Palliative Cares to Older Person under the Nurse ' s Optics

Methods: This is a descriptive, cross-sectional, qualitative study carried out in a private tertiary hospital in the Northeast of Brazil. The survey was conducted from March to June 2016, with 19 nurses. In the data collection, a semi-structured interview, with four questions were used: what does palliative care mean to you? What does care for the elderly in hospice care mean to you? What strategies do you adopt to promote palliative care for the elderly? Tell me about your experience in providing palliative care to the elderly. The technique of data analysis and organization was the Discourse of the Collective Subject.


Introduction
Global and Brazilian population aging is growing and worrying.According to data from the latest demographic census conducted by the Brazilian Institute of Geography and Statistics (IBGE) in Brazil, the elderly are already 11% of the Brazilian population, equivalent to about 17 million individuals aged 60 years old or over.In the Northeast, 10.2% of the population is elderly [1].
Care for this population needs specialized health care, especially in the palliative care, since the diagnosis of the disease, mainly in the presence of chronic degenerative diseases, the elderly already fit this classification.From then on, follow-up is necessary to maintain their physical, mental and better quality of life [2].
The palliative care approach is used to follow up individuals who have a life-sustaining illness and aims to provide quality of life for the patient and family, alleviating and preventing suffering, treating pain and other symptoms affecting the physical, social, emotional and spiritual dimensions [3].
Palliative care for the elderly people can occur in different care contexts and clinical practice.Even though palliative care should be a priority for the home, it is common to find hospitalized elderly people in this situation for a long period, in infirmaries and intensive care units [4].
In infirmaries, the elderly people are usually hemodynamically more stable and may remain close to their family [3].In intensive care units, the aim is to provide modern technological resources for the maintenance of life.However, this technical device, even when satisfactory to offer relief to patients and their families, is not enough to eliminate suffering and anguish [4].
In this context, the nurse has the function of providing comfort and quality of life through basic and complex care, with the multidisciplinary team to interaction with the family, optimization of care, patient safety, training and capacitation of their staff.It is essential that this professional knows how to listen and respond to the wishes, desires, and wills of the elderly in palliative care.
Also, care should be taken in direct family care, carrying out patient care guidelines, and always clarifying doubts about palliative care.Respect for the autonomy of the elderly and their families, encouraging them to participate in decisions, is also an initiative contributing to minimize the anguish that drug and hospital therapeutics usually do not cover [5].
Thus, the study aimed to know the meaning of palliative care to the elderly person from the nurse.

Methods
This is a descriptive, cross-sectional, qualitative study carried out in the medical clinic and Intensive Care Units that treat elderly patients in palliative care in a private tertiary hospital in the Northeast of Brazil.
The study was carried out from March to June 2016.The inclusion criteria were: to be a nurse and to work for at least one year in the ward and intensive care unit of the hospital under study.Nurses who were on leave, maternity leave or another type of leave were excluded.
A total of 19 professionals met the inclusion criteria, of which 10 were from the medical clinics and 9 were from the intensive care units.The nurses were characterized by the letter "E" and the order number of the interviews, for example, nurse 1 (E1), nurse 2 (E2), and so on.
Sociodemographic data were collected from nurses related to age, gender, time worked at the institution, and professional training elderly health and palliative care area.Also, guiding questions were asked to understand the meaning of palliative care in the professionals´ view: 1) How do you perceive palliative care for the elderly?2) What is the main care you take when caring for elderly patients in hospice care? 3) What strategies do you adopt to promote palliative care for the elderly?4) Tell me about your experience in providing palliative care to the elderly, and cite examples.A digital recorder was used and, later, the transcription and typing of the speech were performed.
The Collective Subject Discourse Technique (DSC) was used for the organization, analysis, and interpretation of the speech, consisting of a set of tabulation procedures and the organization of discursive data obtained through testimonies, combining several individual discourses obtained by the research in a single discourse.The technique used consists of analyzing the collected material and removing Central Ideas and similar Key Expressions to construct one or several speech-synthesis that are the Discourses of the Collective Subject [6].
The speeches were grouped into four categories: meaning of palliative care (category 1), the meaning of caring for the elderly in palliative care (category 2), strategies adopted to promote palliative care for the elderly (category 3) and experience in providing palliative care to the elderly (category 4).
All the nurses were asked to sign the Informed Consent Form and agreed to participate in the study.The research was approved by the Ethics Committee in Research of the State University of Ceará, receiving the opinion n° 1,435,048, CAAE: 52773416.1.0000.5534.All the ethical and legal aspects involved in this research followed the precepts regulated by the Directives and Norms of Research in Human Beings established by Resolution 466/2012 of the National Health Council.

