Cancer is a chronic pathology that causes intense physical pain, and spiritual and emotional suffering not only to the affected person but also to the entire family group that lives directly with the patient. In old age, the diagnosis of malignant tumor is much more overwhelming, since it is almost always associated with imminent death. The present work is a literature review on palliative care performed by the nursing team, where online databases were used in order to identify and describe typical palliative care in nursing in elderly patients with cancer undergoing treatment in the hospital environment. In addition, we sought to identify the possible obstacles faced by the team in the satisfactory implementation of care, taking into account the deficient workload related to the topic in the institutions that train nursing professionals. Currently, cancer is among the main causes of death in Brazil, in the midst of this, the need for scientific technical improvement of the nursing care practice in palliative care has been established. Thus, there is a need for continuing education in the hospital environment to ensure the quality of care in palliative care, as well as adequacy in undergraduate curricula in order to promote the proper initiation of nurses and guarantee comprehensive and humanized care for elderly cancer patients in the hospital environment.

Keywords: palliative care, elderly, oncology, nursing assistance

The increase in life expectancy and the aging of the population have brought with them several health consequences, which were previously non-existent or not widespread. One of them is cancer, which has been highlighted among non-communicable chronic diseases, being considered a contemporary problem of global public health. According to the National Cancer Institute - INCA (2020), cancer can be designated as a set of more than 100 diseases that have in common the disordered growth of cells, which invade tissues and organs. These cells divide rapidly and tend to be aggressive, reproducing uncontrollably by the body. From this, malignant tumors are formed that can spread to other regions of the body.¹ 

 This condition is one of the leading causes of death in the elderly and the second leading cause of death in Brazil. The aging process in human beings naturally causes debts in both physical, motor and psychological functions, as well as in the social area. Associated, aging and cancer can be a death sentence for many people. Therefore, acceptance and consequent coping with the disease by both the patient and the family is a difficult, painful and exhausting process.²

Nursing care in these palliative care for elderly cancer patients in the hospital environment requires the professional not only to master appropriate techniques and scientific knowledge that minimize the patient's suffering, but also to have a humanized posture, respecting the individual limits of each human being and at the same time emotional intelligence so as not to absorb the negative emotional charge that is part of the daily life of the professional who deals with this type of pathology.³

This process should be started right at the beginning of the academic life of nursing professionals, in undergraduate courses where it is clearly observed that there is a deficit in the training of students in relation to specific disciplines that can prepare nurses properly, that is, teach the techniques ideals of care as well as the psychological preparation so that the nurse can deal with this aspect of the profession and help patients and family members, also giving them emotional comfort to face all the stages of palliative care aimed mainly at the elderly cancer patient.⁴

The main objective of this research is to identify the role of the nursing team in palliative care not only directed to the patient but also to the family of the oncological elderly in a hospital environment. The specific objectives are: to detail in detail what these cares are and to demonstrate the appropriate ways in which nursing care in palliative care should be implemented and to overcome the obstacles faced by the nursing team in the daily routine of this care.

Thus, it is extremely important for today's society to disseminate knowledge and improvements in the field of palliative care, in the sense of advancing the specific training of nursing professionals to ensure a satisfactory implementation of palliative care in which comfort, pain relief, hygiene, autonomy, dignity, religious freedom, family experience and psychological support for elderly cancer patients in a hospital environment.

Exploratory and qualitative study, with innovative descriptive sampling. The present work is a bibliographical research where the online databases SciELO, LILACS, VHL, doctoral theses, books, monographs were used, in addition to considering the availability of the full text, version in Portuguese, seeking the aspects that are related to the keywords: initially, a search was carried out regarding palliative care, using the terms “Palliative Care”, “Nursing care”, “ontological elderly”, “hospital environment” and “Palliative Care”. With the objective of identifying the concepts about this way of care, mentioned in national journals, through the literature review. In the initial search, the titles and abstracts of the articles were considered for the selection of probable works of interest.⁵

Inclusion criteria were texts that addressed the topic of palliative care, elderly cancer patients, national texts and texts published between 2011 and December 2021. In contradiction, the exclusion criteria of studies were publications that are not related to the theme , available in summary, as well as articles with the year of publication less than 2011.⁶

Initially, 02 books, 02 monographs and 11 articles related to palliative care were found, excluding those that did not meet the established criteria. In the end, 01 book, 01 monograph and 07 articles were selected after associating the inclusion and exclusion criteria, being organized in sheets in which there was identification data of the articles and a synthesis for further analysis.

