Being nurse at a chemotherapy center with the death of an oncologic patient

The aim of this study was to understand the phenomenon experienced by nurses who work at a chemotherapy center when faced with the possibility of death of patients in this service. The study was developed using the phenomenological qualitative methodology and its analysis was the philosophical framework of Martin Heidegger. Study´s participants were eight nurses working at the chemotherapy center of a teaching hospital. Interviews were conducted in January and February of 2012 and four categories were revealed: Experiencing death as a natural life cycle; Experiencing impotence in the death of the other; Experiencing death with the aid of faith; and Experiencing empathy in the possibility of the patient's death. The phenomenon is permeated with pain and discordance, as they find themselves helpless in the finitude of life and in need for personal preparation and professional support to experience death.


INTRODUCTION
The cancer still appears as a condition surrounded by stigma, being usually associated with a sentence of death 1 , being considered today the second leading cause of death in developed countries and fifth in Brazil. According to estimates for 2014, valid also for 2015, indicates the occurrence of approximately 576,000 new cases of cancer 2 .
In this sense, this pathology has been considered as an irreversible process with different meanings to the nurse and patient, established in accordance with their cultural experiences, legends, social fears, and uncertainties formed from the moment that gives the possibility however remote, of his diagnosis 1 . Culturally stigma of death is incorporated to cancer, manifesting itself with its own characteristics in the patient-staff 3 .
For cultural heritage or personal training, every human being carries within him this individual representation of death, which influences from society, media and particularities of each individual contributing to their mystification 1 .
The nursing professional is the person who is closest to the patient in difficult times and who is patient and family when they need to seek explanation or immediate care. Accordingly, nurses need to understand and deal with the feelings that raises the oncology disease as grief, anguish, fears that can arise in situations involving this care. This care requires to know not only about the disease, but to deal with the feelings of others and with their own emotions before the disease with or without the possibility of healing.
This situation was found in studies [3][4][5] conducted with nurses in order to know the impact that care to cancer patients with the possibility of imminent death can promote the nursing team is weakened and experiencing an emotional pressure for their beliefs and values about death and the emotions and reactions of patients and relatives.
Some studies 1,[4][5][6][7][8][9] indicate that nursing professionals have difficulties in living with the patient who experiences his finitude, to potentiated experiment these conflicting feelings from the unprepared, causing a gap between the professional and the patient as well as their families, that is not appropriate to humanized care. It is necessary to better prepare these professionals to cope with situations involving the care of these patients, as well as psychological support to deal with the situation of loss, frustration and death.
Given the above, we decided to undertake a study to answer the following question: What is the phenomenon experienced by nurses in a chemotherapy center, experiencing the possibility of death of patients in this service? Therefore, it is important that nurses describe with their own language how they are feeling and what experiences they are having in this context lived. It was sought to the speeches of the study participants, their descriptions of the experience in order to capture them in their subjectivity, the way they feel to the news of the possibility of death of patients seen in the chemotherapy center.
This study is justified by unveiling the experience of these nurses with regard to the many facets that permeate the universe cancer, empowering the nursing professional to be sure of their everyday practices, transcending the technical limits of care that cancer patients raises. With these findings, permanent education processes involving nurses in the theme of death, reinforcing and expanding personal and professional reflection with regard to the improvement of care, responsibility and sensitivity to the nuances of the cancer experience could be planned.
Therefore, this study aimed to understand the phenomenon experienced by nurses working in a chemotherapy center, facing the possibility of death of the patient for this service.

