Communication related to diagnosis and prognosis to patients with advanced cancer: ethics at stakeed
- Autores: Paolo Melis
- Directores de la Tesis: María Francisca Jiménez Herrera (dir. tes.)
- Lectura: En la Universitat Rovira i Virgili ( España ) en 2021
- Idioma: español
- Tribunal Calificador de la Tesis: Cristina Monforte Royo (presid.), Silvia Reverté Villarroya (secret.), Claudio Sardi (voc.)
- Materias:
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- Resumen
Background: The nurse-patient relationship is the essence of nursing and an integral component of the nursing practice. The relevance of the nurse-patient relationship emerges and may develop from the communication that occurs between a nurse and a patient. In fact, communication represents the necessary and essential means through which a nurse establishes the relationship with the cared person and their family. On this basis, communication has received, as an issue, a lot of attention and, as a topic, has been largely investigated in medical and nursing literature. The Italian Code of Ethics for Nurses (2019) in the section titled Professional relationships dedicates several articles to information and communication. Article 15 is titled “Information about health status” and states: “The Nurse makes sure that the person, or the person indicated by him or her as a reference, receives precise, complete and timely information on his or her state of health, shared with the care team, in accordance with his or her needs and in culturally appropriate ways. It does not replace other professional figures in providing information that is not of its own competence.” This means that the nurse is expected to have an active role in communication. In fulfilling this role, the nurse must relate the content of the information, the patient's information needs, and the meanings and implications of communication. It needs to be added that the nurse-patient communication is a phenomenon that occurs in an interactional context that encompasses the whole healthcare team, patients and the patient’s family and caregivers. In accordance with this, international recommendations and guidelines seem to agree on inviting to consider communication as a global phenomenon to be addressed with a comprehensive approach. Nevertheless, the majority of literature available on communication related to cancer diagnosis and prognosis still focuses on dyadic interactions only. It rarely highlights the communicative interactions that occur at a group level, between the patient and those who care for him or her, namely their caregivers, the attending physician, and the nurse.
This study approaches communication related to diagnosis and prognosis as a phenomenon occurring in an interactional context. Phenomenology is a specific form of qualitative inquiry, but it encompasses different approaches, following the vast philosophical references that underlie the methodological structures. This study conforms to Martin Heidegger’s famous definition of phenomenology.
My starting point is that of enabling nurses to attend to the patient’s communication needs in cancer care; therefore, to fulfil the nurse’s professional mandate and be respectful of all stakeholders, it is essential to approach communication, and more specifically communication related to diagnosis and prognosis, as a complex phenomenon that, having the patient at the centre of it, involves all players that interact with him or her in the caring process. The research question that guided this phenomenological study is: how do patient, their caregivers, attending nurses and physicians experience their communication interactions in relation to diagnosis and prognosis? Aim: The main aim is to explore the phenomenon of communication related to diagnosis and prognosis, by comparing the perspectives of advanced cancer patients with those of their caregivers, physicians, and nurses. The secondary aims are: (a) To enlighten the meanings attached to communication by the four key stakeholders. (b) To understand the phenomenon of communication related to knowing diagnosis and prognosis by the four stakeholders. (c) To individuate the ethical challenges perceived by the four groups of participants in communication related to cancer diagnosis and prognosis.
Methodology: In order to achieve the objectives of this research two studies have been conducted. The first one is a qualitative study that adopted the interpretative phenomenological analysis. It was guided by the purpose of understanding the phenomenon of communication related to knowing diagnosis and prognosis by exploring the perspectives of patients with advanced cancer and those of their caregivers, physicians and nurses. Drawing upon a multi-perspective design, a total of 27 semi-structured interviews were conducted involving the four different groups of stakeholders (7 patents, 7 caregivers, 6 physicians and 7 nurses) – who were linked by a care-cared relationship- in two oncology departments of two hospitals in Sardinia. The second study is too a qualitative study that adopted the interpretative phenomenological analysis. It intended to investigate the phenomenon of communication related to diagnosis and prognosis as experienced by patients, their caregivers, and both their attending nurses and physicians in order to enlighten the meanings attached to communication by the four parties. A purposive sampling of 6 patients, 6 caregivers, 7 nurses and 5 physicians was performed in the two hospitals already mentioned. To sum up: a total of fifty-one semi-structured interviews have been conducted in two oncological departments of two big hospitals in South Sardinia, Italy. The data collection started on August 2016 and finished in February 2017. The patients were enrolled through two purposive sampling, the other participants were enrolled based on their connection to the patient and included their caregivers, attending oncologists and nurses. A rich description of the samples characteristics has been provided. Interviews were transcribed verbatim and a thematic analysis was performed following Jonathan Smith’s steps of analysis. The data analysis was supported by Atlas.ti. version 7.5.7.
The two studies respect the methodological rigour of qualitative studies by taking into account the criteria indicated by Guba and Lincoln: dependability and confirmability, credibility, and transferability. In realizations with expert advice, great attention was paid to self-reflexivity.
Findings: In the first study data analysis made it possible to identify three main themes: (a) The availability of nurses and doctors as communicators conditioned by contextual factors; (b) The "what is it?" and the "what will happen to me?"; (c) Matching and mismatching in identifying the others as speakers. In the second study data analysis produced three themes as well: (d) The infinite range of possibilities in knowing and willing to know; (e) Communication with the patient as a conflicting situation; (f) The bind of implicit and explicit meaning of communication.
Findings depict a context where diagnosis and prognosis-related communication is managed by health professionals in an isolated way, though the team approach is referred by some health professionals as a desired perspective. In this context the health professionals fail to acknowledge the patient’s whole communication process. This disempowers nurses as patient’s advocates and debilitates their efforts to meet their patient’s (and their caregivers) multiple and evolving communication needs. Besides, in a context of scarcely integrated communication interactions, the four parties fail to find each other as resources in the communication process and, when it happens, it does so on an idiosyncratic basis. From an ethical perspective, the interplay of meanings attributed by patients, their caregivers, their oncologists and attending nurses to communication related to diagnosis and prognosis has highlighted complexities and ambiguities that have not yet been resolved. Perplexities and contradictions are still discussed as a result of the contrast between the principle of autonomy and the principle of beneficence and remain unresolved.
Conclusions: The research has allowed to have a comprehensive understanding of the phenomenon of communication related to diagnosis and prognosis and has permitted to enlighten communicative interactions and the meanings attached to the phenomenon of communication by patients, nurses, caregivers, and physicians. This offers a novel insight to reflect on the ethical issues that are at stake in communication related to diagnosis and prognosis in the context of cancer care. The major issue emerging in both studies is the shared perception of extraneousness of the nurse’s role in communication related to diagnosis and prognosis.
In summary, the comprehensive understanding of the phenomenon of communication related to diagnosis and prognosis allowed by the multi-perspective design and the interpretative approach enlightened how the different parties involved interact and reciprocally influence each other. Recognizing and reflecting on the complex interactions in which communication develops can help to analyze singular and shared responsibilities towards the patient, to move towards a personalized communicative approach and to achieve a more patient-centred care.
