Introduction

In recent times, a progressive increase in terminal illnesses has been seen, along with the gradual degeneration of the total population. The improvements achieved for the specific treatment of these diseases have managed to have a characteristic increase in the stability and survival of these patients ¹. In recent years, diseases such as acquired Immune deficiency syndrome and cancer, among other diseases, have our society begging for a healthy response ². According to the definition issued by the World Health Organization the end-of-life care is such care provided at the end of life, whose objective is to advise, suggest, propose and calm grief through early identification, assessment and treatment of suffering among other complications that may occur during the course of the disease, which can be emotional and spiritual. They are addressed not only to the terminal stage of a person, but are also adaptable in the initial stages of the disease ³. This care at the end of life can be carried out in the diagnostic phase, that is, at the beginning of the disease in combination with other types of treatments, which help terminally ill patients to extend their life ⁴. Palliative care (PC) optimizes the quality of life (QoL) of patients, at all stages of life, challenging the problems inherent to a life-threatening condition, as well as that of their families ⁵. This type of care is specifically focused on the prevention and relief of suffering, as well as the treatment of pain together with other alterations, whether physical, psychological, social or spiritual, encompassing the integral sphere of the individual ⁶. PC is a fundamental component of health professionals, with greater emphasis on nursing personnel ⁷, also pointing out the relevance of the spiritual part, emotions and hope of the person, which play an important role of protection and support, when people are in situations of terminal illness, as well as the family ⁸. This is where the importance of the execution of this systematic review lies, which aims to know the nursing interventions in PC as an argument of great impact for the individual, the family and the society ⁹ thanks to the execution of PC in daily nursing practice, it is possible to achieve improvement in QoL, suffering and pain relief or, where appropriate, provide a dignified death, for patients in the last days of life ¹⁰. Therefore, this study is aimed to describe the scientific activity on the PC that is usually implemented in nursing interventions.

Methodology

A systematic review was carried out, for the search of the scientific literature, the recommendations given by the PRISMA method (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) were followed in order to offer a general description of the most monopolized nursing interventions in PC, published in the various scientific journals. The following six electronic bibliographic bases were analyzed: Redalyc, Science Direct, Scielo, REDIB, Mendeley and Google Scholar. The search criteria were according to the descriptors in health sciences (DeSC) and Medical Subject Headings (MeSH), synonyms, related terms, orthographic variation, abbreviations and wildcards, combined by means of the Boolean operators AND, OR and NOT. (“Palliative care”: “palliative nursing care”, “terminal patient”: “terminal patient”, “interventions” : “interventions” and/or “nursing”)¹¹, (Table 1).

The inclusion criteria were: articles published in scientific journals during the 2010-2020 period, articles on palliative care with interventions, articles that include the field of nursing knowledge, and articles written all over the world. Exclusion criteria: PC works that do not contain intervention, articles from years prior to 2010 and unproven disclosures such as: letters to the editor, news, brochures, guides and reviews. Articles that were repeated or that did not meet the eligibility criteria were eliminated from the search. The study variables were: Intervention programs, contents, number of sessions, duration of the program, how and with what instrument they evaluated the programs found. 1223 documents were obtained, selecting 23 of which only 9 articles were reviewed, (Figure 1).

Source: Own development

Figure 1 Flowchart of the search methodology, according to recommendation from the Prisma method for Systematic Literature Review. Year 2010-2020, (n=9). 

Results

Nine articles were selected, finding a high degree of evidence in nursing interventions. However, the research that referred to PC was focused on alleviating suffering, maintaining QoL, symptom control and dignity of the patient in the terminal phase. In the studies reviewed, the sample consisted of 644 patients in the terminal phase of PC services, with a mean age of 45.4 years (SD±15.9), most of whom were female. The results found in the analysis of the articles show that nursing interventions from another perspective helped improve the QoL of terminally ill patients and even achieve a dignified death, thus, favoring the family.

The most used nursing interventions in terminally ill patients in recent years, which were found during the review, were: humanized assistance, specialized PC against usual intervention: results in the patient's QoL, plan with interventions, music therapy, nursing intervention plan, multidisciplinary plan in the management of dyspnea compared to the usual intervention, compassionate intervention, nursing educational intervention in PC in the primary caregiver and art therapy intervention, breaking down each of the intervention programs that are useful in the terminally ill.

Humanized assistance was aimed at the terminally ill and the caregiver family, lasted 3 months, 1 hour per session, 3 to 4 sessions per month were given; the first month the training of the caregiver in PC was addressed, each of the basic measures to improve coping with the disease in people with cancer was reviewed; in the second month, it was worked on assistance in specific care for the caregiver and in the third month the caregiver was trained in crisis management, making greater emphasis on the spiritual side in people with cancer. Their evaluation instrument for this type of program was the QoL instrument and to see its effectiveness initial and final measurements were made, having an assertive response and improvement in the QoL of patients and caregivers ⁽¹².