THEORETICAL APPROACH -METHODOLOGICAL
Given the above, we chose the phenomenological research to allow full understanding of lived experience, revealing the phenomenon that is placed in the context of individual experiences of nurses working in chemotherapy center and experiencing the possibility of patient death of his service 10 .
A phenomenology approach has been widely used in studies by nursing, reflecting the unease in understanding the phenomena experienced in daily life and providing the necessary support for obtaining the knowledge of the dimensions of care 11 .
It was appropriate to unveil the phenomenon experienced by nurse chemotherapy center facing the possibility of death of the patient from his service, the philosophical theoretical framework of Martin Heidegger, whose key issue is not the man but the being, the sense of therefore be seeking to research and understand the being-nurse chemotherapy center without prejudice or theories, but as concrete and as conscious subject experience 12 .
Thus, it attributes meanings to be experienced as personal vision of the world he lives, values, customs and knowledge, experienced intersubjectively with others. The thought of being part of everyday life discovering ways that lead to clear that was forgotten by pragmatic and technological thinking 12 .
The study was conducted with nurses in the CACON chemotherapy central at a university hospital in Maceió, Alagoas. The length of the interviews was January and February 2012.
To conduct the research all nurses belonging to the functional framework of this CACON chemotherapy center were interviewed, totaling eight nurses, all female, aged 31-40 years old, with a time of professional training of two to 16 years and time of practice with oncology patients ranging from five months to nine years.
Permission to conduct the study by the direction of the teaching institution was granted and approved by the Ethics Committee of the Federal University of Alagoas, in accordance with the ethical and legal principles in force under Resolution Nº 196/96 (Opinion Nº 012569/2011-20).
The approach of the subject and explanation of the objectives of the research were performed with guarantee of anonymity Nurse before the death of oncologic patient Lima PC, Comassetto I, Faro ACM, Magalhães APN, Monteiro VGN, Silva PSG and the possibility of refusal, and the scientific nature of the study. Then the interview began by guidance on research with a subsequent request for signature at the TCLE held at the most convenient time for the subjects, being chosen a quiet location free from interruptions to conduct the interview. It was requested that the nurses would discourse freely about the proposed from the theme guiding question: How do you feel working on a chemotherapy center, experiencing the possibility of death of the patient for this service?
The interviews were recorded and transcribed. For analysis, we followed the steps suggested by Martins and Bicudo 10 : Full reading of each interview aimed at a general understanding of the meaning of the text; rereading each interview as many times as required, in search of meaningful statements that focus on the phenomenon studied from the perspective of the researcher, which were denominated units of meaning; processing units meanings of discourses of nurses in a language researcher, through reflection and imagination in search of converging and diverging elements, aiming to find the common themes of the training topics; Synthesis of research that consistently describes the elements of the experience of this nurses 10 .
Aiming the anonymity of the subjects, a pseudonym for each respondent was chosen, through the election of a crystal.
Thus, the structure analysis was performed situated phenomenon and came to the understanding of the experience of the phenomenon experienced by nurses in a Central Chemotherapy.

RESULTS AND DISCUSSION
In this study, being a nurse of a chemotherapy center is to be-there that experiences as a being in the world and it is related to cancer patients as being-with. To this experience different meanings are assigned, which helped to uncover the phenomenon in four categories: experiencing death as a natural cycle of life; experiencing impotence before the death of the other; experiencing the death with the help of faith; experiencing empathy facing the possibility of death of the patient.
Thus, the first category emerging from the study refers to how a nurse of a chemotherapy center experiences death of cancer patients.

Experiencing death as a natural cycle of life
The acceptance that life has a finitude is unveiled as nurses live the phenomenon of death adding it as part of the natural cycle of human life -birth, growth, age and death.

[...] I am very prepared to accept death. Even for my death, I know that one day we will all have this end [...] (Amethyst).
It should be looked for in ourselves the existential sense of getting-to-end. Thus, death is perceived as a concrete fact, but far from happening. At the moment, the being-for-death tries to "think" the death, even if they do critically, carefully and appropriately, it is evident that he apprehends sure well founded. From what we know, men "die". For any man's death is highly likely, but unconditionally certain. It is a natural phenomenon that everyone will, because "man is a being for death" 12 .
[ Thus, the lines of Jade and Granada approach the meaning of death as a possibility that can transcend its existence at any moment. The condition of being-toward-death of a man permits reflection of death as a reality of our existence, living with it continuously 12 .
The being-in-the-world as being limited by circumstances that comprise their shared world is led to think about the future size of its existence and launched to meet them. It is called to project through this challenge, beeing always limited in time as a mortal, weak subject incompleteness 12 .
[ The concern that the health status of cancer patients raises in being a nurse presents as great trigger concerns. The understanding that the nurse has, as being-caregiver regarding the worsening of being-cared, reveals strong interaction between beings. The nurse suffers when witnessing the worsening of cancer patients and sympathizes with him, but the great difficulty lies in permanent contact with terminal life.
Despite claims about being terminally, something inherent to human beings, it seizes the assertion: That the concern expressed by the professional is that we come into the world in order to live life to its fullest. In that sense, being-in-world means to inhabit the world, live in it, not only simply populate it 12 : It is clear, according to previous reports, the emerging need for nurses, while being-caregiver has to be prepared emotionally Nurse before the death of oncologic patient Lima PC, Comassetto I, Faro ACM, Magalhães APN, Monteiro VGN, Silva PSG to face the death of the being-cared. Even if the finitude is perceived as part of the natural course of life, the nurse may not be emotionally prepared to face it and not to deal with their own feelings raised in this experiment 1,13 .
The formation of predominantly technicist character that the academy offered to graduate at the expense of issues related to emotion, particularly those caused by the death contribute to the lack of preparedness in facing death in profissional´s activities 1,3 .
To the nurse who works with patients undergoing chemotherapy, death, besides being a personal concern, it is part of their everyday life reaffirming impotence and frustration of the being-caregiver under the unpredictability of the trajectory of death, feelings that will be described in the second category.

