Communication in death imminence: perceptions and strategy adopted for humanizing care in nursing La comunicación en la inminencia de la muerte: percepciones y estrategias adoptadas para humanizar el cuidado en enfermería

Objective: To investigate the perception of nurses in relation to concepts of communication to the terminal patient and the strategies adopted by them to communicate with the patient in the terminally ill. Methods: Qualitative research, conducted with seven nurses in the intensive care unit of a public health hospital in the city of João Pessoa, Paraíba. The data were collected in recorded interviews, from December 2011 to January 2012, and subjected to content analysis technique. Results: The identified categories were: Perception of nurses about communication with the terminal patient and strategies adopted by nurses for a good communication with the terminal patient. Such categories indicated that the professionals start to value the communication in clinical practice, using it as a strategy to assist the care to the terminally ill patient. Conclusion: this study is expected to subsidize new investigations, because they are still incipient to the research that addresses the communication on patient terminal care.


INTRODUCTION
In the field of health, the scientific and technological advances are contributing to a significant increase in life expectancy, since they raise innovations in the conduct of medical treatment.Soon, these advances provide, often to patients, especially those who are experiencing the completion of life, an extension of the natural process of death and dying, which can intensify their suffering and agony.
Therefore, this extension implies the need for a differentiated care, lined on valorization of quality of life and bio-psychosocial and spiritual welfare of the patient, in order to direct health care and, in particular of nursing, through a holistic and integral vision, revealing itself, so a "humanized care".
It is worth emphasizing that humanized care assumes technical training of the health professional when performing their roles, as well as ability to perceive and understand the patient in his existential experience, paying attention to his intrinsic needs and favoring a positive confrontation of the lived moment, in addition to preserve his autonomy, i.e. the right to decide what he desires to themselves, for his health and body, for being this right one of the first things reduced or lost when he gets sick 1 .
In this sense, communication is the fundamental basis whereby interpersonal relations are established, and it can be performed in a verbal and/or non-verbal way.Verbal communication is characterized by exteriorization of social being and the non-verbal is characterized by psychological being, and its main function is the demonstration of feelings 2 .
A The communication is considered as a process of interaction, in which messages, ideas, feelings and emotions are shared, which can influence the behavior of people who react from their beliefs, values, history life and culture 3 .
The verbal language is conceptualized as the use of writing or speech as communication.The non-verbal communication exercises fascination about humanity since its origin, since it involves all manifestations of behavior not expressed by words, gestures, facial expressions, body orientations, postures, relationship of distance between the individuals, and also organization of objects in space.This can be observed in the painting, literature, sculpture, and other forms of human expression, being present in our daily lives, but often we are not aware of their occurrence, even the way it happens 3 .
Communication, whether verbal or non-verbal, is constituted as an instrument for promoting of a humanized care.Therefore, it collaborates to promote emotional care, considered an ability to understand the imperceptible that requires high level of sensitivity in relation to the verbal and non-verbal manifestations of the client that might indicate to health professionals, especially nurses, their individual needs 3 .
It should be noted that communication, in the context of health care, is not a mere "optional", an "extra", but a vital component, inherent and necessary, the reason why in the educational curriculum of health professionals increasingly includes the deepening of communication related issues.This one does not involve only the care of professionals and patients, but also the relationship between professionals, patients and their families, among other areas, with the scope to promote humanized care 4 .
It is worth noting that this humanized and integral careful is only possible when the nurse makes use of sensitivity, using for this purpose, strategies as contact through the touch, look, hear and speak, attributes that are part of the communication in the care of human beings from birth until his death.
In nursing, to human and individualized care to the terminal patient, it must be use more than scientific knowledge; it is necessary to establish a relationship, in which the nurse is always willing to listen to the patient and to inform him about his treatment and general state of health.It should be noted that this professional, for being more time in contact with the patient, knows more about their answers, exercising a key role in integral care to the individual and his family.
In this sense, it is observed that the communication (verbal and non-verbal) related to the humanized care enables the nurse to detect signs and symptoms and to intervene early in the palliative approach, enabling the prevention of diseases, promote pain relief and other stress symptoms, preserving the life and realizing the death as a natural process, without, however, anticipating the death, either extend the terminal stage, but integrating in their care psychosocial and spiritual aspects 5 .
However, it is necessary to highlight the inability of nursing professionals to address the communication with the patient without therapeutic possibilities.Thus, among the aspects that require greater demand of knowledge in the care of that patient, some nurses point out the communication as a nerve point 4-6 .
Thus, it is noted the importance of communication in the humanized care process, under which the work is performed in health, considering human relationships, either with patients, with the team or with the family.
In this context, it is essential that nursing professionals use the communication to provide an effective and integral assistance, since it constitutes an appropriate and necessary instrument for the care, characterized by attention, zeal, commitment, occupation, concern, responsibility and affective involvement with each other, which is the main focus of nursing, grifted with feelings and based on practical, theoretical and scientific knowledge.
Given the above, this study aimed to investigate the perception of nurses in relation to concepts of communication to the dying patient and the strategies adopted by them to communicate with the patient in the terminally ill.

