Palliative Care Nursing for People with Cancer

Results: The search in the databases indicated 1,591 potentially eligible primary studies, of which the final sample resulted in 14 articles. Content analysis revealed three themes: the palliative care nursing of people with cancer; strategies used by nurses in the care of the relatives of people with cancer in palliative care; nurses’ difficulties in achieving the palliative care for people with cancer.


Introduction
Palliative Care (PC) is defined as an approach that promotes the quality of life of patients and their families who face diseases that threaten the continuity of life through the prevention and relief of suffering, early identification, treatment and assessment of pain and other symptoms, in order to make the patient having the best possible quality of life for the palliation of pain, focusing on the person and not the disease.[1] Rafaella Guilherme Gonçalves 1 , Lucas Batista Ferreira 2 , Heloiza Talita Adriano da Silva 3 , Emily Kathiene Silva Mesquita 4 , Jank Lank Simôa Almeida 5 , Rejane Maria Paiva de Menezes 6  The PC appeared to assist people with cancer, however, due to current changes in the demographic and epidemiological profiles also extends to patients with a chronic disease with no possibility of modifying disease treatment, but still with the possibility of care for improved quality on the dying process.[2] Among the chronic health conditions, cancer is the second leading cause of death by well-defined disease, surpassed only by cardiovascular disease.[3] Cancer is one of the most prevalent diseases as close to a slow terminal illness, which raises fragility and clamor for dignified care in which the ethical standards should be followed so that people could die with dignity.His late diagnosis difficults treatment with curative purpose, reducing the length of survival and quality of life.[4] In the health context, the PC is a form of cancer treatment that requires a multidimensional approach to the human being and a reflection face to this scenario, in which the death, pain and suffering are often present, since the disease lifethreatening and its treatment affect not only the bio-psychosocial dimensions, but also spiritual.
Therefore, multidisciplinary care is considered as one of the essential aspects of palliative care exercised by a professional team consisting of nurses, doctors, social workers, psychologists, pharmacists, physiotherapists, nutritionists and spiritual assistant, among others.[2] Among the care exercised by these professionals in PC, we emphasize the nurse's care, characterized by remaining continuously twenty-four hours of the day with the patient, allowing them to establish an interpersonal relationship of care and still perform the practices of care, and know the existential sense of illness, the demands and desires for promotion practices, protection and recovery of health, the needs facing the dying process.[5] The PC performed by nurses are part of nursing care and includes full assessment of the patient and family, in order to identify the physical, emo-tional, social and spiritual needs.However, despite the recognition of the importance of PC by nursing professionals, some difficulties in their daily practice prevent them from realizing them.[6] These are difficulties related to the physical and emotional overload at work, still insufficient knowledge of the PC, in these professionals, which shows there is a gap around in their training.[7] It is noticed that the dying process and the PC have been little discussed in the academic ground, because the focus has understood the search for a cure.Thus, it is observed that often the healthcare professional has only a basic education (graduation), but it is known not to be enough to make it able to situations in which patients in PC are, which in somehow interferes negatively on quality of care, with respect to this practice (7).Thus, there is there a need for more specific training in order to ensure the implementation of PC in the Brazilian scene.[8] Thus, the purpose of this study is to analyze the scientific literature related to the production of nursing care in PC for people with cancer.Therefore, it is believed that the study could contribute to support the improvement of nursing care in PC offered to cancer patients who need a comprehensive care, continuous and humanized.In addition, it is expected to stimulate along with educational institutions, the need to insert that content in their curriculum components, enabling investment in training for nursing care in PC.

