Academic Master

Health Care

Nurses Roles in End of Life Care


Modern medicine more than 15 years ago returned to the concept of palliative care. Palliative care is a part of public health, therefore, not only state medical and preventive institutions and social structures, but also public and religious organizations, are providing this assistance. According to the WHO definition: “Palliative care is an activity aimed at improving the quality of life of patients with a deadly disease and their loved ones by preventing and alleviating suffering by early detection, careful assessment, and removal of pain and another physical, psychological, social and spiritual suffering.”

Relative to the relief of suffering and care for patients with incurable diseases, the Church has a traditional, centuries-old experience not only of shepherds but also of compassionate widows, walkers for the sick, and nurses of sisters. Pre-revolutionary schools of nurses gave graduates not only spiritual foundations but also high professionalism. Modern communities of sisters of mercy inherited and revived this experience. Sisters of mercy today, where radical medicine is exhausting its capabilities, where professional, patient, long-term, lifelong care is needed. Such experience of nurses, accumulated in the field of caring for cancer patients, is in demand today in the provision of assistance to HIV-infected people, who have severe clinical manifestations and who need constant nursing care. Extrapolation of sisters’ skills in managing cancer patients for HIV-positive problems is justified by the fact that 80% of HIV + have common problems and only 20% are specific medical ones associated with opportunistic diseases.

From the practice of providing nursing care to patients with non-treatable diseases, and among them people living with HIV / AIDS, it follows that palliative care is a continuous medical, psychological, social and spiritual supportive lifelong support.

Accompaniment of the patient and his family begins from the moment of diagnosis and often does not end with the end of his earthly life, but switches to his closest relative, who suffered a severe loss and often needs not only psychological and spiritual support but also medical care.

The role of a junior nurse in palliative care

In modern health care, the role of a junior nurse can not be underestimated. In the palliative care system, where all patients need qualified care, a junior nurse is an indispensable specialist.

A specialist who has been trained, skillfully and efficiently fulfills his functional duties, applying theoretical knowledge and skills in practice. In the general process of caring for the severely ill, the younger nurse more often than the rest of the health workers is in the ward with the patient, and therefore closer to him.

The younger nurse not only cares but also with her attentive attitude, sensitivity, and kindness, strives to improve the patient’s quality of life since the right communication of the medical worker with the patient is already a kind of medicine.

The concept of palliative care

Palliative care is an active universal concern for patients whose diseases can not be cured, aimed at meeting the physical, psychological, social, and spiritual needs of both the patient and his loved ones.

The goal of palliative care is to achieve the highest possible quality of life for the patient. Quality of life means subjective satisfaction, experienced and expressed by the individual. Assessing the quality of life in palliative care should be based on the study of satisfaction and the patient’s opinion.

Palliative care is provided by a group of people who work as a unit, as one team. It consists of doctors, nurses, nurses, nurses, social workers, priests, volunteers, and relatives.

The participation of each member of the team is purposeful and assumes the final result – improving the quality of life of the patient.

The younger nurse in the structure of palliative care.

In connection with the increase in the number of incurable patients, it is the task of medical workers to organize and carry out care for such patients. Care in palliative medicine is seen as a form of medical care and is the most important part of palliative medicine.

With the development of medicine, the role of specialists in primary medical education increased. The tasks assigned to nurses require professionalism and versatility. The junior nurse is now not a nurse, but a nursing specialist who has passed a specialization cycle in a medical educational institution and has received a document of an established standard – a certificate of primary specialization. This increased her status and responsibility for the work.

The junior nurses of the Municipal Educational Establishment “GKB No. 4” are trained on the basis of the Kemerovo Regional Medical College on the specialization cycle “Preparing a nursing assistant for nursing” in the amount of 288 h, with the qualification “Junior Nurse for Nursing”.

Unfortunately, until now, junior nurses are the smallest and least trained group in the professional structure of medical workers. However, the degree of their participation in patient care is very high. Traditionally, the existing ideas about a junior nurse as a nurse performing only cleaning the premises, are changing today. The junior nurse conducts simple medical manipulations, and ensures that the patients are kept clean and where the patients are located. The specifics of the work of a junior nurse are the need to train the patient for self-guidance, and relatives – the basic rules of daily care, to provide basic psychological support to the patient and his relatives.

