Palliative Care to the Elderly Patient with Cancer : Speech of Nurses

Palliative care is aimed at people with diseases without perspective of cure or terminally, aiming to provide a better quality of life. This study aims to investigating the discourse of nurses about their understanding of palliative care to elderly patient with cancer and identify strategies used by nurses to promote palliative care to the elderly cancer patient. It is an exploratory research of a qualitative nature, carried out with thirteen nurses from a philanthropic institution in the city of João Pessoa, through a questionnaire. The empirical material was subjected to thematic content analysis, resulting in three categories: design of nurses to assist the elderly in Palliative Care: promoting comfort and minimizing the suffering, the importance of palliative care in humanized care to the elderly with cancer and strategies for the Promotion of Care of the Elderly with Cancer. Participants highlighted the palliative care as essential in the humanization of care, ensuring the dignity and quality of life among the elderly with cancer without possibilities of cure, adding such assistance, the family. Palliative Care to the Elderly Patient with Cancer: Speech of Nurses


Introduction
Aging has raised important transformation in population and epidemiological profile.The increase in life expectancy reveals itself as an achievement of humanity, evidenced by scientific and technological advances in the Healthcare area, revealing itself as a worldwide phenomenon that results in population aging [1].
This new setting contributes to the emergence of several chronic diseases.Among these, we highlight cancer, the fifth cause of death in Brazil and the second one in developed countries, with estimates of approximately 576,000 new cases until 2015 [2].Along with this, greater occurrence of physical, psychic and social is noticeable, so that the greater the prolongation of life, the greater the advent of sequelae and disability and, consequently, greater suffering for elderly population [1].
With advancing age, the individual undergoes various structural modifications, as well as by repeated exposure to environmental agents that alter the DNA of cells, called carcinogens.The exposure frequency of individuals throughout their lives to these factors explains the fact that the elderly present a greater susceptibility to malignant transformations in their cellular framework and consequently, a higher frequency of cancer cases [3].
Cancer, also known as neoplasia, is a comprehensive denomination for a set of diseases that can affect many different areas of the body and which has as peculiar feature the disharmonious and unpredictable cellular multiplication, spreading beyond the usual thresholds, which may subsequently take over surrounding segments and also spread to other organs, passing known as metastasis, which usually leads to death of the individual [4].
Given the evidence of some significant characteristics of malignancies, the treatment aims to prevent and cure, or is often limited to improve the patient's quality of life, especially in regard to relieving unpleasant symptoms such as pain, which can be softened at around 90% of cases through palliative care [3].
Palliative care is a care modality directed to the human being in his/her entirety, and applies both to patients with progressive disease with no cure prospects, from diagnosis, as well as to those al-ready in a state of terminal illness.The goal of this care is to improve the quality of life, providing psychosocial and spiritual support to the patient and their families from the terminally process of life to the stage of grieving [5].
The World Health Organization [6] defines palliative care as a dynamic and comprehensive care provided to patients without possibility of cure, aiming their quality of life through relief of unpleasant symptoms.A study [7] adds that palliative care is incorporated as an integrated and multidisciplinary therapeutic modality seeking through total and active care to promote the quality of life of the patients and their families, minimizing their physical, psychosocial and spiritual suffering from the time of chronic disease diagnosis to the bereavement period.
Facing the issues addressed in these care, it is important to highlight the nursing care of the elderly patients with cancer diagnosis, as they require a closer look regarding the preservation of individuality, taking into account the natural physiological and psychological changes of age, changes inherent to aging, as well as the suffering attitude related to the limited expectation of life, leading them to a state of apathy, among other signs of decay, fitting to the nurse an active position towards such a situation of fragility of elderly diagnosed with cancer [8].
The nurse is responsible for developing actions to encourage quality of life and independence of older people with cancer, providing a humane and dignified care to the last moment of life.In this regard, a study [9] adds that nursing assignments in terminally process are: meet the imposed requirements before a diagnosis of terminal illness, assist the patient in a state of functional decline or progression of the disease and provide assistance to families during the early mourning and death of their loved ones.
It stands then the relevance of the study, since nursing is significantly present in this context, identifying and using care strategies to assist these patients.It is intended to contribute to the expansion of this theme and to the practice of the nurse, adopting an approach to encourage full life until the last moment and dissemination of palliative care, being condescending so such care are presented, encouraged and debated in academic environment, as in the institutions that care for patients without possibilities of healing and/or on completion of life.
Based on these considerations, this study follows these guiding questions: What is the speech of nurses about their understanding of palliative care to elderly patient with cancer?What are the strategies used by nurses to promote palliative care to the elderly patient with cancer?
To answer the questions proposed, this study aimed to investigate the speech of nurses about their understanding of palliative care to elderly patient with cancer; and identify the strategies used by nurses to promote palliative care to these patients.

