Study of Nurse ' s Philosophy : The Convenient Place to Die Peacefully for Terminal A Patients

Background: A patient with terminal illness who will die should be supported and accompanied spiritually for passing their end of life. The spiritual involvement is needed a convenient place since its support will transform a frightening moment to be a peaceful one. Purpose: the aim of the study was describes the convenient place to die peacefully using philosophical approach. Methods: This study used method of an Actual Problem, it is a philosophy reflective study about the assumption of researcher that a patient with terminal illness wants to be accompanied by people who proper to deliver the prayers. In this study, with one participant problems in the place of die are directly exposed, then it is synthesized to solve a fundamental problem. Analysis and synthesis of unsatisfied place to die to be expected can solve the problem. Results: Hospice care is a program or facility which gives specific care for the patient in end of life. It can be said that hospice is a way of care based on philosophy about the end of life. Hospice can be a convenient place to die because there are its staff who will substitute the role of family, in case they experience physical and emotional burden. Conclusion: Hospice can be an alternative of convenient place for patient with dying process and its nursing care can make the process as peaceful as possible


BACKGROUND
In 2017, the author met a patient in emergency room who was found diagnosed with breast cancer.At that time, patient had experienced loss of appetite for about 4 days, always vomiting and feeling painful.One year ago patients were convicted of breast cancer with metastases in the lungs and liver then chemotherapy were done.Her stomach was swolen and hard.The patient looked somnolence, GCS 10, had trouble breathing, pulse 80x/minute, and temperature 39 Celsius.She had only 35 kilograms of body-weight and height 161 cm.In the emergency room, the patient continuosly vomits and looks weak.She was given oxygen 15 lpm by NRM, and intravenous fluid.Nasogastric tube and catheter were inserted.It took only 1 hour until the patient died in emergency room.Some questions arise.Then, how to take care such patient?Is the hospital the best place to die peacefully?If the answer is no, what is the place or setting for dying peacefully?According to the observations, the family does not understand or confuse how to react to the treatment of terminal condition.Patient with terminal illness need convenient place to prepare spiritual and other end off live.In addition, there are only limited alternative places to help terminal patients.Nowadays, the family has no choice, so they decided to go to the hospital as an incarnation for helping their family member.They assume that not going anywhere means a mistake.Unfortunately, shortly after admited to the hospital, the patient died.The effort to bring patients to hospitals aimed for prolonging patient's life can be interpreted as a futile one.As a nurse, a question emmerges in my mind; "What do the nurses think about these cases?" Based on the description of terminal patients whose deaths have been predicted and the inability to facilitate peaceful dying for terminal patients, then a research question has been formulated: "Where is the convenient place for terminal patients to die peacefully?".The objective of the study was describes the convenient place to die peacefully: "Caring Hospice.,".The study using philosophical approach.

This study used Method of Actual
Problem which developed by Bakker and Zubair (1).It was a philosophy reflective study about handling patient with terminal illness which is predicted will going to the end of life.Problem is focused on the limited choices of place to care dying process that contributes to a decision for bringing a patient to the hospital.In this study, problems in place of dying are directly exposed, and then it is synthesized to solve a fundamental problem.The analysis and synthesis of a place for dying process to be expected can solve the problem, thus appropriate and ethic solution can be attained for this situation.In the end, a whole Philosophy Conception achieved (1).Internal coherency was among all research objects, which were the relation between people in terminal illness, who face the end of life, and the place which is needed for terminal patients to die peacefully

Human who take The Death Way
After someone born to the world, they would be going through growth and development.Growth focuses on the physical dimension, while development on psychological, social, and spiritual.Growth has a time limitation, whereas development is endless.Both of them begin since we were born, continue the journey until reach one point, which is death.How someone going through their life to die depends on how they understand and fills up their non-physical life (2,3).
In the nursing profession, a human is conceptualized as a bio-psycho-sociospiritual creature who can not be separated (3).As biological, a human is a grouping of organs which is work harmoniously in the normal state.These organs function has a similar role though in the different race or ethnic.Psychologically, human determine their character, as seen through the way of thinking, feeling, and behave.Human has conceptualized as a social creature, which is impossible for them to live alone.In addition, a human is also a spiritual creature who live spiritedly because there is a purpose fills their soul.Moreover, human also has conceptualized as a person who unites with their culture.Another concept of human is work to preserve a stability and homeostasis (4).This concept of bio-psycho-sociospiritual is a unique thing, which is no one of a human who has the same life though in the same environment.Human has an adaptive capability to the environment.In the adaptation, a human can do self-care by own self.So, in illness, human adapts while doing a selfcare.Human capability leads them as a determination of their own self when facing consciousness alteration.

