Emotional Bond: The Nature of Relationship in Palliative Care for Cancer Patients

INTRODUCTION

Today, cancer is one of the major diseases whose treatment poses a number of challenges to health and treatment systems. According to global reports, the number of cancer patients and its mortality rate is on rise every year.[12345] During their illness, they experience a number of physical, mental, psychological, and social problems.[6] Over the recent years, to support these patients, provide effective care and control multiple problems, palliative care has been organized in different countries.[78] To achieve its goals, the palliative care approach requires a certain framework with specific steps. One of the basic principles for the formation of effective palliative care is the relationship of service providers (care team) with service recipients (patients). If this principle is ignored, care delivery may become difficult.[910] The principle of relationship in palliative care facilitates other key elements of palliative care, such as decision-making and interdisciplinary care.[11] On the other hand, the proper relationship between the care provider team and the patient results in the satisfaction of the patients with the received care and the ability to adapt with cancer.[1213] In various studies, relationship formation has been reported as a vital and important aspect in the quality of palliative care.[1415] In the relationship process between the care teams and patients, the communication skills and strategies of the care team determine the characteristics and nature of the relationship and overcome the corresponding challenges of the caregiver system.[16] Understanding the nature of a process, such as relationship, helps the understanding the nature of the problem, and the relevant challenges. It can also contribute to the development and organization of that process and provide a specific functional framework. Therefore, by improving the quality of relationship between the care team and the patient, the potential goals of care provider systems are realized to optimize performance.[17] The nature of the care team relationship with patients according to the care approach is different. A few dispersed studies have referred to those features such as empathy, active listening, creating a safe atmosphere for talking about death, and explaining the goals of care.[181920] However, in studies on the palliative care approach, these features have not been specifically identified for cancer patients, and the association and its features have been limited to the patient and a specific group of care team, such as doctors. On the other hand, any care approach, such as palliative care, also relies on the field of care, such as the existing culture of that field.[212223] In different fields, various concepts with a range of characteristics can be part of the nature of a care approach. Given the fact that the nature of relationship in palliative care in Iran has not been investigated, this research focuses on the nature of relationship in the palliative care approach for cancer patients in Iran.

METHODS

RESULTS

Data analysis led to 157 primary codes, 68 original codes, and 10 subcategories and 3 categories: “being alongside the patient, establishing and maintaining cordiality relationship, mutual understanding with the patient,” and finally “emotional bonding” that is main them.

DISCUSSION

The purpose of this study was to explain the nature of the relationship in providing palliative care to cancer patients. In this study, the care team creates an emotional bond with the patient in order to establish a proper relationship while giving palliative care to cancer patients. An emotional bond means the emotional connection between two individuals (care team and patient) with a set of emotions and perceptions between the two sides of communication. This is a supportive connection that allows cancer patients to have a calm and high-quality life. In the present study, the establishment of emotional bond was characterized by being alongside the patient, cordiality relationship and a common mutual with the patient.

Being alongside the patient means being present beside patients and understanding their circumstances. This concept is one of the basic concepts in nursing theories, especially humanistic theories[27] and is an integral part of care. However, given the particular and difficult conditions of cancer patients, this concept is more serious in providing palliative care to them, which is approved by the experiences of the participants in the study. In providing palliative care, the presence of members of the professional care team (e.g., the physician and nurse), family members, and close friends was one of the main components of emotional bond with the patients. In line with the present study, various studies have underlined the effectiveness of the presence of the care team. This effect has manifested in various aspects such as the presence of a care team alongside cancer patients as a nursing art and a response to the communication needs of patients,[28] presence as an important spiritual care for patients,[29] reliable presence as a key strategy in providing prompt and accessible hospice care,[30] and presence as facilitator in building a reliable communication.[31] In addition to the fact that the presence of the family with the patient was a strong source of support in the present study, the nurses also tried to use the presence of close relatives and friends of the patient as a source of emotional support. This usually happens when the patient faces a critical physical and mental problem. In line with the current study, Rutkowski et al.[32] pointed out that patients received emotional and instrumental support from their families and close friends in the palliative care program, which provided emotional support through the strategy of presence and instrumental support through the use of transportation strategy while moving the patient in care centers. It can be concluded that this kind of support indicates the effective presence of the family and close relatives of patients along with him/her. The important aspect of being alongside the patient is that the presence of family and close friends completes the professional care team. On the other hand, the presence of family and friends on its own does not support the patient emotionally, and there is a need for the presence of a professional team. Although palliative care is not available 24 h at home in Iran, the palliative care team is available for patients even outside office hours for the patient. The care team can support them emotionally. This can establish an intimate relationship between the care team and the patient.