Methods
Literature search type as integrative review, carried out through the following steps to its scope: Preparation of main questions and objective of the review, sampling in the literature, data collection, critical analysis of the included studies, discussion of the results and presentation of the integrative review.[9] 3 Therefore, initially the main question is defined as follows: What are the results and implications of scientific studies on nursing care in PC to the person with cancer?
The bibliography survey of the published literature was conducted between April and May 2016, on Internet through the CAPES Journal Portal in the selected databases: LILACS (Latin American Literature in Health Sciences); MEDLINE through PubMed (Medical Literature Analysis and Retrieval System Online); CINAHL (Cumulative Index to Nursing and Allied Health Literatur); and SCOPUS.The keywords selected to search these databases were the terms of the MESH (Medical Subject Headings), also included in Health Sciences Descriptors (DESCs) "Nursing Care", "Palliative Care" "Neoplasms".Ensuring a thorough investigation by a defined and controlled search using keywords combined as follows: Nursing Care AND Palliative Care AND neoplasms.
The inclusion criteria used were: original articles of research available in full text in Portuguese, English and / or Spanish, which addressed the issue and answer the main question; and, of the exclusion, repeated publications in more than one database, which are in summary format, letters to the editor, articles of reflection, experience reports, literature reviews, monographs, theses and dissertations.There were no date restrictions for the research.
The initial selection of items includes the title analysis and summary assessed independently by two researchers, and the final decision for including the articles was made by the researcher.The articles selected were read in their entirety and included those who respondents to the question asked for this review.
The collection of included studies followed an instrument of data collection that contains: item identification (title, country, language and year of publication), journal, database, research objective, methodological considerations, main results and conclusions.[10] After a complete reading of all articles, began the analysis of the results, according to the technique of thematic content analysis of Bardin adapted by Minayo, which identifies the thematic analysis as a way to discover the basic meanings comprising a communication whose presence or frequency means something for the purpose of the study.[11] Then followed the pre-analysis phase through a fluctuating reading of the selected articles, in the search of the central ideas in its content.This step allowed to set the drive as nursing care in palliative care, for the study of matter and context unit, which takes place in the context boundary, in this case palliative care nursing for people with cancer.
From there, followed by exploitation of the data collected and the mental approach exercise between the registration units and the context and meaning cores; it was identified the understanding of the core meaning of the text (which were grouped by similarities or estrangement) [11] arriving to the subjects, which comes from the central ideas identified in the results of this review.

Results
Search in databases indicated 1,591 potentially eligible primary studies, of which 791 met the established criteria.Thus, the theoretical operating in the literature for analysis of nursing care in PC for people with cancer resulted in 14 publications.
The largest production of articles found was concentrated in the SCOPUS database, the largest database of abstracts and scientific literature citations, with about 70% of the articles selected, and all articles of international journals.MEDLINE, with worldwide reach, reached 21% of the sample; and on LILACS, Latin American database, it was found only one article (7%).According to the established criteria, it was not found any article in the CINAHL (Figure 1).
A summary of the main results, together with the conclusions were presented in Table 1.The results showed that there is a concentration of publications in the years 2010, 2013 and 2014.Being the largest periodical journal the European Journal of Oncology Nursing.The largest publishing language was English, as shown in Table 1.
The results showed that only one article described the factors related to the quality of the dying process [12], two others quoted the life quality of people with cancer in palliative care.[19,21] In addition to the articles that addressed the symptoms of palliative cancer patients [16,17], two of them mentioned the PC in the care of the family of people with cancer [14,23] and two others, revealed complex issues involving nursing care: palliative chemotherapy [18] and palliative sedation.
[20] Among the fourteen articles selected, seven of them presented at some point in their results some difficulties experienced by nurses when providing nursing care to people with cancer in PC. [14,15,17,21,23,24,25] Since the analysis of the results of the scientific productions selected, it reveals three themes: the palliative care nursing for people with cancer; strategies used by nurses in the care of the relatives of people with cancer in palliative care; the difficulties of nurses in achieving palliative care for people with cancer.