The role of a junior nurse in palliative care in the team should not be underestimated. She is the first assistant of the ward nurses in the care of the sick. In a palliative care institution, the independence of a junior nurse is significantly higher than in other health facilities. Nursing care is one of the most important components of the activity of a junior nurse in palliative care.

The workplace of the junior nurse is the ward of the patient, where she watches the patient’s condition around the clock. Good care, caring, and creating comfortable conditions for the patient helps him to maintain self-esteem and human dignity.

The junior nurse is obliged to monitor the observance of silence in the department, and the timely disconnection of lighting devices, radio, TV during day and night rest.

All hygienic procedures, and physiological departures of the patient commits in bed. The junior nurse takes care of the patient, carries out all the activities necessary for the personal hygiene of the seriously ill, feeds him, and monitors the performance of the regime prescribed by the doctor.

An important part of the work of a junior nurse is the care of the patient’s skin since patients who are weakened and who stay in bed for a long time are at high risk of bedsores.

To prevent the formation of pressure sores, a junior nurse must carry out the following activities:

• restructure the patient’s bed regularly – in the morning, before daytime rest, and at night;

• Turn the patient on his side several times a day, changing the position of the patient in bed;

• regularly several times a day to shake off the sheet so that there are no crumbs on the bed;

• make sure that there are no wrinkles and patches on the bed and underwear;

• a seriously ill patient, who is in bed for a long time, put an inflatable rubber ring so that the sacrum is above the hole of the circle;

• daily wipe the skin with a disinfectant solution (camphor alcohol, vodka, cologne).

In the Municipal Clinical Hospital “GKB No. 4” the younger nurse takes part in palliative care:

• in the department of hospice for cancer patients in the terminal stage of the disease;

• in the therapeutic department No. 1 for somatic incurable (untreatable) patients – in the terminal stage of the development of chronic disease;

• in the therapeutic department No. 2 – to provide qualified care for geriatric (elderly) patients.

15 nurses per 1 junior nurse who carries out palliative care.

The job descriptions of a nurse and a nurse are, at first glance, the same, but even the same duties the nurse and the nurse perform in different ways. The job description of a junior nurse is drawn up with an emphasis on caring for the sick (annex). Caring for a seriously ill patient, the younger nurse performs more skillfully, qualitatively, and professionally, relying on theoretical knowledge and practical skills.

In order to improve the provision of professional care and psychological support to patients, a junior nurse must engage in self-improvement, since this profession is dynamic and requires constant improvement of theoretical knowledge and practical skills. The concept of “self-improvement” includes visiting nurses’ conferences and participating in them, reading medical literature, attending training sessions on psychotherapy, and mastering new care.

Job description of a nursing nurse

1. The general part

1.1. A person who has passed a specialization cycle in a medical educational institution and has received a document of the established type – a certificate of primary specialization and fit for health in the position in question – is appointed to the position of a junior nurse in a hospital for the care of sick persons. 1.2.The junior nurse is accepted and dismissed by the order of the hospital’s chief doctor in accordance with the current legislation. When hiring a junior nurse in the prescribed manner, a preliminary medical examination is carried out.

1.3. The younger nurse reports directly to the ward nurses, as well as to higher-level officials.

1.4. The younger nurse in his work is guided by this job description, orders, and instructions of higher officials.

1.5. Orders of the head of the department, the doctor of the hospital, the chief nurse, the senior nurse, and the ward nurse are mandatory for the younger nurse.

