The nurse is the professional of the health team, who has the most contact with the patient. She dedicates her time, her concern, her responsibility and her knowledge to care for her patients.
The nurse is the person who gets to know and detect with greater accuracy the needs and concerns of the patient. Their relationship is intimate, of physical and emotional contact.
The nurse-patient relationship is the “human link” that links the endless chain of the complex management of the terminal patient. His attitude of constant concern for providing well-being to the patient; He places her as a “savior” from an undignified death. It is his human commitment that is the outstanding aspect that gives respect to his professional life. It is not their knowledge of scientific advances or their skill in handling the sophisticated techniques that appear every day in the medical research market. Rather, it is that subtle behavior of understanding, within the reach of the intuition of any human being, that makes it indispensable.
It is a combination of scientific knowledge with a personal interest in the act of dying and dying. A mixture of “water and oil”, between the cold application of a scientific treatment and the complex and intense management of human aspects.
This is how the writer Jorge Orgaz expresses it: “Humanism basically means being imbued with an intelligent feeling for human interests. Humanism matters because it forms man and the doctor (nurse) must be human above all.”
To analyze the nurse-patient relationship, I will take into account the following aspects that influence the nurse’s behavior:
Knowledge about the management of terminal patients
Universities that grant diplomas to accredit the professional nursing career do not include knowledge about managing terminally ill patients in their academic curriculum. They do not consider the study of thanatology or the in-depth teaching of palliative care to be essential.
Nursing students excel in their knowledge about the recoverable and rehabilitatable patient. The academic philosophy is based on essentially preparing them in the management of a curable and triumphalist medicine. That is to say, the terminal patient is a topic of rejection, impregnated with ignorance, which lacks academic support. University students have not learned or debated during their studies on the complex issue of managing agony and ultimately death. They do not have a formed criterion to act proportionally in accordance with their scientific and psychological knowledge, with the safety and professionalism essential for the care of the terminally ill patient.
Time availability
The nurse directs her activities towards administrative and bureaucratic commitments that cover institutional economic needs; She has to fulfill countless administrative functions that take her away from her human relationship with the patient.
Their time availability is minimal and they generally listen to the patient with little intention of communicating deeply with them. Their goals are to comply with a series of professional procedures and then fill out the forms that accredit the care legally recognized by the hospital institution. Nursing practice is focused on the proper handling of medical-scientific instructions and formulations. The outstanding nurse in the professional fulfillment of her duties is one who practices nursing procedures to the “letter”, coinciding with medical-hospital techniques and orders.
The time dedicated to understanding and communicating with the patient is not valued or encouraged and tends to be wasted because it lacks planning. Free moments are valuable for nursing staff, when they try to dissipate from the permanent human conflict generated by the suffering of patients and families in the areas of death.
The denial of death, the first psychological defense against pain, is the common denominator of this attitude of the nurse, as of any other person. However, if nursing staff were valued for their human contribution of understanding with the patient, their personal inner growth would be as much as effective in achieving good management of suffering in the terminal patient. Cícely Sanders in this regard says: “Time is not a question of length, it is a question of depth.”
Inappropriate circumstances for the care of terminal patients
1. The terminally ill are not cared for in the appropriate places. They are generally hospitalized in internal medicine wards or units, where they are absurdly mixed with curable patients or patients in chronic conditions, whose management differs substantially.
Others are placed in intensive care, where the nurse dedicates her time to caring for the “device” and advanced technology that invade the patient. Her physical contact is limited to moving the patient’s body either to prevent bedsores, bathing him or manipulating any tube or probe that has been inserted.
People who work in Intensive Care feel rushed and overloaded with work, they must fulfill their duties “against the clock” to avoid the death of patients in critical condition.
2. The nurse’s participation in the health team is limited. The doctor remains the only manipulator of information. It is he who communicates, according to his criteria, the diagnosis, prognosis and treatments to the patient; He makes most of the decisions about the management of the disease, which directly influence the quality and quantity of the patient’s life. He sometimes neglects the pain, anguish and suffering of the dying person, because he dedicates his attention to supervising the treatments that will generate a triumph over death, in addition to a substantial financial contribution.
In part, this medical attitude prohibits the nurse from informing or advising the patient and family regarding the development of their pathology. Perhaps her perception of the patient’s condition interferes with her decision making, differing from those programmed by the doctors. The nurse’s participatory attitude can influence the patient’s will. Likewise, if her attitude is passive, it prevents her from contributing to granting the right that every person has to use their autonomy, with informed consent.
His professional demeanor remains distant. That professional position suggested by the medical staff prevails in nurses, to fully comply with their orders and formulations. As if her function were, above all, to be an unconditional servant and a blind follower of a series of pre-established protocols.
Their criteria, correctly based on daily experiences and constant observation of the physical and emotional state of their patients, are generally not taken into account.
3. The approach to death generates emotions and feelings that are difficult to manage. The nurse can be involved in a moral conflict, when she commits herself to the will of the patient. Understanding the situation of the patient who is going through undignified agony, invaded by both emotional and physical pain, can awaken concerns, anxieties and helplessness in the nurse. Engaging with the dying person forces the nurse to consider her own mortality, increasing her personal fears about death. It is necessary to have a support group that allows her to vent these feelings. Her serenity, ethical criteria and maturity in the face of death are fertilizer for the human contribution she provides to the dying.
The following factors influence the patient’s behavior:
Components that influence your well-being
1. Physical: mobility, communication, activity, degree of alertness. Physical deterioration influences their ability to communicate and their degree of independence to carry out their daily activities. States of drowsiness, incoherence, exhaustion and unconsciousness isolate and incommunicate patients.
2. Social: support from the family group, friends and the health team.
3. Psychological: depression, anguish and multiple fears of death; attitude towards illness.
4. Comfort level: presence of symptoms that interfere with your well-being.
5. Degree of pain: physical pain that encompasses the patient’s care. Suffering that includes pain plus its emotional interpretation, often invaded by anxiety.
Informed consent
The patient’s right to know the process of his or her illness. The diagnosis, prognosis and the benefits or harms of the proposed treatments.
The terminally ill are not periodically informed about their illness; essential requirement to be able to make decisions.
Taking into account that it is patients who demand the truth or who avoid knowing it, this does not exempt health workers from their responsibility to transmit their knowledge and concerns about the management of their disease.
Each person with a terminal illness has a specific time and circumstance that allows them to digest their mortality.
Circumstances that affect your autonomy
States of extreme weakness, accompanied by depression or anxiety, make it difficult for the patient to understand. Inappropriate places that do not maintain respectful silence. Visually cold, unwelcoming spaces that contribute to in-depth and trustworthy communication.
Health personnel who act hastily, lacking time, dedication and emotional contact with the patient. Attitude that isolates him in his reality and leads him to feel unprotected.
The avalanche of scientific procedures that uncontrollably invade the patient, turning him into a puppet of the medical scene. His will has no validity in the face of the saving and triumphalist intention of the protagonists. The dying person enters the “whirlwind of technology” with or without knowledge of his fate and of his probable undignified demise.
Finally, I consider that the nurse-patient relationship will continue to be a marriage of mutual interests. They will be united by the ties of human understanding, which help to soothe the painful aspects of a body disintegrating due to an irreversible disease. Only in this way can we ensure that the agony, with its implicit cruelty, can be more bearable if the nurse assumes the intimate relationship of understanding of it.
Clemencia Uribe Alarcón
Vice President of the Pro Right to Die with Dignity Foundation
Correspondence: [email protected]