Discussions Palliative Care Nursing for people with cancer
This category theme emerged from the most prominent results among other, by presenting a variety of aspects and / or factors that are considered important for the nurse who performs PC with specificity for patients with cancer.
It was identified in this analysis, the meaning of the nurses performance in the CP with the person First exclusion: unavailable items in full text in languages other than Portuguese, English and /or Spanish, resulting in a N = 791.
Second exclusion: After reading the material in its entirety, the articles were excluded if they did not meet the other inclusion criteria or did not respond to question posed for this review, so the end N was equal to 14 publications.Examining the proportion of physical and psychological symptoms that were neglected by nurses.
Various physical and psychological symptoms, except pain, were often observed to be ignored by nurses.These results reinforce the need for comprehensive assessments of both physical and psychological symptoms that are sometimes overlooked and masked in the presence of concurrent symptoms.
7 Challenging situations when administering palliative chemotherapy -A nursing perspective [18] Sweden Qualitative narrative analysis.
Explore challenging situations experienced by nurses when administering PCT for patients with incurable cancer.
Nurses that administer palliative chemotherapy are engaged in a complex task that may lead to a number of difficult situations related to the uncertainty of the result of giving powerful drugs to vulnerable patients, which could, in the view of nurses, lead to aggravation and later death of patients, or in other situations bring benefits.
8 Patients and staff perceptions of cancer patients' quality of life [19] Áustria Transversal.
Identify through health professionals and their patients whether the quality of life of patients depends on their personnel socio-demographic profile and their specific work situation.
It was identified that the nurses had an inadequate idea of quality of life of cancer patients in palliative care.9 The perspective of the nursing staff on terminal sedation in pediatric onco-hematology: A phenomenologic -hermeneutic study [20] Italy Qualitative approach.
Using the phenomenological hermeneutics.
Explore the subjective perspective in end of life practices in three different groups of pediatric oncohaematological nurses.
One of the biggest difficulties that nurses experience in the context of cancer palliative care refers to palliative sedation, as the sedation can be a source of conflict for the family.On one hand the family want to avoid the suffering of their loved ones, but on the other, do not want to be separated from them.The suspension of consciousness eliminates pain, but at the same time eliminates any possibility of interaction between patients and families.Sedation in this case is represented as a preliminary of mourning.
10 How do nurses assess quality of life of cancer patients in oncology wards and palliative settings?[21] Australia Qualitative approach.Using the grounded theory.
Explore in depth as the assessment of quality of life is carried out by nurses in oncology and palliative care wards.
It is observed that the assessment of quality of life in palliative care area has a different purpose, a feature is that it is conducted through a specific orientation, writing assessment tools are used and a care plan, which are recorded they way patients feel, evaluate their problems, discuss the family structure, in addition to other different evaluations.Describe perspectives of nurses to meet the needs of hope and information to patients and families.

