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Increased longevity and chronic diseases have led to a significant increase in the number of people suffering from terminal illnesses. We know that disease-centered care does not meet the needs of these individuals. Moreover, the use of life-prolonging techniques are often the source of unnecessary suffering that it is important to avoid. In this article, we talk about geriatric psychiatry and where it comes from.
Concern for the care of people at the end of their lives is not recent, but emerged several centuries ago and has basically been associated with religious orders and movements that dedicated themselves to providing assistance in hospices out of charity. Back in the 1840s, in France, hospices were used to welcome pilgrims and to care for the dying.
Since then, hospices gradually sprang up all over the world, until 1967, when Dr. Cecily Saunders established Christopher’s Hospice in London, a major advance in palliative care in England. Furthermore, a new philosophy of care based on two fundamental elements began to spread around the world: effective pain control and control of recurrent symptoms of the disease and treatments.
Undoubtedly, the evolution of terminal illnesses confronts people with a series of successive losses, putting their equilibrium at risk. Most authors (Twycross, 2003; Martins 2014) describe the terminal stage of life as the period in which all fears become manifest. For instance, fear of pain, of respiratory distress, of being mutilated, of experiencing painful symptoms, of further deterioration, of loneliness, of others, of abandonment, and fear of death.
Moreover, emotions such as shock, denial, anger, emotional instability and anxiety are often accompanied by sleep disorders, lack of concentration and apathy. These reactions are common and can often lead to a misleading prognosis and treatment. Therefore, it is important to keep in mind that although an individual’s condition at the end of their life may be incurable, treatment may still work actively, since its purpose is to control the symptoms that cause suffering and that may interfere with the emotional, behavioral, social, spiritual and religious sphere (Sapeta, 2010).
Thus, caring for people at the end of their life highlights the importance of human care regardless of an individual’s illness, age or condition. It also emphasizes the role of the nurse and interventions that promote a better quality of life, prevent suffering and preserve the person’s dignity, regardless of the context in which they find themselves.
Understandably, in geriatric psychiatry end-of-life care requires technical, scientific and interpersonal skills. Professionals need to be prepared to care for the person as a whole, taking into account the physical, psychosocial, and spiritual aspects that are affected (Fernandes, 2016). This care may be provided in specific units, but also in all palliative care departments, as is the case of geriatric psychiatry centers, communities, social facilities for the support of the elderly or at an individual’s home.
According to most consulted authors, such as Kubler-Ross (1998), Twycross (2003) and Martins (2014), one way to mitigate this type of need requires strengthening the therapeutic relationship with the members of the multidisciplinary team, establishing clear, open and reassuring communication, offering support, care, and understanding to the patient and their family at this stage of life.
When it comes to hospitality, emphasis is on the importance of being by the side of the individual, active listening, tact, a welcoming attitude, the family’s engagement in the care and decisions related to the interventions to be carried out, and support for bereaved families as a way of experiencing the hidden side of emotional pain. To this end, the family should be present and help whenever possible, as they often know the individual better than anyone else in terms of their habits, longings, fears, and deepest desires.
On the other hand, compliance with ethical standards also promotes morally correct, efficient and up-to-date professional practice. In the context of end-of-life care, the nurse has the duty to “defend and promote the sick person’s right to choose the place and persons they wish to be surrounded by at the end of their life; to respect and ensure respect for the family’s or close persons’ expressions of grief for the loss of the terminally ill person, and to respect and ensure respect for the body after death” (Nursing Code of Ethics of Portugal, 2005).
For the reasons described above, in geriatric psychiatry end-of-life care interventions should be humane and aimed at the systemic evaluation of the individual’s signs, symptoms, needs and expectations. For instance, including the implementation of pharmacological and non-pharmacological measures and their evaluation, follow-up and reporting. Furthermore, promote interdisciplinary reflection when setting priorities for each patient; and intervene in the family dynamics in order to help the patient and their family in this phase of life.
Rosa Simões – Head of Nurses at Santa Isabel Psychogeriatric Unit
Casa de Saúde Rainha Santa Isabel (Condeixa-Portugal)