The World Health Organization (WHO) defines Palliative Care as an approach whose main treatment focus is to improve the quality of life of patients and their families in the face of life-threatening pathologies, through prevention and early treatment of symptoms and physical suffering. , psychic, spiritual and social. In intensive care, palliative care is provided to all critically ill, life-threatening patients with symptoms that compromise their quality of life.⁵ Palliative care is based on principles and knowledge inherent to the various specialties and can be initiated from the diagnosis of the disease, thus avoiding the use of terms such as “nothing more can be done”.⁷

The WHO also defines the principles that must be considered by the multiprofessional team when providing assistance, which are: promoting pain relief and other unpleasant symptoms; affirm life and consider death as a normal process of life; not hasten or postpone death; integrate psychological and spiritual aspects in patient care; provide a support system that enables the patient to live as actively as possible until the time of death; offer a support system to help family members during the patient's illness and cope with grief; multiprofessional approach to focus on the needs of patients and their families, including bereavement support; improve quality of life and positively influence the course of the disease; should be started as early as possible along with other life-prolonging measures such as chemotherapy and radiotherapy and include all investigations necessary to understand and improve stressful clinical situations.⁸

For Gomes and Othero² palliative care presents itself as an innovative form of assistance in the health sector and has been gaining ground in Brazil in recent decades. It differs from curative medicine in that it focuses on comprehensive care, through prevention and symptom control, for all patients facing serious, life-threatening illnesses. The WHO also emphasizes that palliative care must be initiated at the time of diagnosis of the disease, to aim at cure, and if it does not occur, palliative measures can be implemented exclusively, in which care becomes the main focus and not more the cure.⁹

One should also take into account the fact that in a hospital environment, both family members and the elderly patient, when conscious, are emotionally and spiritually sensitive to the imminence of death, demanding fulfillment or spiritual comfort according to their own beliefs. It is not uncommon for family members to seek spiritual help through religious services or even healing rituals in order to provide some kind of relief for their loved one. It is up to the nurse to perceive this need that the family has to contribute in some way to the health of their family member and provide resolute measures in order to adjust this care. Mohallem and Rodrigues (2007) cited by Santos, Lattaro and Almeida⁷ state that “palliative care begins with respect for moral, social, ethical values, beliefs, knowledge, rights, duties and capacities”.¹⁰

In the hospital environment, there is a need for adaptations so that the family member can also feel welcomed and be with the elderly person 24 hours a day, preventing them from feeling abandoned. As for visits, access must be facilitated, with no limit imposed by the hospital, the number of visits must be regulated by the patient himself if he is in a position to decide. In this context, the visit of children is also allowed. It is also very important that the family member be guaranteed access to medical information about changes in the clinical condition and about the stages in the dying process, guaranteeing full psychological and spiritual assistance.¹¹

The nurse must provide means for the elderly to maintain their autonomy, even if limited, in addition to encouraging self-care and involving the patient and family members in decisions and care until the end. It should also encourage the elderly to plan their life and illness routine, in addition to routine care such as relief and monitoring of symptoms and pain. For Gaspar et al.¹ “age is not a factor that disables a person to personally exercise the acts of civil life, such as deciding on their own life and death” (2019).¹² 