2. Responsibilities

The younger nurse for the care of patients is obliged:

2.1. Assist the ward nurse in caring for the sick.

2.2. To learn skills in caring for patients, and social and psychological support of patients and their relatives.

2.3. Ensure that patients and premises are kept clean and tidy.

2.4. To change the bed linen and bed linen.

2.5. Systematically conduct wet cleaning of premises and air chambers.

2.6. Participate in the transportation of seriously ill patients.

2.7. Monitor patients ‘and visitors’ compliance with internal regulations and hospital conditions.

2.8. Ensure the rational use and storage of care items.

2.9. Participate in occupational safety training, occupational safety, and hygienic conditions.

2.10. Observe the rules of internal labor regulations.

3. Rights The younger nurse for the care of sick persons has the right:

3.1. Obtain information necessary for the performance of their duties.

3.2. To make proposals directly to the higher-ranking officials of the department for improving the organization and conditions of their work.

3.3. To improve business qualification through various forms of improving professional knowledge.

3.4. To participate in meetings where issues related to this field of activity are considered.

4. Responsibility

The junior nursing nurse is responsible for the failure to fulfill the duties stipulated by the internal labor regulations and this job description


‘Medical College of Russian Academy of Medical Sciences, Moscow 2Chair of Philosophy RAMS, Moscow

The nursing profession is the most mass medical profession – in Russia about

1.5 million specialists with secondary medical education. Nurses play a big role in the organization of palliative care. Due to close contact with patients, nurses are ideal for monitoring and evaluating treatment outcomes.

The emergence of hospices in our country in the 90’s. made significant adjustments in the organization of palliative care for cancer patients.

A professional “niche” in which the goals and tasks of modern nursing reform in our country could be successfully realized is the system of palliative care.

Keywords: palliative treatment, hospice, pain syndrome, nursing.

Nurses are the most numerous healthcare professionals, the number of nurses in Russia

1.5 million. Nurses play an important role in palliation healthcare. Being in close contact with patients, nurses are ideal for monitoring and assessment of response to treatment. Initiation of hospices in this country in the nineties. Palliation healthcare is a useful field to reform and update the nursing service in this country.

Keywords: palliation healthcare, hospice, pain, nursing.

The nursing profession is the most mass medical profession – in Russia, there are about 1 million nurses, and together with other specialists with secondary medical education (midwives, etc.) – about 1.5 million people.

About 10 years ago our country began the reform of nursing. The goals and objectives of the reform are as follows:

1) overcoming the traditional model of nursing, which has developed since the days of F. Nightingale and was largely preserved in Russia until the end of the 20th century. (the nurse is an assistant doctor with extremely limited professional independence);

2) introduction of new ideas, methodological, ethical, and professional approaches to the system of Russian public health that emerged in the nursing business abroad in the second half of the 20th century;

3) implementation of appropriate systemic changes in nursing in Russia in the field of nursing training, in nursing practice, in nursing research, in professional self-management in nursing (organization and development of independent sister associations);

© Khetagurova AK, Ivanyushkin A. Ya., 2003 UDC 616-006.04-08-039.75: 614.253.52

4) gradual increase of the professional and social status of nurses in the system of Russian public health and in Russian society as a whole;

5) changing the image, increasing the professional authority of nurses in hospitals, clinics, etc., increasing the self-esteem of nurses themselves, and stimulating the motivation of young people’s choice of this profession.

Modern palliative medicine was formed in the mainstream of the hospice movement. The history of modern hospices is 35 years old. Along with the great achievements in the field of chronic pain management, effective treatment of other painful symptoms, usually accompanying dying, and also the achievements in the application of new organizational forms of assistance to the dying in palliative medicine, we have accumulated a rich experience in solving ethical problems, which in the most general form can be determined as the ethic of death with dignity. The founder of hospice of modern type S. Saunders (S. Saunders) wrote back in 1981: “Nursing remains the cornerstone in serving patients in the shelter for the dying” [17]. In the future, we will consider the state and prospects for the development of palliative medicine in Russia in connection with the ongoing nursing reform.

The first hospice in Russia was opened in 1990 in St. Petersburg on the initiative of the English journalist V. Zorz

and physician-therapist AV Gnezdilov with the active support of the public, in particular academician DS Likhachev (who had exceptionally high authority in the country) and writer DA Granin.