Nursing Care on Terminal Illness
Regarding chronic disease, it means happen for so long and slowly, at least for 3 months.How patient's situation when they experience chronical disease is explained by this definition: "…an illness that is permanent or lasts a long time.It may get slowly worse over time.It may lead to death, or it may finally go away..The terminal illness phase was marked with symptoms of low fluid and food intake, general weakness, and respiratory problems, circulation problems also psychosocial and behavioral disorders (6).It may cause permanent changes to the body will certainly affect the person's quality of life".It describes that the patient and family throughout that process would meet the healthcare provider.Doctors or nurses have a responsibility to give an intervention to the patient and family as a human who has self-existence.
As sudden death, a human who dies has no chance to prepare.Yet, in slow dying, it needs a preparation to face those process (7).The aim of that preparation is for the human with chronic illness will be more ready to face the end of that disease.Facing the end of the disease might be led to one question related to the meaning of the end of life, the reaction, and the place to face it.More it can be explained, more peaceful they are in facing that process (8).
The nurse has a precious work, they should make their working world to solve the problems.This working world should provide a value which can be seen and felt by around environment.Every role and function of a nurse has room to demonstrate a competency which is felt by the patient as a need.Those role and function are already clear.The competency that follows each role has already clearly described by the nursing figure .Unfortunately, room to demonstrate those competency has not able yet to be shown.Thus, it is a time for a nurse for rising up to show that there is a room which should be completed by a nurse in providing nursing care to a patient with the chronic and terminal illness.
"Where is the convenient place for terminal patients to die peacefully and a nurse has room to demonstrate a competency which is felt by the terminal patient as a need ?Like healthy condition, patient want to die on the own home, but if this condition has barrier so need some place.One of the problem solving is healthcare facility, is named "Caring Hospice" that differs from another existed healthcare, such as a hospital.

Caring Hospice as alternative Place for Terminal Patient
One of the problem solving is a healthcare facility, is named "Caring Hospice," that differs from another existed healthcare, such as a hospital or public health care.That thoughtful facility is a place for the nurse to provide nursing care independently to a patient who is in a terminal condition or older age.In this facility, the nurse provides care ethical based nursing care, it accentuates nurse-patient compassionate relationship.In "Caring Hospice," that would be built, nursing care should be properly implemented to patient and family.
It had been realized that phenomenon that exists about nursing care service is a text in dying context which needs to be reconstructive.It would be a different form of health care that existed, not replacing those existed.It can be an alternative for the patient.Another thing that differentiates is there is an anticipation program in every stage which would be passed towards dying.
That anticipation program begins since illness diagnosis established until ceteris paribus condition.All of the team members implement anticipation program based on their role and function.Illness diagnosis was done by a doctor, then delivered in periodically meeting.For a nurse, this anticipation program implemented by a nurse through 4 roles; as a practitioner, educator, manager, and researcher.Other roles are advocation to protect patient that integrated through those 4 roles.That anticipation is implemented depend on every healthcare facility, such as a clinic, inpatient room or end of life care facility.All of those places have one aim to provide the best nursing care for the patient so that they can die with dignity.
That thoughtful facility is a place for the nurse to provide nursing care independently to a patient who is in a terminal condition or older age.In this facility, the nurse provides care ethical based nursing care, it accentuates nursepatient compassionate relationship.In "Caring Hospice," that would be built, nursing care should be properly implemented to patient and family.It had been realized that phenomenon that exists about nursing care service is a text in dying context which needs to be reconstructurized.It would be a different form of health care that existed, not replacing those existed.It can be an alternative for the patient.Another thing that differentiates is there is an anticipation program in every stage which would be passed towards dying.That anticipation program begins since illness diagnosis established until ceteris paribus condition.

