Journal of Nursing and Socioenvironmental Health
2014, 1(1):87-93 - http://www.jonse.com.br
Received: 20 June, 2014 - Accepted: 5 July, 2014
DOI: 10.15696/2358-9884/jonse.v1n1p87-93
Spirituality and interdisciplinary team in the end-of-life process:
integrative literature review
Spirituality and interdisciplinary team in the process
Isabel Cristina de Oliveira Arrieira1*, Maira Buss Thofehrn2, Dionatan Almeida3,
Daniela Habekost4, Camila Rose Guadalupe Barcelos Schwonke5
ABSTRACT
Objectives: To know the relationship between spirituality and interdisciplinary work during the end-of-life process and highlight and discuss the contributions
of the spirituality in multidisciplinary teamwork in the care of users who are experiencing the end-of-life process. Method: This is an integrative review.
The bibliographic survey was performed in databases of the Latin American Journal of Health Sciences, Scientific Electronic Library Online and International
Literature in Health Sciences. The descriptors “multidisciplinary team”, “spirituality” and “end-of-life” were used. The criteria for sample selection were:
papers published in national and international journals from the year 2008, written in Portuguese, English or Spanish. Results: Fifteen papers were selected
for the sample, twelve in Portuguese and three in English. After analyzing the data, two discussion categories emerged, namely: “Spirituality under the
perspective of professionals working in palliative care” and “Spirituality as a challenge for the interdisciplinary team”. Conclusion: In light of the presented
studies, one should understand that the spirituality is an indispensable tool for comforting patients experiencing the end-of-life process and their families;
however, there is a gap when spirituality and multidisciplinary team in the end-of-life process are related.
Descriptors: Multidisciplinary Team; Spirituality; End-of-Life
Espiritualidade e equipe interdisciplinar no processo de terminalidade: revisão integrativa da literatura
Espiritualidade e equipe interdisciplinar no processo
RESUMO
Objetivos: Conhecer a relação entre espiritualidade e o trabalho interdisciplinar durante o processo de terminalidade e evidenciar e discutir as contribuições da
espiritualidade no trabalho em equipe multidisciplinar no cuidado de usuários em processo de terminalidade. Método: Trata-se de uma revisão integrativa. O
levantamento bibliográfico nos bancos de dados da Revista Latino-Americana de Ciências da Saúde, Scientific Eletronic Library Online, Literatura Internacional
em Ciências da Saúde. Utilizou-se os descritores “equipe multiprofissional”, “espiritualidade” e “terminalidade”. Os critérios utilizados para a seleção da
amostra foram: artigos publicados em periódicos nacionais e internacionais a partir do ano de 2008, escritos em português, inglês ou espanhol. Resultados:
Foram selecionados quinze artigos para a amostra, sendo doze em português e três em inglês. Após análise dos dados surgiram duas categorias de discussão
sendo estas: a espiritualidade na perspectiva dos profissionais que atuam no cuidado paliativo e a espiritualidade como desafio para a equipe interdisciplinar.
Conclusão: Diante dos estudos apresentados, entende-se que a espiritualidade é uma ferramenta indispensável para o conforto do paciente terminal e de sua
família, no entanto, observa-se uma lacuna quando relaciona-se espiritualidade e equipe multiprofissional na terminalidade da vida.
Descritores: Equipe Multiprofissional; Espiritualidade; Terminalidade
Espiritualidad y equipo interdisciplinario en el proceso terminal: revisión integradora de la literatura
Terminalidad, espiritualidad y equipo interdisciplinario
RESUMEN
Objetivos: Conocer la relación entre la espiritualidad y el trabajo interdisciplinario en el proceso de enfermedad terminal y evidenciar y argumentar el papel de
la espiritualidad en el trabajo en equipo multidisciplinario en la atención de los usuarios en proceso terminal. Método: Se trata de una revisión integradora.
Las bases de datos bibliográficas en la Revista Latinoamericana de Ciencias de la Salud, Scientific Electronic Library Online, Literatura Internacional en Ciencias
de la Salud. Se utilizó los descriptores “equipo multidisciplinario”, “espiritualidad” y “enfermedad terminal”. Los criterios para la selección de la muestra fueron:
artículos publicados en revistas nacionales e internacionales a partir de 2008, escritos en portugués, Inglés o Español. Resultados: Quince artículos fueron
seleccionados para la muestra, doce en portugués y tres en Inglés. Después de analizar los datos Surgieron dos categorías y estas discusiones: Espiritualidad
desde la perspectiva de los profesionales que trabajan en cuidados paliativos y la espiritualidad como un desafío para el equipo interdisciplinario. Conclusión:
Teniendo en cuenta los estudios presentados, se entiende que la espiritualidad es una herramienta indispensable para comodidad del paciente moribundo y su
familia, sin embargo, existe una brecha cuando se relaciona con la espiritualidad y el equipo multidisciplinario en la vida terminal.
