The Communication on the Promotion of Human Dignity in Palliative Care -Challenges for Nursing
Bruno Miguel Freire Monho1, Inês Margarida Peralta Ferreira2, Ferreira Bernardino Ribeiro3, Tânia Sofia Cardoso Alves4 and Maria Deolinda Antunes Da Luz Lopes Dias Mauricio5*
1General Nurse in the Palliative Care Unit of Casa da Saúde da Idanha, Portugal
2Department of Medicine, Hospital Prof. Dr. Fernando Fonseca, Portugal
3General Care Nurse, Hospital Prof. Dr. Fernando Fonseca, Portugal
4General care nurse & surgery service, Hospital Prof. Dr. Fernando Fonseca, Portugal
5Department of Health of the adult and ancient, Adjunct Coordinator in ESELisboa
Submission: February 06, 2019; Published: March 20, 2019
*Corresponding author: Maria Deolinda Antunes da Luz, Professor Coordinator of Nursing course at the Nursing School of Lisbon, University of Lisbon, Portugal
How to cite this article: Bruno M F M, Inês Margarida P F, Ferreira B R, Tânia S C A, Maria D A D L L D M. The Communication on the Promotion of Human Dignity in Palliative Care -Challenges for Nursing. Palliat Med Care Int J. 2019; 2(2): 555585. 10.19080/PMCIJ.2019.02.555585
Abstract
The conceptualization of palliative care is recent, despite the fact that comes from ancestral roots. Customers target of palliative care are often people in situations of extreme vulnerability. It is in the valuation of human integrity in the situations of fragility that the promotion of human dignity wins evidence. This humanistic perspective, the basic philosophy of nursing care presupposes the interaction as key to care. The communication is a basic instrument for nursing, as well as a pillar of palliative care. If in palliative care we are faced with situations of great vulnerability and there is where we see the concern for human dignity, there is when.
The present article aims to understand the influence of communication as a basic instrument for nursing in the promotion of human dignity. # through the literature review and appealing to the model of the Dignity of Chochinov, identifying interventions associated with the communicational skills of nurses that promoted the dignity of clients in palliative care. If the dignity is an intrinsic value that reaffirms the recognition of someone as a person and respect for this condition, the communicational intervention it is what promotes the dignity for those that transmit the customer palliative respect for your individuality and appreciation of his personal history
The nurse must adopt a posture of sympathetic understanding, active listening, and availability, attention to emotional needs, to non-verbal components (such as the physical presence and the visual contact), the management of expectations and the encouragement of self-care
Keywords: Nursing care, Palliative Care, Communication, Dignity
Introduction
Before the confrontation of the nurse with the suffering of the patient and the contact with the fragile and vulnerable side in Palliative Care, arises the need to focus on this critical and reflective analysis on the promotion of dignity in this context. The relevance of this approach is corroborated by the codes of ethics and deontology professionals who claim that the nursing interventions are carried out with the concern of defending the dignity of the human person [1].
The human being is a being of relationship. Since its beginnings, the man is regarded as a social being and interpersonal relationships. As such, the communication becomes a key process for us to live as a community. Transposing this reality for nursing, the communication appears as one of basic instruments. Therefore, the nurse must ensure the success of communication that takes provision in the framework of the provision of care, heretofore that the level of effective communication leads us to more positive results” [2].
In this way we can conclude that, the importance of communication is much important as any other activity of our main activities in our lives. Starting from our empirical experiences in the area, we infer that the communication is a determinant factor in the promotion of human dignity in PC and taking into account the point of view of communication is a preponderant aspect in the promotion of human dignity [3].
This work consists of a critical analysis and reflective of an extensive review of the literature on a particular theme and bounded, whose main objective is to identify how the communication promotes the dignity in PC. For this purpose, it was performed a bibliographic databased based on considering the credibility and present investigation done, especially in the nursing area. After the analysis of texts, was drafted the final report and so this article. The result reflects an alliance between the critical analysis of the current panorama and the analysis of the texts. The critical analysis starts on an empirical experience that the elements of the group have in this area, as well as the basic training in PC.
Palliative Care
The adjective palliate and noun palliation come from “palliate (participle of palliative) in the root form palliate, historically form palliation, palliated, palliating”, with origin in Latin to express “cover with a cover; cover up, disguise.” The palliative adjective is currently attributed to what “has the quality of calming, of temporarily slowing down the pain (what is said about a medicine or treatment),” which “serves to alleviate pain or attenuate a painful attack (what is said in the middle, as an initiative, etc.)” [4]. As a result, PC’s can be defined as total care for clients with life-threatening diseases, such as their families, provided by a multidisciplinary team, in the period in which the disease is no longer responding effectively to curatives treatments [5]. The World Health Organization (WHO) can also enrich this definition:
“An approach that aims to improve the quality of life of patients and their families, for those who are facing problems due to an incurable or a serious disease with a limited prognosis trough the prevention and relief of suffering, employing an precocious identification and rigorous treatment, not only of the physical problems such as pain but also psychosocial and spiritual problems” [6].