In the specialized PC intervention versus usual intervention: results in the patient's QoL lasted from 1 to 3 times a week, 3 activities were carried out to obtain an increase in hope where the patient had to write one or several letters, poems, take photographs, or write music, to other people related to hope; then a video was made with the story of the patient’s life and it was made known to other people, and finally the user freely carried out an activity before evaluating it again. For its evaluation, a Psychosocial Activity Living With Hope Program was required. During this measurement, the researcher was with the patient, during the presentation of a video called living with hope made by the group of researchers, which consisted of a series of interviews with patients with PC, as well as their families who saw hope as their own technique to face suffering, as well as their tactics to preserve it ¹³. The intervention plan included three stages: stage 1 included conversation by means of an interview, an assessment was started with the different scales of pain, depression, social resources, self-esteem and multinutritional. In stage 2, the patient was invited to an exploration of his history, an action plan was made for the interventions to be carried out with the patient and the family. The care action plan was established and initiated in accordance with the disease and symptoms each patient had. The most common complaints were pain management, activity intolerance, depression, family coping, tiredness in role performance, and nutritional imbalance. In stage 3 an assessment and evaluation of the experience was made, the instruments used were Barthel index scales or Maryland disability, VAS (EVA by its acronym in Spanish) visual analogue scale, Yesavage geriatric depression scale and Rosenberg self-esteem scale. The results showed that this type of intervention was efficient in terminal patients ¹⁴.

The music therapy session was performed twice a week for three months; each session lasted 20 minutes, and was evaluated with three self-completion questionnaires to be filled out before and after each session. The MOOD questionnaire with 20 items and 3 response options to assess mood was used. The Hospital Anxiety and Depression Scale (HADS) questionnaire with 14 items and 4 response options to assess the degree of anxiety and finally the Visual Analogue Scale (VAS) of 0-10 was applied in terminally ill patients ¹⁵. The nursing intervention plan was a program that lasted ten days with home visits, focused on maintaining each of the basic needs (respiratory, communication with the family and patient, personal hygiene, skin and food cleanliness, pain relief, defecate and urinate -elimination- comfort and safety). The patient’s evaluation consisted of indirect anamnesis, physical examination and review of the clinical file, clinical nursing judgments were established from signs and symptoms, problem and etiology, using the nursing process, for each case ¹⁶.

The multidisciplinary plan for the management of dyspnea compared to the usual intervention lasted 4 weeks. This plan consisted of psychological counseling to identify triggers of dyspnea crisis, as well as tactics to reduce and control symptoms, respiratory control techniques, management of secretions and airway clearance, cognitive, anxiety control, reflection and transformation in the condition of life. It was performedt at different times in two groups, through an interview before the intervention; the second evaluation was carried out 2 weeks after the beginning of the intervention.

The third evaluation at 4 weeks, corresponding to the end of the intervention ¹⁷. The compassionate intervention was addressed three times a week with a duration of one hour; the content was the relationship of trust and therapeutic bond, relief of suffering, causes of relief of suffering, transcendence of the patient's suffering and compassionate intervention, the evaluation was with Pamela Reed's Spirituality questionnaire, obtaining a statistically significant result ¹⁸.

The educational intervention of PC in the primary caregiver, the experiences of CFV, pre and post-intervention in the primary caregiver of the patient in the terminal phase of the disease were explored, addressing emotional support, spirituality, pain, feeding, defecate and urinate -elimination, hygiene in the primary caregiver, comfort and safety, this intervention program was evaluated with an observation guide ¹⁹. During the art therapy intervention with individual sessions in the patient's room, twice a week, one hour per patient, the content was active listening and observation, it caused improvement in the QoL in each sick individual, especially in the domains of existential and psychological wellbeing, as well as in the relief of symptoms. The benefits expressed by patients, families and professionals emphasized emotional relief (greater peace of mind in the face of an end-of-life situation), stimulation of pleasant sensations (enjoyment with artistic creation, wellbeing, and relaxation), concentration on something that creates distraction, and pain relief ²⁰. The results show that the interventions reviewed had a high impact in favoring terminally ill patients and their family caregivers.