In the present study, achieving a mutual understanding with the patient was one of the characteristics of emotional bonding. A mutual understanding happens when a therapeutic team is emotionally within the range of the patient's emotions. In the relationship between the care team and the patient, a mutual understanding on behalf of the palliative care provider towards the cancer patient is the most important path to the formation of mutual understanding. According to a study by Michael et al.,[33] patients and families ask the care provider to consider their preferences, requests, and values during care, which is directly related to the mutual understanding of the patient. The findings of the present study suggest that mutual understanding is a result of accepting the patient's condition, emotional response through more attention to the patient and sympathy without pity. In the present study, to achieve a mutual understanding, the patient is accepted by the care team given his/her whole condition, while at the same time, a realistic image is provided for him/her. This finding shows the attempt to balance the emotions in a specific situation, which Shimoinaba et al.[34] have proposed, as well as the level of emotions associated with the concept of human-to-human communication. Nevertheless, the psychological state of the patients and supporting them was emphasized in this study. Providing the patient with a realistic picture does not mean the sudden disclosure of bad news, yet it means that the patient is not given a false hope and gradually accepts his condition. This is discussed in the findings of various studies, and it relies on a number of factors including the culture, rules, and personal characteristics.[35363738] Accepting the patient's conditions and understanding these conditions places the caregiver in a mutual emotional path, which creates sympathy with the patient. This sympathy does not simply end with an emotional response by the caregivers to put themselves in position of the patient, and it is often followed by a reaction or response. The findings of other studies referred to this strategy as one of the basic goals of palliative care.[3940] In the present study, the performance that followed the emotional response to the bond between the patient and the caregiver was an important factor. It manifested as the “sympathy for the patient.” This emotional response is also related to the concept of being alongside the patient and the friendly relationship. The emotional response is a positive and supportive strategy for a cancer patient, which could be influenced by various factors such as the attitude of care team and community culture. In the context of Iranian palliative care, this emotional performance ultimately leads to intimacy and an emotional bond. This practice is described differently in various studies, for example, attention even to small details of patients[41] and performance with affection toward patients.[4243] In the present study, some participants had already encountered the patient's experiences, which made them feel sympathy for the patient. Sympathy is a result of human nature characteristics, social communication in society and the attitude of people toward a phenomenon such as cancer, but the important thing is not to transfer the sense of sympathy to the patient so that the patient does not feel pitied. The study by Sinclair et al.[40] has shown the notion of sympathy as an unpleasant feeling for patients. In fact, the patient's perception of the sympathy shown by care team determines whether it is suitable or not for palliative care. In this study, the care team paid considerable attention to this issue that is considered by the care team in the present study. To achieve a mutual understanding with the patient, in addition to considering the psychological state of the patient, the care team also attempts to manage their own spirits so that they do not suffer in the long term. Recent studies have shown that long-term work with patients who are in a life-threatening condition can cause psychosocial distress in care providers, and ultimately affect the process of effective care.[44454647] In fact, long work that has been known as the reason for various stresses shows a frequent and long-term relationship between the care team and patients with life-threatening illnesses. In the present study, the caregivers tried to prevent stress and psychological damage by managing their mind; however, it should be noted that a long-term emotional bond may break the emotional and psychological boundaries between the patient and caregivers, and consequently cause mental health damage to the care team. To address this issue, appropriate communication strategies should be used, and the care team needs to receive necessary training in this regard. Orellana-Rios et al.,[48] in their study, have shown that proper sympathy and free minds are the most important strategy to stay away from these stresses. However, Sinclair et al.[49] pointed out that working with patients who experience life-threatening conditions makes caregivers better understand the meaning of life, live at the moment, and grow spirituality. This does not contradict with the prevention of mental health and self-protection.