Method
This is an exploratory research of qualitative nature.The survey was conducted in a local philanthropic institution, located in the city of João Pessoa -PB, which has a number of 60 beds, working based on donations and resources provided by the Unified Health System (SUS).The choice of this location was given because it is an institution that receives a significant number of older adults diagnosed with cancer, often with no prospect of cure.
13 nurses, who met the following inclusion criteria, participated in the study: being a clinical nurse; being active during the data collection period; having at least six months of operation in the selected institution for the proposed research; and agreeing to participate in the research proposal.
Because it is a qualitative research, the determination of the sample is given from the verification of data saturation, which allows the quality and understanding of the phenomenon studied [10].
Data collection occurred through the application of a questionnaire composed of two parts: the first one, composed by the characterization of the participants, whose approach emphasized the demographic profile, academic training and professional experience; the second one consisted of questions inherent to the objectives proposed by the study.
The application of the instrument was made with the selected nurses in their working environment, according to availability of time and schedule to participate.It is noteworthy that initially we kept in touch with the institution Nursing Coordinator to schedule their convenient day and time.
To ensure the anonymity of the participants, the speeches used from the empirical material collected were encoded by the letter "E", followed by a numeral, obeying the order of the nurses interviewed, whose sequence was from E_01 to E_13.
The material obtained was qualitatively analyzed, through content analysis technique, which consists of a union of dialogue analysis strategies, aimed to acquire methodical sequences and practices for perception of concepts, in addition to permeate parameters that generate information and production of new conceptions [11].This technique is operationalized by the following steps: pre-analysis, material exploration and processing of results, inference and interpretation.
It is worth noting that the research was carried out respecting the ethical aspects recommended by Resolution n. 466/12 [12] of the National Health Council, especially with regard to the consent of the participants, secrecy and confidentiality of data.In this perspective, the research proposal was approved by the Research Ethics Committee, of the Health Sciences Center of the Federal University of Paraíba (UFPB) under the CAAE n. 39068114.5.0000.5188.

Results
Tables from 1 to 4.