Results
The results were divided into the profile description of the subjects and topics related to the categories obtained in the participants' speeches.
The nurses interviewed were aged between 27 and 53 years old, 84.2% were female, and 15.9% were male.The working time at the institution was 57.8% from 1 to 5 years, and 42.2% from 6 to 16 years.The time that professionals worked in the sector and lived with patients in palliative care was 78.9% from 1 to 5 years, and 21.1% from 6 to 8 years.None of the nurses interviewed had specialization in palliative care or the elderly.

Category I. Meaning of palliative care
The meaning of palliative care for nurses was obtained as a central idea: to promote patient and family comfort.It was observed in 94.7% of the interviewees.DSC: 1.

E17.
Thus, providing physical, social, spiritual and family assistance.

E15.
without the use of invasive measures. E3.

Category II. Meaning of caring for elderly in palliative care
The central ideas obtained through the meaning of caring for the elderly in palliative care were: 89.4% provide the elderly with family time and comfort; and 10.6% professional satisfaction.DSC: 2.
Palliative care is more geared towards the elderly because he is already in this final stage...The elderly people are a more fragile, more sensitive due to the wear and tear of their physiological system [...]
[…] it is a form of quality of life in the third age [...] E5.

Category III. Strategies adopted to promote palliative care for the elderly
The care strategy used by the nurses had the following central idea: to promote comfort, care, and support of the palliative care team.This was elaborated from the discourse of 100% of professionals, as can be seen in DSC 3: First, the palliative care team comes to talk with the family, evaluating the patient, seeing if he needs palliative measures.Then, the family signs a term, and here we start with the most specific care for that patient... ... We bathe, we put the diet, we raise the head of the bed, so he does not bronchus-inhale the diet, we give pain medication, we change the position [...] E14.

...If we see that it is already very uncomfortable.
E1.
[...] we evaluate the pain, respiratory discomfort, we enter with continuous analgesia, whether through oral or intravenous morphine, fentanyl and dormonid in the infusion pump, tramal.

E3.
we evaluate the pain, respiratory discomfort, we enter with continuous analgesia, whether through oral or intravenous morphine, fentanyl and dormonid in the infusion pump, tramal. E10.

Category IV. Experience providing palliative care to the elderly
From the experience reported by the nurses, the central ideas were obtained: humanization with patients and relatives (47.36%);Adherence and non-adherence of family members to palliative care (26.31%); comfort (26.31%), as observed in DSC 4: For me, humanization is most needed with that elderly person and with the family ...

E15.
Moreover, then, we should treat well, care and not abandon patients in palliative care. E14.

Patients who have not been palliative care, and who have experienced respiratory distress [...] and need intubation, some invasive measures, or go to the ICU have already happened. [...] When we explained the concept of palliative care for this family, they decided, even in a situation of urgency, they really saw that it was best for the patient to provide comfort and not to take invasive measures [...].
E3.

E9.
In the time... when the patient is stopping, they no longer want palliative care, they change their minds, we have to invest.E10.