Discussion

Based on the purpose of describing the scientific activity on the most implemented PC in nursing interventions, it can be mentioned that the contrast of the research carried out with intervention programs in terminally ill patients in recent times is essential and of utmost importance, with the spread in the world of chronic degenerative diseases of terminal illnesses that have caused an important impact in the oversaturation of health services ²¹. Professionals in the area, and especially nursing, compensate for this demand in treatments and satisfy patients with this type of terminal illness, using holistic end-of-life care for patients ²². According to what was reviewed, it has been mentioned that terminally ill patients should have humanized assistance from their family members to improve their QoL and increase their spiritual wellbeing, with greater emphasis on patients with cancer ⁽¹². Nursing care should be oriented to PC such as pain relief, support, active listening and advice for the family, compensating the essential needs of the terminally ill patient ⁽²³. In a study, an increase in hope was observed in terminally ill patients with an intervention program where the terminally ill patients were allowed to explore their experiences and feelings, obtaining as a result the ability to face the illness, as well as its acceptance ¹³. In another study, an intervention plan was established that included different scales for the comprehensive assessment of the terminally ill, obtaining improvement in symptoms, such as pain management, activity intolerance, depression, family coping, fatigue in role performance and nutritional imbalance. This showed that an intervention program can be designed according to the pathology to improve the QoL of the terminally ill patient, even supporting the family from other perspectives ¹⁴. Some researchers established intervention programs such as music and art therapy, having a high effectiveness in existential and psychological wellbeing, as well as in symptom relief ^15,17,20. According to the basic needs of the patient, studies were found that showed that it is vitally important to address a comprehensive care plan in the terminally ill, in order to meet physical, psychological and spiritual needs ¹⁶. Likewise, a study showed that spirituality is an important part in people suffering from terminal illnesses, this type of intervention was focused on the relief of suffering by detecting the causes, the pain of the soul, the transcendence of suffering and compassionate intervention, this being an important tool and essential for the terminally ill patient and their family ¹⁸. Additionally, in the bibliographic review, a study was found that mentioned the importance of the primary caregiver and their affective relationship with the terminally ill patient, suggesting an educational intervention of nursing PC in relation to emotional support, spirituality, pain, feeding, defecation and urination -elimination, hygiene, comfort and safety ¹⁹.

The content of this systematic review is clear, that is, nursing interventions in PC are scarce and the information is limited, given the little knowledge on the subject in our country; it was frequently observed that those who maintain the leadership of PC is the field of psychology and medicine ²⁴. In the contrast of the nursing interventions found, the different results of the intervention programs, the characteristics, contents, sessions in which each intervention was carried out, as well as their duration, focus and, above all, the instruments used for its evaluation were identified and interpreted ²⁵. According to what was reviewed, it was seen that each of these nursing interventions had a purpose. The research reviewed indicated that its application in PC of terminally ill patients was effective, from the required point of view ²⁶. The results found indicate that the nursing personnel generate improvements in the efficiency of subsistence of the patient and family, as well as the inspection of symptomatology, a decrease in the emotional load due to the illness, progress in the body, emotional and spiritual change, both of the patient and the family ²⁷. It is proposed to carry out a nursing intervention program in PC that contains interventions such as meditation, therapeutic touch, relief of suffering, dignified death and assistance or presence of family members, to help improve the QoL, dignified death and spiritual wellbeing ^28,29,30.

Conclusions

Nursing interventions in PC were positive, with a high degree of scientific evidence, to help the subsistence of the sick person - and the family; likewise, they contribute to reduce discomfort caused by the disease, guaranteeing progress in the terminal stage. According to the reviewed articles with intervention in the disciplinary field of nursing, it was possible to define a general and real panorama that studies with intervention in PC are scarce. The amount of research reviewed for this study was restricted. According to results of nursing interventions in PC, they generate improvements in care in the subsistence of the terminally ill and the family, as well as the vigilance in the appearance of symptoms, reduction in the emotional overload perceived due to the disease, progress of the stage of physical and spiritual health as well as satisfaction with the care received, that is why through this review the importance that nursing plays in each of the interventions in the PC of patients with terminal illnesses was observed, for this reason a comprehensive approach should be carried out on the subject, since these interventions are effective and the need for this care increases progressively, in conclusion, it is essential to increase studies with this approach on end-of-life care that provide safety in CP nursing interventions.

According to the search for articles, the possibility of new programs using the CP is ratified, which mediate in a preventive or late manner in users who show terminal phase conditions. The representation that generates a premature or late CP is a relevant field, this care guide composed with the curative procedure, symbolizes an effective impact in the inspection of symptoms, improvement in the QoL, relief of suffering at the end of life, help to the patient to have a good death, with the additional aim to help the family. Studies are needed to establish more clearly the interventions that the nursing professional can carry out in this type of patients, since it is a wide field for its study and the need of the population is increasing.

Conflicts of interests

The authors declare that there is no conflict of interest.

Financing

The authors declare that there was no funding of any kind.