Experiencing impotence before the death of the other
This category was possible to unveil facets of the phenomenon that was hidden, referring to the experience of nursing staff across the powerlessness facing the possibility of death of cancer patients.
When questioned about their experiences at the possibility of death of the being-cared, the beings-caregivers expressed within time and space in which they operate their see, feel and experience: Regarding the possibility of nurses experiencing death experienced by cancer patients becomes more pervasive, the ending of this presence. The cancer patient ceases to be-with, not to live in the same world over, and it is from the world that nurses can be-with him. The death is revealed as loss experienced by nurses to suffer the loss, do not have access to ontological loss as such, "suffering" by dying, because, who stays, is not allowed the experience of the death of the other, only to be "together" 12 .
In this sense, to experience the possibility of death of cancer patients as stated in the Aquamarine report: It is seen like a difficult process that disrupts the team that remains in the world as a being-with a death 12 . Some authors 3,14 stated that there may be patients with whom nurses provide a differentiated and unique relationship. Thus, to feel deeply the possibility of death of the beings-cared, there are nurses with feelings of sadness and emptiness, for the preservation and extension of life are its objectives, therefore, may feel unable or frustrated when they do not get success in their attempts.
It is noticed that the feeling of helplessness in the fight against cancer, is remarkable in reports from nurses and comes from the inability of the being-caregiver promoting the maintenance of life of the being-cared. This understanding comes as a result the training aimed at maintaining life [7][8][9][10][11][12][13][14][15][16] . The loss in control of the situation and the possibility of death as something right, despite technological resources, cause the nurse stare limitations and question their professional skills.
It is as if life depends on the maintenance of the competence of the staff responsible for the patient, as expressed in some repots:

[...] Which sometimes makes me a little anxious is that even giving the best of me I cannot add anything to the treatment of this patient [...] (Emerald). [...] it is a powerlessness feeling to know that I work in an area that many people die and it is normal [...] (Amethyst).
Even though, in most cases, they do not realize the dimension of their actions of caring, the nurses are as being-with the cancer patients, it is also a human being like him. In their actions and interventions, they promote an openness to the other that favors care. Caring of cancer patients in pain, the professional begins to reflect on the subtleties of life and often realize how helpless they are before death. In this context, feelings of worthlessness emerge, especially when they realize the inevitability of death 6 .
[ Immersion of the feeling of fear before the cancer is considered a disease of complex treatment that can result in death, leaving in the being-with as caregiver, the feeling of insignificance, vulnerability and anguish over the disease allowing it to be at its professional routine, reflecting their way of being-in-world, from its representations, attitudes and modes of expression with which lives on their life 12 .
Authors corroborate in the experience of these nurses regarding to the work of nurses in oncology leads to physical and psychological wear and acknowledge the need to seek help to minimize this loss as therapies, meetings, discussions. It is extremely important that professionals seek ways to minimize their suffering, mainly seeking psychological help for a better quality of life 3,7 .
For nurses, as being-caregiver of cancer patients, dealing with the psychological aspects arising from finitude, it has been a difficulty due to the lack of training for the management of this problem. In this context, we apprehend that the being-caregiver as the being-cared need to help, and often this help is in spiritual way as unveiling in the third category.

Experiencing the death with the help of faith
In this category nurses experience the understanding of death under the spiritual perspective. Death has many meanings, according to the culture of those who are facing and look of every being-in-world. For some, it represents the end of life, for others just one passing by. The way how to face death is unique but depends on the history of life, faith and religion of every being. The belief in a religion helps in accepting the death of more gently way and it is associated not as the end but as a transcendence to the beginning of a new stage 6 .
The church and the family can be considered the foundations that prepair the being-caregiver for the coping of the finitude of the being-cared. It is seen in the following speech: [...] I think the preparation for death is due to life, family and church. I think the church helps a lot. The teachings we receive from Jesus, how He sees life as He also sees death. So for the evangelical, I think death is more acceptable than another class, you know? So, prepare for death, not to suffer so much is the same religious preparation, religious background [...] (Amethyst).
The understanding of death through transcendence is inherent in human beings. This understanding refers to any being-in-world, because it is in understanding that exists existentially mode-of-being 12 . Therefore, it is not common that nurses look for faith, seeking answers to queries and inquiries coming from their inner being as a way to understand the route that the being-cared traveling to crave indulgence for their suffering.
Most often these questions remain unanswered before the uncertainties of life, causing death passing increasingly further on the understanding of nurses as: Spirituality is designed as a basic human characteristic, in relation to the way of being in the world to wonder at finding ways for the sense of being-in-world. For this reason, we seek spirituality as support to overcome the difficult moments of life. Authors confirm that the search for spirituality in crisis grows 15,16 .
Thus, the sadness of the being-caregiver approaches the being-cared, experiencing a relationship of empathy, unveiled in the fourth category.