In Russia, about 300 thousand people die of malignant neoplasms annually, and 70% of them need palliative care [9]. At present, about 45 hospices are opened in the country in 13 (out of 89) subjects of the federation, and 19 hospices are still in the organization stage. In St. Petersburg, 10 hospices are open – this is the only megapolis in the country, a system of palliative care for terminal patients has been created. The first hospice in Moscow began operating in 1994 – first as home care (outpatient service) for oncological patients of the IV clinical group, in 1996 a 25-bed hospital was opened, and soon – a day hospital. Today in Moscow there are 5 hospices.

Whoever visited the First Moscow Hospice, always left him under a strong impression. Chambers for patients (for 1, 2 and 4 people) are spacious, equipped with functional beds, communication with the nursing station, there are showers, and toilets, and each ward has a separate exit to the courtyard. If the patient is unable to move, then on his bed, he can be taken to the courtyard or (if he is an Orthodox Christian) to a beautiful chapel visible from all sides in this Moscow district. The head physician of the hospice V. V. Millionshchikov told about one patient who within a week or two quietly fell asleep only when she was taken to the chapel. Although in the design of the hospice there were discussions about the advisability of building an Orthodox chapel (taking into account the multi-confessional nature of the city’s population), from our point of view, the decision taken is still correct given that it is the first hospice in Moscow, The religious needs of patients of other faiths are also created here. The head physician of the hospice emphasizes that for all the years of the hospice’s work there was not even a shadow of any interconfessional contradictions. Relatives of the sick also have all the conditions to stay with their loved ones in the ward or nearby in a separate room. Staff working conditions meet all the requirements: on the 2 nd floor of the hospice building, there are conference halls, nursing, and medical offices.

Despite this, there is a problem with medical personnel in hospice. The nursing staff is also not fully staffed. Hospice is a budget institution. Given the charitable donations to the hospice, the salary of medical personnel is higher here than in most other budgetary medical and preventive institutions in the country. Still, the problem of lack of staff remains. The head physician of the very first Russian hospice, AV Gnezdilov, wrote about the staffing problem in the hospice: “The staff turnover in the hospice is barely compensated by the presence of a stable contingent of believers … they who work” by heart “basically keep all the activities of hospice ” [4]. The fact that modern Russian society is not able to solve the personnel problem of hospice service is a serious problem of the Russian society itself, which goes beyond the sector

of health. The leaders of the hospice movement in our country as immediate tasks put: 1) a substantial increase in the budgetary wage rates of nurses and hospice physicians; 2) a reduction of their working day; 3) reducing the age limit for retirement.

In addition to hospices in Russia, other organizational forms of palliative care are also used.

In 1991, the Ministry of Health of the Russian Federation organized the Center for Palliative Care for Oncological Patients whose main tasks are the development of modern technologies for providing medical care to patients who need supportive therapy and organizational and methodological work to improve palliative care for cancer patients. In addition, 9 territorial centers have been created, and 14 more are at the organization stage. Assistance is also provided in 53 pain management cabinets (15 of these are in the organization stage) and 23 palliative care units in multi-city hospitals (10 of these are in the organization stage) [9]. The number of specialized outpatient and inpatient departments in the country is not enough, as can be judged from the situation in Moscow, where there are only two such stationary departments (40 and 20 beds). Finally, to a certain extent, the tasks of providing palliative care are being addressed in nursing hospitals, the patient population of which is predominantly not oncological but geriatric.

Thus, the main moral and ethical problem is the inaccessibility of qualified clinical palliative care for a significant part of the oncological patients of the IV clinical group. According to some literature, the need for such assistance in 1999 was satisfied by 59% [9]. The situation will be even more serious if we take into account, for example, the need for palliative care for AIDS patients.

In the sphere of distribution of medical resources, Russia should direct as much money to palliative care and anesthesia as too radical treatment, as it has been practiced in economically developed countries in recent years [22]. It is about changing priorities in health policy, which will require a sharp increase in the number of nurses and doctors specializing in palliative medicine.