METHODOLOGY
It is a field study with a qualitative approach.The scenario of research was the intensive care unit (ICU) of a hospital located in the city of João Pessoa-PB.This cited institution is considered a reference in the State of Paraíba, for the attendance of individuals carrying infect-contagious diseases.

Communication in death imminence
Brito FM, Costa ICP, Costa SFG, Andrade CG, Santos KFO, Francisco DP The study population was composed of 96 nurses.For the sample selection the following criteria were adopted: that nurses were in professional activity at the time of data collection; and they had at least one year of professional experience in that location.The sample was composed of seven assistance nurses who work in the unit selected for the study.
This study was conducted in accordance with the principles of Resolution 196/96, of the National Health Council 7 .The research project has been approved by the Research Ethics Committee of the Medical Sciences Faculty of Paraíba, under the Protocol 58/11.
Data were collected from December 2011 to January 2012, through a form containing questions related to the objectives of the study, using the structured interview technique with recording system.The interviews were transcribed in full, respecting the colloquialism of speech.To maintain the anonymity of the participants, the testimonials were referenced by means of the letter "N" (for nurses), followed by numbers, from 1 to 7.
The empirical material from the interviews was coded and approached qualitatively, through the technique of content analysis 8 .

RESULTS AND DISCUSSION
Seven relief nurses participated in this study, aged between 29 and 51 years old, five females and two males.As regards to the professional qualification, five nurses were experts and possessed of one to eight years of professional experience.
Data were grouped into two categories: Perception of nurses about communication with the terminal patient and strategies adopted by nurses for good communication with the terminal patient.

Category I -Perception of nurses about communication with the terminal patient
In the field of health, more precisely in the area of nursing, the communication is a common thread to promote humanized care, happening by a dynamic process, which can be expressed by its dimensions, verbal and/or non-verbal, involving perception, understanding and transmission of messages.In this context, the first factor pointed out by nursing professionals, as important to put into practice the theory of humanization is communication, and when perceived and carried out properly, it will be possible to provide an integral and humanized assistance to the patient 9 .
With regard to the terminal patient, is of utmost importance that the nurse has knowledge and communication skills to decode their needs, which are sometimes difficult to understand, and thus provide the reduction of symptoms and the best possible quality of life.In this way, the nurse, when understands, knows and practices the communication (verbal and non-verbal) and may subsidize the patient in the confrontation of the completion process.
Verbal communication is characterized by the use of words expressed both through the written language as spoken, valid and clear, so that the other understands the transmitted message 10 .
In this line of thought, it is worth mentioning some testimonials of participants involved in the research, which refers to the perception of verbal communication in the care to patients in terminal stage, as evidence the following excerpts: It is of utmost importance, because all clients in terminal phase needs a verbal communication to remove all the anxieties and that agony, even fear of the own death (E2).
[...]Although they are already in terminal phase, sometimes some don't respond verbally.But, then we need to communicate, because the last sense that we lost is hearing.Even without being able to respond through gestures, they're listening, are feeling our presence (E3).

[...] So we look for various ways to talk with them, and show how far we think they can know what's really going on (E5).
Is to maintain a relationship with that person and know her needs, and also spend some teaching, any word that could help her at that moment (E7).
These reports reflect the valorization of verbal communication as a strategy of care adopted by the nurses who participated in the study, in order to assist the patient to express their needs.Through these testimonials it is noted that these professionals realize that verbal communication occurs through the use of strategies such as: thematic awakening about the religion/faith, in order to orient to the forgiveness of faults that may interfere with the inner peace and fear of death; help with support words; perform teachings, promoting the maintenance of communication despite the absence of dialogue.It should be noted that the use of these strategies can reveal the needs of terminal patients, and thus provide integral and humanized care.
It is appropriate to point out that the reports of the participants of the study are coherent with the research conducted with professionals who work in assisting critical patients, which emphasize the importance of verbal communication with emphasis on dialogue, in order to clarify questions and identify the needs, aiming at promoting a humanized assistance 11 .In this sense, the authors 3,6,12 reinforce that verbal communication is considered a tool of utmost relevance of caution on completion, since it can assist in reducing the psychological stress of the patient, as also enables to share their suffering.Thus, it is observed that the use of verbal communication reveals to be a therapeutic measure demonstrably active with terminal patients.To this end, it is imperative that the professional modify his view, moving from doing to listen, understand, comprehend, identify needs, for only then, plan the actions in a more humanized way.