In the present study, entering the emotional sphere of a patient in order to start a relationship has been reported. However, this needs to be approved by the patient. In other words, it is necessary to win the patient's trust so that the caregivers experiences the patient's emotional experience. In similar studies,[5051] winning patients' trust is one of the main factors in creating a deep emotional bond between oncologists and cancer patients. Tanco et al.[52] showed that the continuity of trust and staying in the emotional sphere relies on factors such as age, level of depression, and level of patient's hope. Entering into the emotional sphere of the patient in the present study was related to factors such as sex, age, language and geographical culture, and the participants pointed to these factors in forming the emotional relationship. However, the care team formed a regular supportive and cordiality relationship in providing palliative relief to cancer patients to stay in the emotional sphere of the patient. This suggests that if the care team does not create a regular cordiality and supportive relationship with the patient, it will be a critical factor that drives the care team out of the patient emotional sphere. Seccareccia et al.[20] refer to creating friendly communication as a close relationship with patients and their family. Such a relationship gives patients a sense of belonging and makes them feel that they are receiving real care. In the present study, the care team members used intimate terms such as “mom” or “dad” while speaking to the patients. In the same vein, Seccareccia et al.[20] believe that using the name of the patient and his/her family members is one of the most important elements of establishing a friendly relationship, which has satisfied the patients with the quality of care. The use of words such as mother, father and the name of the patient can vary in different cultures and care settings. The use of such words facilitates the cordiality relationship in Iranian society. Furthermore, in a study by Palumbo et al.,[53] establishing a friendly and cordiality relationship created a supportive and relaxing atmosphere for the patient. In the present study, cordiality relationship has a supporting aspect and is aimed at protecting the mental health of the patient. In addition, the care team in this study has tried to keep this connection uninterrupted and lasting. This regular and uninterrupted relationship was in line with the patient's support, which can reflect the need of cancer patients in various physical, mental, and psychological problems. To overcome their physical problems, the patients tried to maintain a lasting relationship with the care team while on the other hand, the care team did not end its relationship with the patients in order to support them psychologically. Similarly, Sekse et al.[31] emphasized that spending more time with patients and having regular relationship with them prepares both nurses and patients to create a special bond. However, this particular bond must have features that are characterized in the present study through the establishment of an emotional bond. Cordiality relationship was the most important feature of the emotional bond in the palliative care system in Iran. That is because the issue of friendship and intimacy relies on the personal characteristics of the people and the culture of the health-care system. This issue has been emphasized in palliative care in this study. In fact, it can be seen that in Iranian context, the creation of cordiality is cornerstone of the relationship between the patient and the care team. This relationship is extended into the emotional sphere, and it has become more widely considered in cancer patients due to the severity of their condition. Furthermore, in order to achieve intimacy, time is one of the most important factors. Cancer patients are exposed to the disease for a long time and thus, they are engaged with the care team for the same amount of time, which a reason for the formation of the relationship between patients and care teams.

CONCLUSION

The experience of participants in this study suggests that being alongside the patient, achieving a mutual understanding with the patient and creating a cordiality connection forms the nature of relationship in the provision of palliative care. The care team members try to form a relationship in which the patients are emotionally supported, while at the same time, they avoid any psychological damage. In other words, good and effective relationship based on emotional bonding is the basis for supporting cancer patients while providing palliative care and improving quality of care.

The findings of the present study can be used in future research and implementation programs in health systems, especially in countries that are at the early stages of palliative care organization. First, despite the formation of a proper relationship between the caregiver and the patient, in order to optimize this relationship, training programs can be effective for care teams as well as the family; these educational programs can be in line with the concepts of the present study: being alongside the patient, mutual understanding and friendly relationship. Second, creating a proper structure for providing palliative care in a variety of environments, especially hospitals and homes, plays a huge role in the formation of an effective relationship with the patient and development of this relationship. Furthermore, due to different structures in different areas, the nature of the relationship between the care team and the patient can vary. Consequently, different studies should be carried out to discover the characteristics and strategies related to the nature of the relationship.

However, concepts obtained in this study can be applied in almost similar areas. However, the limitations of the present study include a small number of palliative care centers in Iran. The mentioned centers also had limitations in the provision of care services such as workforce, which undoubtedly could have an impact on the delivery of care services.