Discussion
The characterization of nurses participating in the study was described from socio-demographic data.Among the nurses in the study, 69% were female, with ages ranging from 20 to 59 years.Data show that 93% of participants reported ages ranged from 20 to 49 years.
Other studies in the same thematic line also show the prevalence of female nurses and aged between 25 and 45 years, corroborating this study [13,14,15,16].
Corroborating the data found in this study, a study discusses that the practice of care is usually observed in professions whose predominance is feminine, once socially, the preconceptions of professions considered feminine are directly related to charity, to domestic service, care and education of children.Proceeding from this the feminization of nursing in society [15].
As regards the age of the participants, the prevalence of economically active professionals in the context of nursing is highlighted, namely, professionals who enjoy good physical condition for performing their professional activities.
The time of performance of the participants in the institution varies from six months to 15 years, and the majority (38%) is in this service for less than a year.The prevalence of professional nurses with practice period of less than five years often is due to intermittent periods of admission, featuring unstable and temporary links, in which contractors are temporary with possibility of large turnover of human resources in the service [16].
As for the time of academic training, this varied from one to 20 years, whichever time of one to five years, 77% of participants, demonstrating a considerable number of participants with little training time providing services in the context of the research scenario.It is currently observed in the State of Paraiba a wide range of educational institutions and more nurses coming from private colleges.A study [17] points out that this disparity of training institutions is basically due to the considerable expansion of higher education nursing courses in private educational institutions in different regions of the country.
Despite the nurses declare performing professional activities as general care nurses, 38% of them report having specialist degree, 7% reported having completed postgraduate studies in master's level and 23% do not have graduate degree.
It is noteworthy that among the specialists, two nurses are experts in the field of palliative care.Most participants, 77%, held a qualification course, demonstrating interest in perfecting themselves, but not necessarily for the practice of palliative care.Concerning the titles of the participating nurses, there is some obstacle to realization of master's and doctoral courses, as they perform their work activities in a wide workload of 40 hours per week (minimum) and these courses, mostly, require greater commitment of time.
From the analysis of the empirical material of the study, obtained from the subjective questions and guiding proposals, in order to investigate the speech of nurses about their understanding of palliative care to elderly patient with cancer; and identify the strategies used by nurses to promote palliative care to these patients, three themes were revealed: "Conception of nurses on assisting elderly in palliative care: promoting comfort and minimizing the suffering", "The importance of palliative care in humanization of care to the elderly with cancer" and "Strategies for the promotion of palliative care to the elderly with cancer".
Category I (Table 2) emerged from statements that demonstrate understanding of nurses about the elderly with cancer under palliative care.It's possible to note the tendency of participants to direct such assistance to patients in order to minimize suffering, promoting comfort.This understanding can be glimpsed in E_03 e E_05 reports.
The speeches reported by E_03 e E_05 bring ideas that support the proposals defended by the type of Palliative Care, demonstrating that this philosophy of care is in essence aid proposals that diminish the suffering and pain of the patient, providing thus comfort and quality of life, a key element for maintaining dignity of the patient with no prospect of cure [18].
The speeches of the participants reveal the reality faced by them to assist the elderly with cancer.By declaring their perception of palliative care, these professionals emphasize some clinical manifestations, specifically pain, since it appears as the most common symptom in patients diagnosed with advanced cancer, with an incidence greater than 75% [9].
It is noticeable that professionals add specific needs of the patient to this definition.In addition to the physical manifestations, complications of emotional order are considered, emphasizing the importance of welfare for a whole, minimizing the painful sensations, and at the same time, embracing the emotional comfort.Regardless, there is a passage from one of the deponents (E_08).
It is essential for professionals involved in the study to highlight the needs of physical and psychological harm in care for the elderly patient with no prospect of cure.However, it is deemed important to emphasize the spiritual dimension, given that the principles of palliative care advocate multidimensionality, prerequisite in promoting the integral and humanized care to patients in incurability situation of their disease and/or terminal illness.
The comprehensive care and pain relief are gaining ground over the curative actions where the reluctance exacerbated by healing gives way to the primacy of human dignity, based on attitudes of respect, essential, even in the certainty of finitude, from the moment of diagnosis, when the survival chances are exhausted [20].In this premise, it highlights the testimony of E_09.
The speech of E_09 reveals different characteristics in caring for elderly patients with cancer, showing that the nurse, when caring for people in this situation, focuses his/her assistance in palliative care principles, changing the curative action for palliative while allowing relief of their suffering and quality life.
However, it is emphasized that some researchers propagate that the theoretical and ideological bases that underlie this philosophy of caring are still in structuring process, so that the exercise of palliation is a challenge for health professionals, primarily because throughout history, both science and academic behavior, responsible for vocational training are geared to technical and curative treatment [21].Thus, the importance of palliative care is clear, where the remedy has a broad meaning, based on the entirety of being, considering the multidimensionality and humanization of care.
Category II (Table 3) brings in its approach the importance of palliative care as an essential proposal for humanization of care, safety and dignity to the elderly patient with cancer, without possibility of cure, adding the family foundation to that assistance.Initially, professionals have expressed this philosophy as integral to humanized care, as evidenced in the testimony of E_06 and E_07.
Palliative care was addressed as specialized care, building a relationship that involves feelings, esteem and faith, at the same time it takes care of and welcomes the elderly and their families, seeking in its principles the essence of humanized care.
In the speeches mentioned, it is noticeable the sensitivity of these professionals to see the perspective of the patient and, above all, respecting their wishes and conflicts regarding their current circumstance, adding the family to this context.In this way, it is possible to build a relationship of reciprocity, where the patient divides higher anxieties, challenges and needs.As a result of this humanitarian assistance, professional develops a helpful relationship with commitment, protection, sympathy and affection for these patients [22].
Based on the foregoing, the importance of care for the promotion of integral and humanized care is undeniable, since it directs the professional to promote decent care, helping the elderly to experience his/her finitude and suffering, as the specifics that include aging and terminally ill.Corroborating this assertive, it emphasizes the E_08 nurse's testimony.