Communication in death imminence
Brito FM, Costa ICP, Costa SFG, Andrade CG, Santos KFO, Francisco DP As regards the non-verbal communication, this occurs through interpersonal interaction without the use of words with meanings for the transmitter and the receiver.In it, are used facial expressions, gestures, arrangement of objects in an environment, body postures and their purpose is to complement the verbal, replace it, contradict it or show feelings 10 .
With this approach, only a participant in the study emphasized the importance of this dimension, since, in addition to complement the verbal communication, nonverbal communication also emerges on the most intimate feelings of patients, especially those who are experiencing the completion of life.

[...] So, with the unconscious, although you do not have a verbal response if you have a non-verbal response and pretty sensitive. For example, when you notice change of vital signs, sometimes, the pressure increases, increases the heart rate. For more sedated, he is, he achieve to "pucker" the forehead. So, you have an answer, you know? And many come to die after! Not exactly on the same day, but it seems that is a relief for them [...] (EI).
It is observed in this declaration that the participant in the research looked for the existence of non-verbal communication.Such testimony become visible, emphatically, discursive details which confirm the perception of non-verbal signals in patient care in terminal phase, as the physical signs presented by patients.It can be observed that, although they are sedated and deprived of verbal communication, patients make use of facial expressions to communicate in a non-verbally way.
Thus, it is crucial to the care of the patient without healing possibilities that the professional realize, understand and use appropriately the nonverbal communication.It makes possible the perception and understanding of feelings, doubts and anxieties of the patient, as well as the understanding and clarification of gestures, expressions, looks and symbolic language typical of who is dying 13 .Thus, it is evidenced that is essential the perception, understanding and valorization of the process of nonverbal communication, since it constitutes an instrument that makes possible the realization of a care based on humanization.
Given the above, it is observed that the verbal communication emerged as the most cited, and notes that the majority of nurses participants of this study did not emphisize the nonverbal communication as essential to promoting a humanized care to the terminal patient.

Category II -Strategies adopted by nurses for a good communication with the terminal patient
Feelings such as fear, anxiety and depression are expressed by individuals who are experiencing the completion of life and, somehow, could influence and intensify their suffering process.The paradigm of nursing assistance must be based on humanization of care and coupled to the process of interpersonal communication, where emerges as a care strategy in order to assist the patient in their confrontation, facilitating the interaction and passing attention, compassion and comfort.
It is worth pointing out that the verbal communication strategies can subsidize the humanized care.The promotion of empathy and environment interaction, repetition and certification that the communication was understood, the use of a tone of voice appropriate, honest and transparent are examples of such strategies 14 .
Based on this premise, it is indispensable that the nurse use verbal communication strategies to reduce such suffering and provide a better quality of life on this experience of difficult moments.Such considerations can be contemplated in the following declarations from survey professionals:

[...] We have to have security and you have to know to pass confidence, that security for them. [...] To accept
and have a dignified passage, have a quiet passage, he accepted that reality.Most of the time, although they are unconscious, as how they listen, they will have a decent terminal phase, without so much suffering, because, as they accept, they rest in peace (E3).I try to communicate through words.Even though they are with the eyes closed, unconscious.But, so, I arrive, I comment, I am always here in the ICU, I always try to say: Look guy, you are here in the ICU! Strive yourself!Be strong!You will get through this!So, I like to say.They sometimes are intubated, with sedation, but I usually say that.[

...] I always, always speak aloud (E5).
The speeches express the concern of professionals in established verbal communication as a strategy of care to their patients, to provide support, security and trust, transmit strength and hope, which is crucial in the context of the terminally ill.
There is also a focus on the part of respondents to use this communication mode, even with patients who are unconscious and sedated.
The presented ponderations are in harmony with the statement of a survey conducted with nurses operating in the area of Oncology, in which these reported several behaviors in the care of the patient without possibility of cure, as to transmit confidence, support, aim to make the best, devote himself to the end, establishing ties and interventions in a technical and human character, valuing human dignity 3 .