Discussions
The first category revealed that nursing care should provide comfort to the patient, trying to minimize their suffering through emotional and social support.Comfort is a central feature of nursing care to promote quality of life for patients in palliative care [7].All nursing staff should be alert to elaborate interventions that may minimize or avoid potential discomforts to the elderly without treatment proposals.
In many situations, the nurse performs actions in a mechanized way centered on techniques and procedures, forgetting the psychosocial and spiritual comfort.However, when the individual has an illness that threatens their life, the presence of physical, psychological, spiritual and social exhaustion affects the patient and his/her family.This can be aggravated by the age of the elderly, their importance in the family, and the very structure of the members who compose it [8].
By having greater proximity to patients and relatives, the nurse has the responsibility to prepare them for the news of an unsatisfactory prognosis.It is important for the professional prioritizes relief from suffering and to understand that healing is often impossible.In many cases, professionals may feel powerless because they cannot save the patient´s life, and this reflects in the care of the patient and his or her family members [9].
In relation to category 2, it is known that in the social imaginary, old age is endowed with wear, limitations, physical losses and social roles that end with death [10].This view is perceptible in the discourse of professionals, who consider that the elderly person is more susceptible to palliative medicine since he is fragile and dependent.Another study carried out by professionals about the process of dying of the institutionalized elderly evidenced death as a stage of life, as a moment of relief, of an end to suffering, of rest for the longevity and of everyone around them [11].
The process of dying can be approached in different ways, depending on the historical moment, the socio-cultural contexts [10] and the education acquired during the whole intra and extra-family life.It should be emphasized that in Brazil, educational proposals aimed at the teaching of thanatology are still scarce in universities, hindering to confront everyday practice with death and dying [11].
In the reports, it is observed how much the family element is recognized as essential for professionals.In this way, the meaning of the approximation of the elderly with the family for a quality death is revealed.Illness and Palliative care may be responsible for resuming family relationships after a conflict period.Also, they can further strengthen existing bonds [2].
If family members are well-oriented, they will more readily accept the finitude of their loved one.In the hospital environment, it is relevant for the elderly to have them nearby for comfort and safety.A plan of directed nursing interventions and guiding can corroborate the family member's balance and ways of adapting to the reality that he or she experiences [12][13].
The hospitalization of the elderly can cause suffering to the nursing professional when associated with the finitude of life and social issues [14].This can be perceived by the discourse formed in this category, which is impartial, endowed with emotion and permeated by the culture of the professional.The fragments of the speeches reveal little science about palliative care, and many feelings about them and caring for the elderly.
The speeches in category 3 revealed that for patients in palliative care, nursing interventions in the hospital context, most often involve technical procedures such as bathing, sanitizing, puncture venous access, administering medications, among other procedures, to meet patients' needs.The technique is a practice that is present when one prioritizes some biological need of the patient [15,16].However, in this context nursing care, must go beyond technical procedures and consider the other needs of individuals, contributing to their well-being.
The pharmacological drugs are implementing and, in particular, non-pharmacological measures, such as music therapy and relaxation [11].According to the reports, it is perceived that the therapeutic relationship related to the dimension of dialogue, orientations, psychological and spiritual support was many positions of the palliative care team, rather than the care nurses themselves.The speeches are full of strategies related to the physical and biological dimension.Through the speech, it is clear that the interventions were directed to techniques of the daily routine of the service, to the detriment of emotional support, which was the responsibility of the specialized team in palliative care.
It should be emphasized that not all health professionals are prepared to use strategies of communication and therapeutic relationship in their routine of service [17].This generates a fragile care due to the lack of trust and bond between caregiver and patient, causing the patient's family member resistance and the elderly to palliative care.
As mentioned in the reports, the nurses' concern about the clinical status of hospitalized elderly patients, especially regarding care with venous and subcutaneous therapies, is defined as demarcating hypodermoclysis as an effective practice in palliative care.The elderly often present cachexia and dehydration, which makes the endovenous route impaired, which may compromise nutritional and hydration conditions.It is emphasized that hypodermoclysis is a subcutaneous therapy for clinical support and replacement of fluids, electrolytes, and medications [2].
Pain relief was also greatly emphasized by nurses.In palliative care, the drugs most commonly used for moderate pain are tramal and codeine; and morphine in situations of intense pain [18].A more comprehensive assessment, including physical, psychological and emotional aspects, is needed for effective pain relief.Also, pain identification with specific scales is an important tool for patient management, as they provide quantitative data on such a subjective and personal complaint.In the evaluation of pain, pharmacological and non-pharmacological therapies complement each other.Another study refers the attention of health professionals focused on the pain of the elderly in palliative care [11].
It is essential that professionals express their responsibilities and limitations, considering a more humanized care, with respect, freedom, communication and love to interact better with the family and longevity [19,11].
The discourses of the last category revealed themes such as humanization with patients and relatives, adherence and non-adherence of family members to palliative care and comfort.Humanization can be defined as the act of humanizing, caring and be a concern for the other, since it is human dignity.It is essential to serve the family and the elderly in their entirety, prioritizing not only the technique but also sensitizing to the problem of the other [20].
Although not all the families are worried, and they are considered a distant structure, generating annoyance and of negative interference to the confrontation of the disease [17]; It is very difficult for some family members to accept the death of their loved one.
It is important that the multi-professional team sensitize the family to the fact that death is something inherent to the human being; and that palliative care provides a better quality of life.

Conclusion
The study showed four categories: meaning of palliative care, the meaning of caring for the elderly in palliative care, strategies adopted to promote palliative care for the elderly, experience in providing palliative care to the elderly; and four speeches.Through the nurses´ speeches, it was observed that the care provided to the elderly in palliative care should prioritize comfort and quality of life.This can be achieved through dialogue and attention between family, multi-professional team and nursing team, as well as with pharmacological and non-pharmacological therapies.
It is suggested to carry out new research involving the palliative care of the elderly, contributing to the sensitization of nurses to promote adequate behavior in palliative care and the valuation of old age.
then, palliative care covers much more than younger patients.Nursing care allows this elderly person to spend more time with the family [...] because at the moment, he most needs the comfort and care and attention of the family, [...] but the relatives have little knowledge about what in fact rules the palliative care... E6.
patients.[...] Hypodermoclysis [...] decreases the risk of infection ...Many patients cannot be more stuck, for example, the blood gas is no longer made [...]Many patients cannot be more stuck, for example, the blood gas is no longer made [...] also has care staff Palliative care that guides the family... to accept the patient's death [...] talk... about how they are perceiving ... palliative care....