The report highlighted above (E_08) shows the nurse vision on care for the elderly with no prospect of cure, showing how palliative care is needed in this situation.In this assistance, professionals have the look back for humans, seeking to contribute to the process of dying with dignity and experiencing finitude in the best possible way.The elderly is not seen by the severity of their disease, but as an individual endowed with particularity and needs.
It is worth noting that the participant's speech above meets the proposals circulated in palliative care, which values life and faces death as a natural process.Therefore, it does not delay nor prolongs death, but protects human being in their anxieties and fears, providing support for patients to actively live their finitude process and at the same time supports the family and caregivers in the grieving process [23].
Based on these concepts, the authors added that palliative care is more than a method, it is a philosophy of care led by basic principles that can be summarized as follows: comprehensive care; support to the patient's family; promotion of autonomy and dignity of the patient; active therapy; and a respect environment about the patient and family [24].
Given the prospects related to palliative care, it highlights the importance of the care provided by nursing to the elderly cancer patient.The nurse is the closest professional to the patient and his family, before that, he/she must be prepared to deal with the peculiar discomforts to the clinical picture of the elderly cancer patient [25], trying to act so as to promote a humanized care, establishing a trustful and safe relation with the patient.Thus, it is understood that the perceptions of nurses in the study highlights palliative care as a proposal that contributes to the enhancement of interpersonal relationships among professionals, patients and families, improving trust between both parties, recognizing humanization of care as a fundamental strategy for palliative relief of discomforts and promotion of dignity to the patient, being of essential significance for promoting the quality of life, especially for the elderly cancer patient.
Category III (Table 4) presents the strategies used by nurses in the care of elderly patients with cancer and under palliative care.Through different methods, therapies are employed in order to meet the needs of the patient.
Concerning these strategies, the professionals showed conduct that responds the multidimensional needs of elderly patients.Among these, the participants highlighted: the pharmacotherapy both in pain relief as in the control of other symptoms, non-pharmacological therapies, nutrition and communication/qualified listen.
Emphasizing strategies related to the needs in the physical scope, we highlight the testimonials of E_07 e E_13.The excerpts of their statements show biological interventions that meet the physical needs of the elderly with cancer, showing symptomatology that interfere in the patient's comfort, and to meet this physical need immediately, they highlight the pharmacology.
In palliative care, the administration of medications is frequent, mainly to ensure patient's comfort.Pharmacology is a therapy that meets the complex and intense symptoms of the patient, and its administration usually is an assignment of the nursing staff, since they are the professionals who have the closest contact with the patient and are responsible for the care [26].
This experience allows nurses to see the different possibilities within the pharmacotherapy, and associated with this, non-pharmacological interventions that assist in care, providing comfort to the patient, as expressed in excerpts of testimony of E_03a and E_10.
The statements highlighted above, once again, emphasize the pharmacology in the care of elderly patients with cancer.The excerpts highlight the importance of analgesia, and added to this therapy, biological interventions are cited, effective and auxiliaries in unpleasant situations for patients under palliative care, such as: change of decubitus, oxygen therapy and nutrition.
Still on the pharmacology, authors add that the nurse must know the symptomatic evaluation methods, pharmacokinetics and pharmacodynamics, as well as how to guide the premises staff to strictly follow the treatment, according to the intervals between doses and individualizing the medications according to individual needs of the patient [24], given the need for administration of these drugs both for pain relief, as in the control of other symptoms resulting from the disease advances.
Within the biological strategies, aspects related to nutrition were also highlighted by a participant.Functional and structural changes arising from the aging process influence the nutritional status of the elderly, and when associated with diseases, such as cancer, it increases the vulnerability to malnutrition.This follows from the aggression of some tumors, which associated with curative or palliative therapies cause gastrointestinal disorders that impair the patients' quality of life [27].
In addition, the nurses surveyed stressed therapeutic strategies in the psychological level, the promotion of palliative care to the elderly, highlighting the importance of paying attention to it, paying attention to their psychological needs and providing psychological support, as evidenced by the passage of E_12.
The above highlights the attention to psychological needs in elderly care.Through the attention to this need, the nurse can assess some psychological conditions and request support for the psychologist.Based on this understanding, it is essential to adopt welfare practices that meet this need, in order to provide a better quality of life, minimizing the men-tal suffering during the confrontation of cancer and prevention of psychopathologies, as depression.
About depression, study emphasizes the importance of evaluating aspects such as the cognition and depression in the elderly with cancer, since this psychopathology is the most common disorder in the elderly and very common in cancer patients, whose relationship is established by the advancement of pathology or side effects encountered during the therapies [28].
Based in these narratives, it is observed that these interventions are essential in assisting the elderly with cancer.In relation to psychotherapies, professionals consider communication and listening as essential facts in the promotion of palliative care, as evidenced in testimony of E_03b.
Communication stands out by promoting the construction of links between patient, family and professional.Through dialogue, listening and transmitting positive feelings, it comes to trust and credibility, reducing the patient's wishes in terminal illness [8].
On promotion of Palliative Care to the elderly with cancer, it is the responsibility of health professionals, specifically nurses, to establish support relationship with the patient and his/her family, through effective communication, the control of symptoms, of measures to relief of suffering and support to family members before the completion of life [29].
In this intention, study of the therapeutic communication in nursing, also called qualified listening, relates to communication as a key intervention in reducing anxiety for the elderly cancer patient.The development of this mode stems from the dedication in caring, stimulating and guiding the elderly patients with cancer, about different subjects pertaining to his/her pathology [8].
Finally, speeches tended to proposals that responded to a holistic assistance, since the professionals presented attitudes aiming at the integral and humanized care.However, it is necessary to contemplate the different dimensions of the human being in the practice of care provided by these professionals, and use of educational strategies to disseminate and strengthen this philosophy of care.