Communication in death imminence
Brito FM, Costa ICP, Costa SFG, Andrade CG, Santos KFO, Francisco DP The non-verbal communication also constitutes strategy in care to terminal patients.Non-verbal strategies in its study, as physical contact based on touch, facial expression, body attitude and physical appearance 14 .Such strategies have been elucidated by the participants of this study, as evidence the following reports: [...] So, the touch is very important in this moment.If you can hold his hand and try to talk to him, so everything is easier.In addition to talking, the touch is pretty strong!Maybe even better than talking [...] (E1).
I personally caught in their hands.[...] We can only by lip reading, expression of the look, communicate with them [...] (E4).
[...] With the patient who already has a lower level of consciousness, we communicate with some sounds of exclamation, or some touch, so that he can still feel heard, or we try to be heard with this touch, with these no verbalization of communication, using touch, the exclamation, the contact with the patient skin-to-skin, the handshake, more physical touch with this patient (E6).I think the touch very important.You touch on the arm, on the patient's chest.To touch in any part, [...].So, the touch, the look, the facial mime, a smile is very important.It's that look that you won't be watching the patient as a being on a bed.You're seeing a human being.So, that look more affectionate, looking, somehow, to show that you're there and you're worried about him (E7).
In the declarations is notorious the recognition of non-verbal signals as a strategy in the care to the terminal patient.Among these signals it stands out, especially the affective touch, mentioned by participants.The kinesthetic body language, as the smile and the distinguished look, was also referred.These signals imply certain knowledge of professionals as regards the subjectivity of non-verbal communication.
Corroborating this assertive, the study developed with health professionals identified the use of signs of non-verbal communication as a strategy on assistance to patients under palliative care.The non-verbal signs more reported by participants were the affective tone and facial expressions, like look and smile 15 .
The facial expressions, like look and smile, denote interest and empathy, which raises a bond formation by interacting with patients.In addition to portray emotions, the look features an important function: regulate the flow of the conversation 16 .
It is worth mentioning that the affective touch is characterized by physical contact that transmits a message based on valorization of the emotional aspect of the individual 16 .The touch is used as a form of non-verbal communication between the nurse and the patient, thus establishing a relationship of empathy, emerging from this relationship the very essence of the purpose of nursing 17 .Thus, the using of the affectionate touch is of paramount importance to humanized care to the patient out of therapeutic possibilities, and all the professionals involved in this care must have knowledge and skills relating to that theme.
In these sense, in research conducted with nurses, when interviewed, realized and appreciated the non-verbal communication, to better evaluate the expression and necessary care to the patient 18 .It is noted, therefore, the affective touch as the only non-verbal communication nominated by the participants of this study.That said, it is essential to emphasize that the health professional, especially nurses, when using the communication as a strategy to take care, will be able to assist the patient in the coping of its process of illness, mainly on the terminally ill.

FINAL CONSIDERATIONS
The essence of humanized care in nursing is the interpersonal communication, which translates in the interrelationship between the professional and their patient.This constitutes a fundamental axis, an essential instrument in order to provide support and sustenance to the person in front of the most difficult moments of his life.
In this study, it was observed that verbal communication is perceived, used and valued by the nurses as an instrument for the promotion of humanized care to the terminal patient.And, regarding to the non-verbal communication, this was not contemplated by most participants in the survey.
On the other hand, with regard to strategies for good communication, respondents stressed that use verbal communication and non-verbal to subsidize the humanized care in nursing to patients in terminal stage.The verbal communication was employed as common thread to provide support, security, confidence, transmit strength and hope, which is crucial in the context of the terminally ill.As for the non-verbal communication, this was recognized by the professionals through the affective touch, in order to contribute to the improvement of the quality of life of these patients.
In this way, it is hoped that this study provides new reflections and further research about the use of communication in the context of care with patients without possibilities of cure, aiming to humanize the relations between the nursing professional and patient on completion.It is appropriate to point out that the study presents some limitations, including the inability to generalize the results, so it is a qualitative research, with a reduced number of participants.
[...] For the conscious patients, everyone uses mainly verbal communication.[...] Talk about the meaning of life, talk with him to ask forgiveness, about several things, if he has something, that he apologize [...] (E1).
You have to come closer and have to speak, regardless if the client is in a coma or not, because even in a coma he listens.[...] So, it is a support, a help!This is humanizing [...].Is you together with that client try to raise mostly the ego, what's down, what's dispirited there, thinking there is no way out, and usually has!It's just a hand!We have to give a hand, raise!(E2).