N°Title
Building trust and dialogue was identified by nurses as a key to successfully meet the needs of hope for patients and families.
12 Knowing the family: Interpretations of family nursing in oncology and palliative care [23] Canada Qualitative approach.
Using the philosophical hermeneutics.
Identify and interpret the family nursing practices that address the concerns and support the meaningful involvement of family members in the care of their loved ones.
Educate families is identified as a fundamental practice for all nurses, the action of educating occurred within the context of a carefully crafted interface, which functioned as a bridge between the world of good and world of cancer.
Explore the perception of oncology nurses on palliative care.
Nurses in this study described contextual aspects that strongly influenced their ability to provide palliative care.The participants expressed significant frustration with the limited time available to interact with patients and their families.
14 Striving for Emotional Survival in Palliative Cancer Nursing [25] Sweden Qualitative approach.
Using the grounded theory.
Develop a grounded theory of nurses who care for palliative cancer patients in hospital care.
The emotional overload is one of the main concerns of palliative oncology nurses, this overhead means that they become overwhelmed by emotions that arise in the care of cancer patients.Source: Research of the integrative review, Natal/RN, 2016.with cancer, in the process end of life, it is essential for the patient, for other professionals and family members, and their importance varies from the care related to improving the management and relief of pain and fatigue, even the development of communication skills and attention to psychosocial aspects, and in addition to the technical competence.[13,22] At the same time is clearly that nurses who engaged in this improvement especially when it comes to pain management, and seek ways through the acquisition of knowledge and practice evidence-based [16] we can see that professionals nursing reveal difficulties in assessing, recording and working with the pain and also the symptoms of impending death, resulting in anxiety and doubts about the measures taken in the care of patients [26], which reveals the need for appropriate best practices of care.
When pain or other symptoms are not treated properly, it generates more anguish and suffering for patients and their family members; and when refractory in the control of these symptoms exists, the palliative sedation is a treatment option.[27] In fact, the PC are defined by the World Health Organization as approach that improves the quality of life of patients and their family members to address the problems associated with diseases, using prevention and relief suffering through early identification, proper evaluation and treatment of pain and other symptoms into the physical, psychosocial and spiritual order.[28] Based on this concept, we may emphasizes in the literature found, that suffering and physical pain were considered by the nurses determinants in deciding about palliative sedation.Moreover, the suspension of consciousness can be considered an option when the patient is aware of the proximity of death, which helps relieve anxiety.[20] In addition to the care related to pain management, other physical and psychological symptoms are neglected and / or neglected by nurses due to other concurrent symptoms.[17] Although it still seems to occur with some frequency, currently the psychosocial aspects have been very highlighted for these professionals, who recognize the need to continue being supported in hope, performing PC in cancer patients with life limiting prognosis.[22] Appearance this queue to be confronted, need the practice of trust and dialogue, to achieve the only possible target in some circumstances.
In accordance to the definition of the World Health Organization, the quality of life in PC should be improved.[28] Therefore, the nurse performs this evaluation by a specific orientation, through tools written and thorough evaluation of bio psychosocial and spiritual symptoms in the care plan, in which are recorded the patients feelings, measuring their problems, analyzing the family structure, in addition to the evaluation of the different aspects of the patient that may be influencing the quality of life of them.[21] Finally, it was noted that some nurses express themselves with some frustration when it comes to nursing care in the PC, especially in the item of time available, essential for the interaction and the provision of care to patients and their families.[23,24] In this sense, it also recognizes that in the endof-life process, the spiritual care becomes important, appropriate and beneficial; however, most terminal cancer patients do not receive such assistance.[15] Spirituality and religion are important in the care of people with diseases without possibility of cure.Therefore, health professionals, especially nurses, can be prepared for this activity, although basic and unspecialized.[29] Strategies used by nurses in the care of the family member of the person with cancer in palliative care The second category of this review refers to the nursing care of the family member of people with cancer.In PC, the assistance of nursing staff is not limited only to the patient who is under their responsibility, but also for their caregivers, family and friends.
Therefore, the nursing team should be prepared to deal with the family members feelings.When faced with the chronic degenerative condition of the cancer, they showed up sad and helpless facing the pain and suffering, bringing to themselves those feelings.[30] At times, the family tends to protect patients from hearing the truth about their prognosis, requiring the nursing acumen to act in this situation and for identifying into the patient the desire for knowing its prognosis.[23] It is noteworthy That the performance of the nursing staff linked to the family provides extremely beneficial effects, as the family helps to identify the real needs of the person with cancer by including the family into the care, which is essential for the promptness of care.However, for this fact become possible, it is essential that the family members receive an educational support through guidance on how should be carried out the assistance to the person cared for.[31] Thus, nurses can enhance the positive aspects of personal and targeted care; given the opportunity to enable the family to achieve these at home.Thus, trying to meet their needs that refer mostly to the information, being essential the establishment of effective communication.[14] Therefore, it is important that the nurse is technically prepared and have sensitivity to assist the patient and the family, who need support, and find into the nursing the bond of trust that provides comfort at that difficult time.[14] In the literature, there is, among other strategies used by nurses, training for the realization of care, through demonstration, dialogue, training of family groups, interdisciplinary approach and the use of leaflets; thus reliable communication becomes an element to minimize the difficulties of the family.It adds that it is necessary to establish a relationship of trust with the professional in order to the family members feel free to express their difficulties, valuing prior knowledge.[14] Other studies confirm that educate families is identified by nurses as a key practice.[23]