Conclusion
When investigating about the nurses understanding of palliative care to elderly patient with cancer, it was noted that the views of the participants were based mainly on promoting comfort and pain relief, meeting the premises spread by this mode of care.However, it is emphasized the importance of professionals to be attentive to the biological aspects, and also to other dimensions that make up the human totality.In this view, it is possible to perceive some limitations in promoting care, since, in addition to the described bases, it is necessary to involve social and spiritual dimensions to build a care focused on human wholeness and palliative care.
The study showed the importance of this philosophy of care to the elderly cancer patients, since the nurses brought in their speeches this modality as essential to humanize care, ensuring the dignity and promoting quality of life for the elderly with cancer without the possibility of healing, adding the family foundation to such assistance.The speeches have demonstrated palliative assistance as a proposal that values interpersonal relations between professionals, patients and family.
With regard to strategies used in palliative assistance, some therapeutic strategies were used by professionals for the physical and psychological needs of the elderly patients under palliative care.However, some shortcomings were observed, referring to the psychotherapeutic interventions, especially regarding spirituality and religiosity.There were no speeches that favored such therapies, however, both are essential practices to promote comfort and balance of the patients and their families facing circumstances that involve the completion of life.
This study verified the understanding of nurses on palliative care in the elderly with cancer, showing different strategies of care.The recognition of this approach as an integral and humane practice becomes essential, to be distinguished from the others since it fosters multidimensional aspects and provides the elderly and their families a less suffered progression, with comfort and a better quality of life.
Therefore, this study is expected to subsidize future research in academic level and to contribute in the formation of knowledge, in order to disseminate this care mode among nursing students, nurses and other health professionals.

Table 2 .
Conception of nurses to assist the elderly in Palliative Care: promoting comfort and minimizing the suffering.
E_08It is the special care we provide to the elderly who have no prospect of cure, and it seeks to meet their needs whether physical or mental E_09 These are care to relieve pain for patients with endstage cancer.Because at that stage, treatments for cancer patients are not intended to cure, and some are stopped, and the patient feels a lot of pain, so they're in palliative care; it does not cure the disease, but it relieves the pain and quality of life for these elderly [...] Source: Research data, 2015.

Table 3 .
The importance of palliative care on humanization of assistance to the elderly with cancer.
Category II E_06 [...] palliative care is essential for all, especially for the elderly.They are losing their cognitive, functional roles over time, thus requiring increasingly humanized and expert assistance [...] E_07 [...] It is important that the elderly can feel care, relieved, even though it has no cure, passing them esteem, faith above all, caring, humanization, not showing pity; always encouraging towards their situation, bring the family closer to them so that he does not feel abandoned [...] E_08 Palliative care has its importance because it directs patient care without the prospect of cure, promoting a dignified death, therefore, we must care until the end, because the certainty of life is death [...] Source: Research data, 2015.

Table 4 .
Strategies to promote palliative care to the elderly patient with cancer.