The Health Team of "Caring Hospice,"
Patient's health condition who admitted in "Caring Hospice," is in chronic towards the terminal stage.Staff who works there is healthcare provider or another profession who understand the chronic-terminal situation.Although, patient in that condition, a healing concept in Curing-Caring range needs to be understood by health team.Healing does not mean cured yet has a higher and deeper meaning by digging an understanding about life meaning from each body components, then collaborate those components result become a new better and meaningful understanding.More detail, Olson (2001) said that "Healing in the dying sounds like an oxymoron.But to heal is not necessarily to cure.To heal is to bring various levels of oneself: cellular, physical, intrapersonal, interpersonal, societal, spiritual, perhaps even cosmic into a new relationship with each other" (8).
An ability to excavate this healing concept should be owned by all of "Caring Hospice," team member based on their competency.Assess the patient based on healing meaning is done at the moment, before, and when to undergo dying.It can be done by knowing patient's understanding of their condition with other and The Creator.The intervention that provided is referred to those healing assessment result.It can be said, every intervention which been implemented has a customized to patient needs.
Healing concept mostly linear to Holistic Concept (Holism), that also should be understood by "Caring Hospice," team.Holistic focuses on a unity continued and related each other.The term of heal and health origin from holism means "be a whole".Those things reflect life process that is described as a unity of body, mind, emotion, and spirit, that can not be separated and dependable each other (6).As linear as healing, holistic is also means must be recover.So, those understanding can be used in both situations, to gain recovery and also dying.
Related to "Caring Hospice," team, those team member should implement the holistic concept in every stage of illness that were passed by the patient.It can be said that holistic concept reflects all activities of "Caring Hospice," team member to gain a healing process which is implemented by patient and family.The healing process and communication skill are needed to gain those process.
Communication is used for in order to share the information continually among the patient, family, and team member.Through this information, concept contains equality meaning among team member because all received information ends up with patient's healing.Beside that concept, all team member must understand ethical rules as a guide to implement the intervention.
Other needed concept by health team is education and anticipation.As for healing attained, an education from "Caring Hospice," team to patient and family is needed.That education is provided earlier before dying phase comes, it should do in every stage along illness pathway.Education contains the explanations about the journey of illness that will be passed and the things that wanted by family and patient on those process.Then, after patient and family understand those process, they will decide what kind of support that patient wants in end of life.Based on study report, a patient that receive an explanation about dying and its related expectation will attain a more peaceful dying (7).Nurse can provide explanation to the family using technology like video or direct education.Education using technology more helped family to understand about progress of diseases and care to the patient (9).
Those anticipation program aimed in order that patient would be understand about what will happen in the future.As patient might feel pain, unexpected a recovery and all of these information have been delivered before death comes.That anticipation program is a component of communication.
Thus, every discussion that would be done together by patient and family need a planning, although in every discussion would develop based on the situation and condition of patient and family at that moment.All of that concept is delivered in religious context, that means all of the delivered interventions refer to the belief of patient and family.It explains that every "Caring Hospice," team member respects to believed religion and belief of patient and family.

The Composition of "Caring Hospice," Team Member
The member of "Caring Hospice," team is an individual who needed by patient and family based on capability for providing intervention.That member can be classified into two parts; health team member and non-health team member.In health team member including nurse, doctor, pharmacist, dietician, and social worker.Inter-professional collaboration in the workplace is likely to increase health care quality, achieve nurses' outcomes, reduce health care cost1, and increase patient safety and patientcentered care (PCC) practice (10).
In the inter-collaboration professional need some coordination.Coordination is defined as the art of teamwork to achieve an organization's goal in a collaborative way in which there is communication and effective information exchange among health professionals, making it easier to reach equipment.Cooperation occurs when health care professionals work together and share knowledge and skill.Partnership and shared decision-making are as important as the other aspects.Those three components are paramount in collaborative practice.If partnership and shared decision-making were well implemented, then health care options for the patients, negotiation among health professionals, and collaborative team skills would increase (11).
Nurse, be responsible to coordinate all of the aspects related to the patient.The nurse implements the assessment to the patient's health periodically based on patient's condition.The symptoms which worsen are handled by the nurse and discussed together with other health teams.The capability of the nurse to manage those responsibilities refers to their gained training and education.Doctor, be involved in the health service of the patient in "Caring Hospice".The doctor provides an intervention based on their competency, role, and function.In "Caring Hospice." the doctor does not think to cure, but she/he thinks an intervention to alleviate patient's suffering, such as reducing the pain.All of those activities should be done in humanity context.
The pharmacist has a role to comply the need for therapy that been prescribed by a doctor.Together with the nurse, the pharmacist looks the reaction of drugs which are received by the patient.The role of the pharmacist in the hospital where they directly meet the patient, never been seen in Indonesia.This thought is proposed to make the role of pharmacist be perceived by the patient.Beside three health profession that mentioned before, another non-healthcare professional is needed.The known health profession is: Social worker, it is planned that every patient lies below a social worker.In Indonesia, the existence of social worker has not been a part of health service yet.It is expected through "Caring Hospice", a social worker can be a part of health service.The social worker is expected can help the problem-related life, such as assisting the family to manage BPJS (universal health coverage in Indonesia).Those supports would reduce the suffering of patient and family who have been burned out to face the illness.
Chaplain or Ustaz, their commitment is not common in health service.Since the aim of this institution to serve an end of life, where the patient will facing the God, thus Ustaz or chaplain's existence is pivotally needed.As same as nurse's existence, so that chaplain will provide a service for 24 hours a day.It probably makes chaplain will work in shift context.Thus, there will be an intervention called Spiritual Service in "Caring Hospice."Besides the technical staff, management staff is needed.This management staff should suitable for the nurse's expectation to embody theirs existence, so those staffs are a nurse who has a management certificate.