Descriptores: Equipo Multidisciplinario; Espiritualidad; Terminalidad
Doutoranda. Enfermeira do Programa de Internação Domiciliar Interdisciplinar PIDI-HE-UFPel. Email: [email protected]
Doutora. Docente da Faculdade de Enfermagem UFPel. Email: [email protected]
3
Enfermeiro do Hospital Escola da UFPel. Email: [email protected]
4
Mestre. Enfermeira do Programa de Internação Domiciliar Interdisciplinar PIDI-HE-UFPel. Email: [email protected]
5
Doutora. Enfermeira Coordenadora de Ensino Pesquisa e Extensão do Hospital Escola da UFPel. Email: [email protected]
* Autor correspondente: Endereço: Marechal Deodoro 1081/303 Centro Pelotas. Fone: (53)81351920
1
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Spirituality and interdisciplinary team in the end-of-life process: integrative literature review
Introduction
In Brazil, the heath care model diffused in training
courses of the health area is still very much focused
on prevention, promotion, diagnosis, treatment and
healing of diseases, thereby providing less space for the
emotional, cultural and spiritual aspects demanded
by the users and their family members. These agents
are important for the welfare of all individuals, taking
into account that the human being is comprised of
four quadrants, which are: physical, emotional, social
and spiritual (1,2).
It is worth emphasizing that this model is ineffective
against a situation that becomes increasingly common
in the everyday life of health professionals, which
means the impossibility of healing a user after a
suitable treatment.
When it comes to palliative care, one should
realize that there is a need for a work that involves
a multidisciplinary team that has interdisciplinary
action, prepared to provide a comprehensive care by
adding the spiritual care to the biological, emotional
and social care, thereby increasing the quality of life
and soothing the pain and suffering (3).
Furthermore, palliative care is the set of active
and comprehensive actions provided to users with
progressive and irreversible diseases and their
families. In this context, the multidisciplinary team
plays the role of providing physical, psychological,
social and spiritual comfort to the patient’s family
and, especially, to the patient itself, thereby supplying
its needs until the end of its life (4).
The professionals who working with patients in the
end-of-life stage need to acquire technical knowledge,
interpersonal and emotional skills, in order to identify
symptoms of pain and suffering. No expertise in the
health area can provide effective care in isolation, since
the process of dying is complex and requires a wide view
of multiple aspects of the individual and of its family (5).
Therefore, it becomes necessary that the professional
keeps in mind that the user in the end-of-life stage
detaches itself in a progressive way from material
goods, its projects and its own image by synthesizing
a new dimension of its existence and searching for
the true meaning of life and answers that go beyond
the physical status of the human being, which might
soothe the chaos generated by the disease and provide
an inner reorganization, besides the opportunity to
rethink concepts and priorities of life (6).
88
Commonly, the health team witnesses the failure
in the applied therapy and feels powerless, precisely
because of the focus of care is geared to heal patients,
even if the ideal of palliative care is organized in a
systematic way, by giving absolute support, including
to users’ families. It is of utmost importance that
all health professionals who work with users in the
end-of-life stage know how to concisely identify
and intervene in the spiritual needs, by providing a
humanized care, which prioritizes human dignity and
eases up the process of dying (2).
These considerations justify our interest in
developing an integrative review on the Spirituality
and the Interdisciplinary Team in the End-of-life
Process across the world literature, with the aim at
offering the interpretation and the possible formation
of new concepts of work developed in this field and
making an association between the everyday life
and the lived experiences and ideas that ease up the
professional practice and enhance the care provided
to all individuals involved in the process of dying of
the user.
Accordingly, we stipulate as guiding question
of this research: What is the relationship between
spirituality and interdisciplinary teamwork during
the end-of-life process?
In order to answer this question, we have the
overall objective:
- To know the relationship between spirituality
and interdisciplinary teamwork during the end-of-life
process.
Specific objective:
- To highlight and discuss the role of the
spirituality in multidisciplinary teamwork in the care
of users in the end-of-life process.