Experiencing empathy facing the possibility of death of the patient
Empathy is a sine qua non in relation to the nursing profession. When working in this category, it was possible to make discoveries with regard to the situation experienced by the being-caregiver of cancer patients in chemotherapy center, insofar as they approach the possibility of death.
[...] I suffer with these things. I suffer and I think we will continue to suffer, we need to continue suffering because otherwise ended, right? We will turn a wall without any feelings [...] (Amethyst).
From the speeches emerged that the nurse while being-in-world keep sensitive to that experienced in this context not to turn away from human existence.
Studies corroborate and reinforce the need of nurses perceive a being-care 1,4 . Therefore, when nurses live with the patient longer than other health professionals, especially when extended care is needed in a chronic disease allowing modifying the being-caregiver for the being-cared.
[...] Every child face I see I remember my son! I get emotional... and I suffer, I am distressed to see that mother and put myself in that mother, I feel that I never want to be in her place. The truth is that [...] (Aquamarine).
Nurse before the death of oncologic patient Lima PC, Comassetto I, Faro ACM, Magalhães APN, Monteiro VGN, Silva PSG Realizing in the place of a mother who has a child undergoing chemotherapy nurse enters the subjectivity of being-mother and experience the hardships that this situation imposes, to the point of never wanting this experience for themselves.
For the interaction with the patient becomes therapy, the nurse must try to understand the other's experience, experience it like this, always being careful not to lose its role as a professional or even their identity. When this understanding of the world of the other is established, we can say that this is empathy, essential for nurses to understand the world of the other. Only then he can offer individualized and longer care 1,16,17 .
The intersubjectivity that is expressed in the relationship between being-cared and being-caregiver enables mutual aid and conviviality. Thus it can be seen that this relationship is beset by issues involving emotional and psychologic 17 .
These relationships when addressed to another in a compelling and meaningful way are called by Heidegger of concern which indicate the basic characteristics of having consideration for others and to have patience with each other.
As empathy is revealed in the act of perceiving how a being-in-world thinks or feels, nurses reported difficulties in caring for cancer patients at certain stages of life: It is apprehended in this discourse, that it is difficult to work with an adult to understand the pain and suffering experienced, verbalized by them. In this sense, being-with is a way to relate, feel, think, act, live with their peers in the world, sharing with others. This co-exist, being-with each other, enables the conditions for understanding the experience of the other and see what he sees through his gestures, his way of being, his language 12 .
Being-in-world is in constant relation to oneself, but also with the presence of other beings in situations experienced in their daily lives. At this meeting, how man relates to their lives and is considered being-with-the-other, so that each individual can share and absorb the feelings of others. Being-with-the-other is still pure and fundamental characteristic of human beings 12 . Looking to exist in the world of I-You relationships, respect, empathy, acceptance and understanding of each other are held only from the mutual commitment between two people, a perspective in which the other is not seen as a mere white paper, but as a being with infinite possibilities and own characteristics 12 .

CONCLUSIONS
The unveiling of the phenomenon experienced by nurses working in a chemotherapy center with the possibility death of cancer patients, allowed to understand the importance of being prepared to deal with death, because it arises, in most cases, as a painful phenomenon and difficult to accept, especially when it comes to cancer patients.
The experience of nurses on the experience of the possibility of death of cancer patients allowed these professionals to see death as a process inherent to life, causing them to reflect on their own finitude and perceiving themselves powerless before the terminally ill. In these feelings is leaning religiosity to overcome sharing the being-care suffering. And, cultivating empathy and understanding of the experience of other mechanism while being-in-world.
Given the phenomenon unveiled, it is highlighted the need for a continuous psychological support service to professionals working in oncology, because the study clearly demonstrated the emotional suffering while performing the role the being-caregiver of the cancer patient.
Finally, it is highlighted the need to address over death since graduating with a view to personal and professional preparation in order to reduce stress and anxiety when discussing and having daily contact with terminal, providing the professional preparation and clarification their concerns forward to the unknown, to be able to maintain an interpersonal relationship help, which is the essence of the act of caring.