According to the International Council of Nurses (ICN) (2009), the PC represent the holistic care of the patients with progressive and advanced diseases for those who seem to not respond to the curative treatment. In consonance with [6], the PC includes four fundamental pillars: symptomatic control – Mobilization of pharmacological strategies; proper communication - Using effective relational and communicational skills to the patients and to their families ; family support- Including the family into care process evaluating their needs; Team work- Integrating the contributions of professionals from different areas, with the common aim of the comfort and wellbeing of patients and families. These four strands are viewed with equal importance, being that the practice of PC well done without would not be achieved if one of these four strands were underestimated.
Nursing in Palliative Care - Current Conceptualization: According to [7], it was in the postmodern era that the first nursing theories emerged, theories that considered the adequacy to the holistic principles for the practices of care. This is the new chain of thought that the paradigm of transformation arises, representing a change of mentality whose dynamics emanate from the continuous interaction between complex and global phenomena with the world [7].
For the nursing, the attention has been directed to be the individualization of human care and the specificity of each person as unique being. This kind of thinking in Nursing covers the theory of the humanization of care by Jean Watson, in which the person is seen as a harmony between all its aspects: body, soul, spirit and health. According to [8], the nursing care does not manifest itself only as an attitude or an emotion, can also corresponds to an intersubjective process, a moral ideal which aims to protect, improve and preserve the dignity of the person that is being taken cared.
In PC, this concept of caring is reflected when nurses interact with patients, to understand their experiences and enabling the expression of feelings and thoughts. Thus, it establishes the purpose of reducing the suffering of patients and families, in order to facilitate the process of adapting them to this living experience5. Two of the most important dimensions of this kind of caring centered on the aid relationship are the empathy and the respect for the dignity of each patient and family. Thus, through the use of different communicative strategies by the nurses, the principle of autonomy is promoted for the patients and their families to help them when comes to make better decisions, always taking into account their values, needs and emotional state [7].
Dignity
Dignity is a complex concept and hard to define, because its limits may change depending on the context in which they are inserted [9]. In Ancient Rome, in the middle of 16th century XIII, the word Dignitas meant “merit”, “reputation”, being associated with the concept of hierarchy [9]. A crucial point in the transition to the modern concepts of dignity appeared in the Renaissance, when in 1480, the Italian philosopher Pico della Mirandola (1463-1494) associated the concept of human dignity to freedom [10]. Years later, inserted in the context of ideological builders of liberalism, it was the German philosopher Immanuel Kant (1724-1804), who gave one of the most decisive contributions to the definition of this concept, to which we can say that:
In the kingdom of ends everything has either a price or a dignity. What has a price can be replaced by something else as its equivalent; what on the other hand is raised above all price and therefore admits of no equivalent has a dignity. The man has no price, has no equivalent, and has, yes, dignity [11].Then the premise “ acts in such a way that you use humanity, both in your person and in the person of another, always and simultaneously as an end and never only as an end “ [12].
With the end of the Holocaust became imperative to build a world under new ideological foundations. To do this, was developed in 1948, the Universal Declaration of Human Rights. This document contains about 30 articles, which are named the basic human rights, based on the premise that human dignity is the recognition of a value, representing himself as the moral principle based on the purpose of the man itself and not in the usage. The manifestations of rationality, freedom in themselves that make man be in constant development, in an incessant search for personal fulfillment
Dignity in Palliative Care: As has already been mentioned, in Palliative Care, due to vulnerability of their patients, it is essential that the approach of health professionals has as one of its focuses is the preservation of the dignity of the patients. In accordance with [13], the principle of human dignity In medical ethics, is revealed by the development of palliative care: it is to give each person decent conditions of both life and death, this means having the appropriate conditions to its status as a human being. In the name of their dignity, patients must be treated as people whose body is not a machine that can be repaired [13].
According to this last point, a person should be seen as a multidimensional being that transcends the body limits. In an attempt to outline the different domains of Dignity in PC, one of the most recognized work developed in the scientific evidence is the model of human dignity in patients at End of Life of [14]. The objective of this theoretical model focuses on the identification of clinical and demographic variables that affect the dignity. The model is graphically represented in the following table 1:
In this way, “emerges in the discourse of a patient as a relational dimension of human dignity, which is constructed through interaction with others” [6]. Consequently, the communication becomes an essential aspect in promoting the dignity of the ill people
Communication in Palliative Care
Throughout the ages, there have been many authors who wrote about the communication, its concept and its characteristics as a basic instrument for nursing. In this case, it is important to define the concept applied to the area of nursing. Thus, the communication can be defined as:
A process of creating and recreating information exchange, sharing and put in common feelings and emotions among people. The communication transmits whether consciously or unconsciously by verbal and nonverbal behavior, and more comprehensive way, by way of acting of actors. Through them, we mutually learn and understand the intentions, opinions, feelings and emotions experienced by another person and, as the case may be, bounding significant ties with her [15].