Method
In order to achieve the overall objective, we opted
for the integrative review method, since this method
allows us to summarize the already completed
researches and obtain inferences from a matter of
interest. When successfully done, an integrative
review requires the same standards of austerity, clarity
and replication used in primary studies.
Although the methods for conducting integrative
reviews are varied, there are standards to be followed.
In the making of this study, the methodology
proposed by Cooper (1982)7 was used, which defines
J. Nurs. Socioe. Health, 2014, 1(1):87-93
Arrieira ICO, Thofehrn MB, Almeida D, Habekost D, Schwonke CRGB
integrative review in five steps by establishing the
criteria of austerity for each one and the aspects that
compromise their validity: 1ª) Formulation of the
problem: it involves the definition of operational
and conceptual variables that will guide the search
for studies; 2ª) Data collection: it involves choosing
elements that will be the reference for the survey; 3ª)
Data assessment: is the process of critical analysis
performed on the collected data; 4ª) Data analysis
and interpretation: the separate data are synthesized
into a unified statement on the research problem;
5ª) Presentation of results: dissemination, through
research report or publication.
The bibliographic survey was conducted on the
internet, in the databases LILACS (Latin American
and Caribbean Health Sciences Literature), SciELO
(Scientific Electronic Library Online), and MEDLINE
(Medical Literature Analysis and Retrieval System
Online - International Literature on Health Sciences).
In order to conduct the survey of publications,
we made use of the descriptors “Multidisciplinary
team”, “Spirituality” and “End-of-life process”, and
they were extracted from the MeSH (Medical Subject
Headings), through the use of the option “AND” for
research purposes. The grouping was performed in
the following sequence: Multidisciplinary team AND
Spirituality; End-of-life process and Spirituality;
Multidisciplinary team AND End-of-life process
and Multidisciplinary team AND End-of-life process
AND Spirituality.
The criteria used for sample selection were: papers
published in national and international journals,
included in all areas of interest; journals indexed in
the databases LILACS, MEDLINE and SciELO; papers
published from the year 2008, written in Portuguese,
English or Spanish.
As for the exclusion criteria, they were: informal case
reports, books chapters, non- scientific texts, scientific
papers without availability of access to the text in its
full version, scientific papers without presentation
of abstract and those which do not respond to the
study objectives. It is worth remembering that papers
repeated after the cross-check of descriptors were
counted only once.
After the availability of the search results from
the chosen criteria for inclusion and exclusion, we
performed a thorough reading of scientific papers,
with sights to seek the best adequacy in relation
to the research question of this study. The sample
obtained, according to the cross-check of descriptors,
is presented in Table 1.
In the databases MEDLINE, LILACS and SciELO,
the descriptors “Multidisciplinary team”, “Spirituality”
and “End-of-life Process” were typed on search boxes
of the system and linked by the connector “AND”, in
order to obtain the result of cross-checks, thereby
displaying papers in English, Spanish and Portuguese.
When performing the cross-check of the three
descriptors indexed by the connector “AND”, no
scientific paper published in the above mentioned
scientific databases was obtained.
The cross-check of the other descriptors in the
databases LILACS and MEDLINE resulted in a total
of 100 papers, all of which were obtained by the
VHL (Virtual Health Library), with 14 from the first
database and 86 from the second database displayed
above. Of these 86 scientific papers from MEDLINE,
58 were immediately excluded from the sample
because they were published before the year 2008.
Of the remaining 28 papers, 12 were excluded due to
not having full text online or abstract available; one
was in a foreign language that is not compatible with
the inclusion criteria and 12 did not respond to the
guiding question of research, leaving only four papers
for the sample.
Of the 14 papers from the database LILACS, two
had no available text, five were prior to 2008 and six
did not respond to the objectives and the guiding
question. Therefore, only one paper obtained by the
cross-checks of descriptors in this database was used
in the sample, since the others was not satisfactorily
adequate to meet the proposed study.