Difficulties in achieving palliative care for people with cancer by nurses
In the items studied the results related to this category demonstrate how incipient and experimental nursing practices presented in this context still are.
It was noted that the main difficulties were the work overload, [14] not enough time to evaluate the quality of life of cancer patients [21] and providing assistance that involves the spiritual aspects [15], and to meet and interact with the families [23], which raises often, in nurses, expressions of frustration with the limited time for interaction with patients and their families in PC. [24] It is observed that there are some difficulties in the daily work of nurses for a quality nursing care in PC, including both physical and emotional overload, quantitative aspects of the work (such as working hours), excess of patients under their responsibility and health status of each patient.[6] The emotional overload is one of the main concerns of palliative oncology nurses; this means they become pressured by emotions that emerge from the care of patients with cancer.In addition, external factors such as lack of time, resources and attitudes of teammates can influence in the risk of being overwhelmed emotionally.[25] A major challenge for nurses is how to deal with art and science in a coherent approach that reflects the individuality, choice, dignity and compassion in the environment where the care is developed.[2] The complex process of nursing care involves beyond the physical signs and symptoms, attitudes and simple actions such as touch listen empathize with the suffering of others, helping in what the person is unable to do so.This practice often is not appreciated by the nursing team, although it is the representation of the complex care of these professionals.[2] In this context, it is observed that nurses have difficulty dealing with the patient and the family, as they are influenced in their formation for not showing emotions from the experience of suffering of others; and as a coping or defense, they fantasize that death will not happen, or acting as if the patient could recover.This behavior is common in many hospitals, including specialized in cancer.[32] Consistent with other studies [33], it was identified a huge lack of preparation of nurses facing the death and the dying process, causing suffering to the team that influence the quality of care provided to the patient and his family.From this, professionals just experienced sensations of pain for the loss, or feelings of denial, dissatisfaction, sadness and even anger because they cannot sustain life, resulting in low self-esteem and burnout among staff nursing.
It is clear that the lack of preparation and lack of knowledge about palliative care occur due to the absence of this content in the compulsory curriculum component of students in undergraduate institutions; therefore, training nurses complete their courses without theoretical basis and / or practice in the PC; which represents the only alternative for millions of people dying from cancer in the world, therefore the lack of preparation of these professionals in the field of work is reflected in the practice of nursing care to the person at the end-of-life phase.[34,35] It was also found in the selected bibliography, other complex issues involving nursing care in the PC to the person with cancer.Among them, we highlight the palliative chemotherapy which is becoming common for patients with incurable cancer.Since nurses are the ones who frequently administer chemotherapy, they are more likely to face difficult situations during the execution.The dilemma is incorporated into chemotherapy energy and the difficulty of predicting whether a patient is resistant to conditions relating to resist treatment.[18] Nurses when administer palliative chemotherapy are engaged in a complex task that can lead to a number of difficult situations related to the uncertainty of the results of the administration of potent drugs for vulnerable patients, which could, in the opinion of nurses, get worse and lead the death of the patient or, in other situations, bring benefit to the patient.[18] The loss of control of the situation and the possibility of death, despite the resources such as chemotherapy, make nurses look at their limitations and question their professional skills.[36] Another complex issue, which is one of the difficulties experienced by nurses in the context of PC of cancer, refers to palliative sedation, since sedation can be a source of conflict for the family.Family members want to avoid the suffering of their loved ones but do not want to be separated from them; this is due to the suspension of consciousness eliminates pain, but at the same time eliminates any possibility of interaction between patients and their families; therefore sedation is a preliminary mourning.[20] Therefore, the decision to use (or not) to palliative sedation requires extensive discussion in teams, in which is respected, above all, the role of the ill person and their families in decision to be made, considered essential condition for characterization that practice.It is also noted that in order to guarantee the right to information and respect for the autonomy of the sick person, the use of palliative sedation should be proposed in advance, ie, during the disease process, while the subject has not affected the capacity of making decisions.[37] Therefore, among the difficulties encountered, it is observed that nurses need training that addresses issues related to palliative care and continuous training in order to achieve scientific practice, according to the needs of people with cancer and their families.

Conclusions
Although cancer established as an existing illness for a long time, and efforts of studies in search of a cure, it is noticed the existence of great suffering for patients and families facing this disease that threatens the continuity of the life.In addition, cancer permeates stigmas and provides the possibility of rejection and expulsion of nurses, because of the difficulties in dealing with the common symptoms of the disease.
The practice of PC requires from nurses the vision and sensitivity, since providing such attention to the person at the end of life phase includes attention not only to the physical pain, but also the symptoms and physical, emotional, social and spiritual signs of the patient and family members, highlighted as important in nursing assessment, although they are not common practice in nursing care in the context of the PC.
From the analysis of the articles of this review we identified some difficulties that may influence nursing, whether or not with PC, and among them we can mention the lack of time for these professionals and physical and emotional burden, being aware of the complexity of nursing care in the process of death and dying.
So there is a need for greater emphasis and frequently in the PC approach, whether in scientific studies from academy, either in discussion groups of care practice, because it involves all the complexity and importance for the current situation, considering that cancer is one of the leading causes of death in the world nowadays.From this perspective it can provide more theoretical basis for management planning and care activities, as well as improvements in the specific training and increasing awareness for professionals working or not with PC.

Figure 1 :
Figure 1: Flowchart of the methodological steps of the integrative review.Natal, RN, 2016.
Nursing plays an essential role in the provision of palliative care for patients with cancer in advanced age.However, the therapeutic value of being in the family environment seems to depend on how homecare nurses provide patient-centered care.Communication skills and attention to psychosocial aspects, not only technical skills, stand out as important attributes for a skilled nursing care in home care.This article is available at: www.intarchmed.comand www.medbrary.com6