As for practical nursing interventions, pain control, hypodermoclysis and dressings in tumor wounds or malignant skin lesions are evidenced. In addition to these, psychological care, patient hygiene and comfort measures are necessary. In relation to pain, this question is subjective because each human being reacts differently to the stimulus of pain. So that some physiological patterns such as heart rate, temperature, respiratory rate when altered help the nurse to identify the presence of pain. Allied to this, the nursing team can and should also use the Visual Analogue Scale - VAS, which helps to measure the intensity of pain reported by the patient. For Biasi et al.⁹ “the patient expresses his behavioral and emotional reactions by his facial expression, by crying, or by verbal expression, what is his reaction, (fear, anguish, irritation, insomnia, among others). In this way, it is also possible to assess pain through the patient's behavioral response.¹³

There are also other scales such as the “Palliative Performance Scale” that serves as a functional assessment and has 11 performance levels ranging from 0 to 100 with intervals of ten. PPS should be used every day in the hospital environment and can also be used in outpatients and home visits. Another scale used is the symptom assessment scale - ESAS- and consists of a small questionnaire with nine determined symptoms and space for a tenth symptom (Figure 1)that must be mentioned by the patient and recorded daily. The patient is asked to assign a score from zero to ten to each pre-established symptom, with a zero score referring to the total absence of the symptom and a score of 10 the highest intensity. If the client is unable to answer the questionnaire, it can be answered by the caregiver, however, subjective symptoms such as tiredness, anxiety, must be left blank.¹⁴

Figure 1 Edmonton Symptom Assessment Scale – ESAS.

Other palliative nursing interventions aimed at elderly cancer patients in a hospital environment are: well-being, family interaction, respect, therapeutic communication techniques and communication with the multidisciplinary team. All this with a view to ensuring the autonomy of the elderly cancer patient with a focus on improving the quality of life through humanized care, mitigating their suffering as much as possible. For Markus et al,⁶ “the act of humanizing requires a good mood from the nursing team, to build therapeutic relationships that allow relieving the tension inherent to the gravity of the situation, protecting the dignity and values ​​of the palliative patient”.¹⁵

Palliative care always aims to promote patient comfort even though it goes against advanced life-prolonging techniques, which use painful procedures with little chance of success. “Palliative actions to the detriment of the technological complexity of the unit, can allow this patient who is in his finitude to complete his life cycle with dignity, respect and with as little suffering as possible.¹⁶

However, nursing faces some difficulties in carrying out this care due to the lack of information and preparation of the team to deal with patients suffering from such a disease. According to Markus⁶ “it is necessary for nursing professionals to have prior knowledge about palliative care, in the search for qualified and meaningful assistance for patients who are in these conditions. [...]”. For Gonçalves³ there is insufficient teacher training in palliative care since the insecurity and suffering of this category is noticeable when it needs to position itself on palliative care, the result of little or no training in the area revealing itself as a weakness about this theme.¹⁷

In addition, the lack of theoretical basis in nursing courses with regard to palliative care makes humanized and standardized actions difficult. Since the nurse needs specific and technical training regarding the application of palliative care, assisting the client affected by the different types of cancer in all its stages, performing humanized interventions and focused on the well-being of the human being in a holistic way.¹⁸

It should also be taken into account that the more a population ages, the more the demand for qualified health professionals for palliative care increases, this points to a path where the current way of training nurses in public and private universities in order to to establish teaching plans where palliative care in general is worked with better efficiency so that the desired excellence in palliative care can be achieved.¹⁹

The study is relevant, since it reflects on the importance of implementing palliative care in nursing care for elderly cancer patients, who, due to physiological changes typical of aging, are more vulnerable and sensitive to this condition.

From the establishment of the initial diagnosis to the end of the health-disease process with or without evolution to death, the practice of palliative care is essential. Therefore, it is essential that the nursing team is prepared to recognize the needs of patients in all their dimensions.

In view of this, there is also a need to establish a culture of teaching palliative care in undergraduate health courses, to the detriment of its implementation only when the professional begins to practice the profession and is faced with a situation as delicate as dealing with an elderly client with cancer and his family members weakened by the process of accepting the disease, difficulties with the sudden change in routine and fear of facing grief.

For its complete completion, it is important to clarify that this study reached its objective, as it successfully concluded the proposed objective, contributing methodologically to the elaboration of new research on the topic addressed.

None.

The authors declared no have conflict interest for the study.

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