Table 1 - Cross-check of descriptors
Cross-checks
“Multidisciplinary team” AND “Spirituality”
“End-of-life process” AND “Spirituality”
“Multidisciplinary team” AND “End-of-life process”
“Multidisciplinary team” AND “End-of-life” AND “Spirituality”
Total
J. Nurs. Socioe. Health, 2014, 1(1):87-93
MEDLINE LILACS SciELO Sample
1
2
51
4
86
5
31
6
0
7
36
5
0
0
0
0
87
14
118
15
89
Spirituality and interdisciplinary team in the end-of-life process: integrative literature review
In order to find the papers of the database SciELO,
due to the reduced number of papers found in the VHL,
it was also necessary to seek and cross the descriptors
on the website itself (SciELO Brazil), which was made
in the same way of the other cross-checks. 118 papers
were obtained, of which, upon careful reading and
application of inclusion and exclusion criteria, 10
were selected and included in the sample.
Thus, of the total number of scientific papers found,
15 were selected for the sample, with 12 in Portuguese
and three in English.
After screening and choice of the selected papers
and critical reading, through the inclusion and
exclusion criteria and aiming at keeping up the
warranty and reliability of research, the studies were
tabulated in accordance with the following categories:
title, author (s), database and year of publication.
The selected papers were assessed by the authors
in relation to the quality of their information, and,
finally, included for assessment and discussion.
Results
From the search strategies of studies, 15 scientific
papers were selected for subsequent analysis and
discussion and five for complementary reading, as
described in Table 2.
Discussion
With basis on the presentation of the papers
selected for the composition of this study, we indicate
relevant aspects on the spirituality in the end-of-life
stage, the relationship between the health team and
the sick person and the concerns for the needs that
should be met during the process of dying. These
aspects will be presented below in two categories.
Spirituality under the perspective of professionals
working in palliative care
Palliative care has the essential objective of
controlling pain, relieving symptoms and reducing
suffering, not only physical, since the strength of
the human being is an inseparable unit that also
encompasses the spiritual dimension, thereby easing
up the welfare of the patient and of its family (8,9,10).
It is impossible not to relate the end-of-life
process with a team of health professionals with
different areas of knowledge and operation. Palliative
90
care depend on a multidisciplinary approach, in
which each caregiver, within its area, will provide
a comprehensive, harmonious and quality care by
turning its gaze to the physical, psychological and
spiritual spheres (11). A single professional, no matter
how dedicated it might be, cannot deal with all
dimensions of human care (12).
Nonetheless, one should observe that the academic
teaching about palliative care is still precarious, which
hinders the provision of an adequate care on the part
of the health professional for this type of patient (2,13).
The training is based on scientific knowledge, which
is a cultural heritage passed on to the undergraduate
student. That way, it finishes the course without being
prepared to work in conditions in which the healing
is no longer possible. Accordingly, the spirituality has
not also a focus on undergraduate courses, which
turns the detection and the approach of the health
team in palliative care into challenges (11,14).
For patients experiencing the end-of-life
stage, the health team means the pathway to
comprehension, knowledge of oneself and rescue
of ethical and human values (15,9)​​. That is why it is
important that professionals work in a uniform way
by contemplating the needs of sick people under
different perspectives, establishing, along with other
team members, common goals and preserving the
dignity during the process of dying (16).
The harmony and the connection among members
of the multidisciplinary team are essential elements
for the successful implementation of quality palliative
care. Professionals need to work together by analyzing
each case in a single way and elaborating new manners
for holding care shares. In addition, it is essential that
the professional itself recognizes its spiritual limits and
use them in practice, thereby smoothening upcoming
situations related to the life or the death itself (12,14). It is
clear that the spiritual issue plays an important role for
the patient in the end-of-life process (17). Spirituality
is an expansion of the meaning of life, strengthening
and maturation of ideas and projects, comprehension
of the existence itself for the patient experiencing the
end-of-life stage (18).
Spirituality as a challenge for the interdisciplinary
team
One should observe that the spirituality has not
the deserved and necessary focus in the current
scientific literature. The exploitation of this issue by
J. Nurs. Socioe. Health, 2014, 1(1):87-93
Arrieira ICO, Thofehrn MB, Almeida D, Habekost D, Schwonke CRGB
Table 2 - Scientific papers included in this study
Title
A formação na graduação dos pro ssionais de saúde e a
educação para o cuidado de pacientes fora d e recursos
terapêuticos de cura
A espiritualidade no aproximar da morte...
