of improving the communication behavior of doctors towards patients with cancer during the transition from curative or oncologic treatment to palliative care. The research used the COM-ON Checklist, which consists of specific items for the transition to palliative care, general communication skills, physicians' skills for handling the emotional needs of patients, and other significant ones 17. 18 . The study developed a brief communication skills workshop to assist oncology health professionals during the transition from active anti-cancer treatment to palliative care 19 .
In this context, it is necessary to highlight the potential of health information technology (HIT) 20 . E-Health technologies can improve the quality of care provided, reduce medical errors, and allow efficient communication to support joint decision-making. Findings indicate the importance of speech therapists, who allow the maintenance of oral communication as much as possible and work in the transition to alternative communication, protecting patients' right to express themselves, without interruption of the possibility to communicate 21 . Another study used the PACIENTE protocol and found that the worst task to be performed during communication is "talking about death," followed by "discussing the end of attempts to curative treatment," and the "diagnosis" in itself 22 .
The studies are unanimous in stating that more research is needed to identify the tools that are suitable for making these assessments in the context of different symptoms and settings and to develop the necessary training by health care providers to integrate these tools and the information they produce into clinical practice.
The category of studies on palliative care with an emphasis on communication carried out with patients and family caregivers ( Table 3), found that the most important subsidies for patients, at the start of their treatment, are: the availability of physicians to discuss the disease and answer their questions, trust in the team, and accessible and understandable communication 23 . Studies emphasize that it is essential that nurses, in their practice, identify the needs of children with cancer through verbal communication, characterized as the dialogic aspect of Nursing, and non-verbal communication, in which the child is perceived as a unique being in the relationships of care 24. 25 .
So the communication between team/family is essential in the construction of care for patients with cancer since the absence of communicative action could compromise the fight against the disease 26 . On the other hand, a study conducted with family members of children and adolescents with cancer noted a feeling of helplessness in the care of children, adolescents, and family members when the expression "there is nothing else we can do" is verbalized, confirming that the clarity, knowledge, and objectivity with which information is passed on to family members are, in general, ambiguous, inaccurate, and often lacking in comparison to the philosophy of palliative care 27 .
Findings point to a lack of knowledge by family members when a child and or adolescent with cancer begins palliative care 28 . In these situations, the family notices the team's lack of interest in the continuation of treatment, thus losing trust in information and conducts 29 . Therefore, trust mediated by good communication and constancy of care are seen as fundamental for the satisfaction of caregivers and cancer patients throughout the course of the disease. Thus, in palliative care, assistance to patients with cancer and their families should be more human and holistic, based on strategies such as communication, which can develop a therapeutic process based on universal humanistic values with benefits for all.

CONCLUSION
The present study contributes significantly to clinical practice in the context of palliative care in oncology, with an emphasis on communication. However, considering the reduced number of publications on the subject over a period of eight years, future studies are recommended to subsidize the expansion of knowledge in the area.