For this reason, the effective communication assumes itself as a basic necessity with the patient/family intervention in PC. Communicate effectively in this context is a challenge, since it requires the mobilization and development of basic skills at the level of communication between the triad nurse-patient-family, emerging the need of adequate training [6,16].
It should also be noted that the components of communication are not restricted to verbal exchange of information, cognitive content, because there is also a contrast affectively manifested in nonverbal behavior and the way of being of which person. Similarly, it is possible to observe that nearly 75% of the communication in nursing practices is nonverbal, resulting more authentic and genuine and less subject to the disapproval conscious [6]. Even though that this manifestations may be less evident, they are not less important than verbal communication, since they are the emotions implied in the words expressed by the person, that make others react [15].
The literature reveals that the mobilization of communicational skills is an effective therapeutic intervention, providing to the patient “sharing of fears, worries, doubts and suffering, contributing to the decrease of psychological stress and ensuring their autonomy, providing more quality and conquering more personal satisfaction” [17].
The influence of communication in the promotion of human dignity: Many professionals have carried out investigations with the aim of exploring the meaning of dying with dignity and the aspects that influence in PC. One of the key aspects with a strong impact on the preservation of human dignity is the communication established between health professionals and the patients [3]. Then comes the need to understand which type of communicational interventions the nurse can put into practice to safeguard the dignity of the person they are in charge of taking care. In an attempt to bring such communicational interventions was devised the model of the dignity of [14] with the communicational skills of nurse responsible for general care. Below we have the list where we can observe the interventions (Table2): With regard to physical distress, the communicational strategies combines the pharmacological strategies during a symptomatic decompensation, the nurse that enhances the customer’s comfort, helping him to deal with this moment [18].
To apply the interventions from the table above, the nurse will enhance the mental preparation of clients and families with the evolution of the disease, anticipating possible functional loss and cognitive disorders. In addition, allows customers to initiate a preparatory process of mourning, i.e., the process of acceptance of their finitude, without losing the faith and hope [18,19]. Studies carried out by show that most patients want someone to care for them at the end of their life - a doctor or a nurse – so they can share their experiences and have someone to help them how to clarify the evolution of the disease, assigning a meaning [20] (Table 3).
According to [18], in the constant attempt to defend the dignity of their clients, the nurse must give attention to your emotional needs as also as to the families; negotiating and establishing realistic goals, making sure that there will be “better days and bad days”; discuss the experience of one day at a time, focusing on the daily -Confirming this belief in the premise of carpe diem -; and balance the transmission of true information with the promotion of hope [6,18].
Following this line of thought, these strategies that facilitate the experience of the disease process in the palliative stage, still include: the encouraging of the patients to take advantage of the days they feel good and help them to overcome the days when they feel worse; anticipate often negative scenarios that may not occur but encouraging them to maintain habits and routines that will meet their tastes and preferences (such as, for example, respect their schedules), in an attempt to preserve a sense of normality the patients; encouraging they to not staying focused on death uninterrupted, because “life could be worth living even when sick” [18] (Table 4).
There are several studies that show that the establishment of meaningful relationships with the people around us is a crucial aspect in the promotion of human dignity in PC [3]. For this to be possible, it is fundamental that the nurse knows how to listen to customers in an active form, giving them confidence and a genuine empathic understanding. In addition, it is possible to build meaningful relationships if they are not present the affection and love, with a positive feeback [3]. Thus, Therefore, it becomes basal that nurses to acquire and improve communicational and relational skills that will allow the construction of relationships to promote human dignity.
Conclusion
The experiencing of the cognitive and functional decline of a human being, culminating to his death, forces the nurse to confront the visualization of his own death, which inevitably is associated with a powerful emotional component. Here, the investment in self-knowledge of the nurse and the development of relational and communicational skills become essential. Being aware of your skills and limitations is an important tool for the construction of a relation for effective therapeutic help, given that the nurse can see where his intervention is having the desired effect, promoting the well-being physical, psychological and emotional aspects of the nurses. As such, the importance of self-knowledge lies in the way we view ourselves and face the world around us.
According to the present done work, we can affirm that dignity is an intrinsic value of the human being as a result of recognition as a person. Based on the premise that the Man is a being of relationship in constant communication with those who are around him, thus we conclude that their “dignity is only possible through ontological solidarity with all members of our species” and “inevitably we immersed in it, we realize ourselves through relationship and help to the other “ [12].
In order to operationalize the promotion of dignity in PC, the group proposes that nurses adopt a empathic posture of understanding and focused in the respect of the patient, by the transmission of true information; managing the expectations, which allow the maintenance of hope by setting realistic goals; by the transmission of true information and that allow the maintenance of hope by setting realistic goals; self-care incentive, which promotes the autonomy of the client through the valuation of his personal project.
Dignity is a concept with faint limits and difficult to define. It is expected that this work has contributed to a better understanding of what is dignity, helping the perspective on nursing care. In this way, it is intended to sensitize the nursing community for the adoption of a clinical practice that safeguards the dignity of the patients, enhancing it in this phase of vulnerability.
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