Desa os do enfermeiro diante da dor e do sofrimento da
família de pacientes fora de possibilidades terapêuticas
Religião e espiritualidade: um olhar de pro ssionais de
saúde
Análise da natureza da dor espiritual apresentada por
pacientes terminais e o processo de sua re -signi cação
através da intervenção relaxamento, imagens m entais e
espiritualidade (RIME)
Autonomia em cuidados paliativos: conceitos e
percepções de uma equipe de saúde
Signi cados e práticas da espiritualidade no contexto dos
cuidados paliativos em pacientes oncológicos adultos
Práticas de cuidado na perspectiva interdisciplinar: Um
caminho promissor
Ditos, não ditos e entreditos : A comunicação em cuidados
paliativos
Concepções sobre cuidados paliativos: revisão
bibliográ ca
J. Nurs. Socioe. Health, 2014, 1(1):87-93
Bifulco
Iochida
SciELO Brasil
2009
MEDLINE
2009
SciELO España
2011
SciELO Brasil
2013
SciELO Brasil
2010
SciELO Brasil
2008
SciELO Brasil
2010
MEDLINE
2011
MEDLINE
2012
LILACS
2011
SciELO Brasil
2009
SciELO Brasil
2010
SciELO Brasil
2008
SciELO Brasil
2008
MEDLINE
2012
Oliveira
Silva
Bergman
Fink
Kwan
Litwin
Cobb
Dowrick
Lloyd-Williams
What Can We Learn About the Spiritual Needs of
Palliative Care Patients From the Research Literature?
researchers is an important tool for discussion of new
ideologies in the practical applicability of palliative
care. In addition, the act of deepening the knowledge
of spirituality in the end-of-life process can foster
a common understanding, which provides a more
complete view of how the spiritual needs of dying
patients can be understood and worked. The current
Year
Elias
Giglio
Pimenta
Spirituality and end-of-life care in disadvantaged men
dying of prostate cancer
e role of chaplains within oncology interdisciplinary
of teams
Database
Savory
Marco
Gomes
Margarida
Fernandes
Komessu
Espíndula
Do Valle
Bello
End-of-life issues in the acute and critically ill patient
Cuidados paliativos: interfaces, conitos e necessidades
Author
Silva
Matos
Pires
Sousa
Carpigiani
Silva
Sudigursky
Floriani
Schramm
Sinclair
Chochinov
studies are much more focused on conceptual issues
than on the practices and evidence of the true role and
the application of the spirituality in these cases (19).
Even though we have knowledge of the importance
of spiritual issues involving the end-of-life process,
there are still great challenges to achieve the full
integration between interdisciplinary teams of
91
Spirituality and interdisciplinary team in the end-of-life process: integrative literature review
professionals and spiritual care, and it is usually left
in the second place within the health institutions (20).
One should also realize that this is a matter that is
not widely approached in a conjunctive form in the
literature. The knowledge of scientific studies that deal
with the spirituality and the multidisciplinary team in
the end-of-life process is restricted to works that deal
with the issues in a separate way, which produces a
worrying gap, when considering the dimension and
importance of palliative care for patients without the
therapeutic possibility of healing.
Conclusions
The search for scientific evidence in studies that
deal with the spirituality and the multidisciplinary
team in the end-of-life process has resulted in 14
papers with year of publication between 2008 and
2013, originals and reliable in relation to the criteria
for inclusion and exclusion applied, assessed and
interpreted in a critical and concise way.
In light of the presented studies, one should
understand that the spirituality is an indispensable tool
for comforting patients experiencing the end-of-life
process and their families by fostering self-awareness,
expanding ideas, organizing feelings, easing up the
comprehension of the disease, and it is impossible to
practice the huge dimension of palliative care without
making efforts towards achieving the spiritual issue.
There is no palliative care without a multidisciplinary
team. A single professional has no conditions to
provide an adequate care to a patient who is in the endof-life stage, since the needs of this patient exceed the
biological pain and take social, cultural and spiritual
proportions, and they can only be met with the support
and dedication of the entire team.
Nonetheless, one should observe a gap when
spirituality and multidisciplinary team in the endof-life process are related. The studies deal with the
issues in an individual way, and the correlation is rare,
especially between team and spirituality. Possibly, this
occurs because of the difficulty of health professionals
to recognize the spiritual needs of patients and of
their families, which is result of the precariousness of
undergraduate courses that do not prepare students
to deal with situations in which the healing is not
possible.
It would be very helpful to develop deepened
scientific studies correlating the matters discussed
92
in this integrative review in a concise way. It is
worth highlighting that the palliative care is an
increasingly common reality in the everyday life of
health professionals and that the patient in the endof-life stage needs special care actions that exceed the
limitations of science.
Conflicts of Interest
“The authors declared that there is no conflict of
interest of any nature”.
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