The Entry Path of "Caring Hospice,"
The placement of the patient in Hospice based on their condition is an appropriate thing.Hereby, it needs a discussion among health professions, from multidiscipline to incarnate this "Caring Hospice".Thus, the entry path of Hospice is needed.After the doctor establishes a diagnose which states that patient will undergo a chronic disease that will end with death, then the doctor will deliver to the integration team in "Caring Hospice,".
Each of team members will play a role and function based on their competency.Periodically, this team will share the progress of provided care each other.Whether along the journey of continuity care will be took of care at home or resting place is suited to patient expectation and/or family.The information service such as email or other information technologies can be used to ease the communication.

Spiritual Service in Caring Hospice
Spiritual service does not common in Indonesia."Caring Hospice," clearly states that recovery is not its aim.As general, in literature has discussed spiritual aspect, especially religion aspect in this paper, because most people in Indonesia believe in God.At the end of life, spiritual service is provided by Ustaz or chaplain based on the religious belief of patient.The patient ready for passing a separation to the world and the loved ones.It is a grieving for a family who has been left.The family prays with the phrase's God to bring a calamity patient will be left as well as for their own self.
The self-submission to God is the main aim in end of life.Thus, the aim of nursing care in this phase is to provide a chance to Ustaz or chaplain to accompany a separation then provide a room and time for patient and family to pass it quietly.
The Ustaz or chaplain together with family plan a patient's separation process.The chaplain also makes a plan to identify who will release the patient's death.It means not everyone must do that.That thing can avoid the unwanted assumption, for example when a soul hard to release from the body, not all of the people know about it.Thus, the privacy of patient until the end of life becomes a focus for health team.Then, it will be good for family who has been left.If the thoughts of Hospice's staff can be incarnate, thus there will be a essence in health service.It might happen if there is an improvement in the management of Indonesia's public health.

CONCLUSION
"Caring Hospice," is an advisable place that aimed to release the patient undergo to another universe, after the world.A form of intervention that provided is to fulfill basic needs, such as hydration, nutrition, and oxygenation.Those needs still fulfilled because it is an obligatory requirement in life.Avoid kinds of curative treatments will prevent a redundancy.It is wasted of emotional, financial, and spiritual.Being not redundant is a moral message to obey.Treat a human properly will demonstrate a noble behavior, it is a behavior that owned by The Creator, which shows how high of the dignity of human, either as a giver or a perceiver of nursing intervention.In this way, in this nursing care facility will reflect a nursing intervention which is mentioned as nurse noble role.For people who believe in the God's existence, the nursing intervention is a transaction with The God.
The absence of this Hospice being a challenge for nurse profession in performing their existence.Nurse profession has already determined the idea of developing this "Caring Hospice".This facility will represent a good image of nurse profession.The environment will look the nurse profession and feel the nurse existence.Hereby, besides giving a benefit to the patient, this Hospice existence will give an improvement of nurse's existence.The existence of Hospice aims to improve the quality of life of patient and family who experiences a life-threatening disease.It is aimed to help a patient to gain a dying process as normal as can be; not to be accelerated and also not to be slowed down.