The training of domestic doctors and nurses in the field of palliative medicine began immediately in the first years of the independent activity of St. Petersburg hospices No. 1 (since 1990) and No. 2 (since 1992), as well as the First Moscow Hospice (since 1994), where schools and seminars on palliative medicine with the participation of teachers (doctors and nurses) from Great Britain were held repeatedly. Of course, such schools could cover only dozens of domestic doctors who received here their primary training in palliative medicine. Such training is systematically conducted on the basis of the Republican Center for Palliative Care of the Ministry of Health of the Russian Federation. After graduation, a certificate from a specialist in palliative medicine is issued here. Nursing training

began at the Medical College of the Russian Academy of Medical Sciences, where, on the instructions of the Department of Educational Health Care Institutions and Personnel Policy of the Ministry of Health of the Russian Federation, a training program on this discipline was prepared.

The experience of Russian hospices shows that among their patients two groups of patients are sharply distinguished: socially protected and socially unprotected [2]. As AV Gnezdilov wrote: “The peculiarity of Russian hospices is that two-thirds of patients die in the hospital, this is a” substandard figure “since it indicates a low social level of the population. The presence of miserable living conditions and difficulties in relationships with relatives force patients to seek here, in hospice, their last resort “[4].

Socially unprotected terminal patients, as a rule, are single. We are not talking here about the loneliness of dying patients in an existential sense, as Leonid Tolstoy wrote in his novel The Death of Ivan Ilyich: Ivan Ilyich experienced a completely new feeling of “loneliness among the crowded city … and numerous friends and family – loneliness, fuller than that could not be anywhere: neither at the bottom of the sea, nor in the earth … “[18]. This applies exclusively to the everyday life of such patients, when a dying patient does not have loving relatives, there is no one to take care of the dying person, to help him through the last, often painful, “path to death”.

Of course, the development of palliative medicine in Russia was faced with problems that existed in Western countries approximately two decades ago. Let’s take the problem of treating chronic pain in terminal patients. It is important to emphasize that the solution to the problem of analgesia in such patients stems from the philosophy of modern palliative medicine, the essence of which can be expressed in the words: “If it is impossible to interrupt or even slow the progression of the disease, the quality of life becomes more important by the logic of things than its duration” [20]. In terms of treatment of chronic pain syndrome, this means: that a dying patient should receive pain medications (if necessary including opioids) as much as his condition requires, as long as he needs. As is known, this ethical and at the same time clinical imperative in the first stages of the development of modern palliative medicine met resistance in some places in the West: “Palliative care centers were one of the first to demonstrate the importance of regular round-the-clock administration of analgesics, especially oral administration of morphine. Demonstration centers were established in some countries, but they had to contend with the ignorance of doctors, nurses, pharmacists, and the public, sometimes turning into active antagonism “[12].

More often it is oncologists and anaesthesiologists who are very well aware of the clinical, pharmacological, and also social and legal problems of anesthesia in their patients. Perhaps, to a lesser extent, they are aware of philosophical, theological-confessional, socio-cultural, and ethical aspects of anesthesia. About those cases when the pain syndrome, due to different objective and subjective reasons, is ineffectively treated in one or another

of a particular dying patient, AV Gnezdilov, perhaps, too harshly (but generally fairly) says: “… only our sick fellow citizens have the right to” legal torture ” [4]. These words of AV Gnezdilov, as well as the above example from the field of psychiatry, not only testify to the deformations of the ethical order that has developed in some decades in some domestic physicians but also about the great tolerance for the pain syndrome as if to something if not normal, then inevitable. When a nurse from the UK who conducted a seminar on palliative medicine in St. Petersburg was asked if there were any differences in the attitude towards pain in patients in her homeland and in Russia, she replied: “Yes. Russians suffer the pain “[7]. That is, they do not always hope for timely and effective medical assistance.

Regarding the role of nurses in solving the problems of anesthesia in terminal patients, this role was determined by WHO experts: “Nurses play a big role in the organization of palliative care. They have a special responsibility for disseminating information, giving recommendations and educating the patient and his family, and also for keeping the patient at home with the same care as in the hospital. Due to close contact with patients, nurses are ideal for monitoring and evaluating the results of combating pain and other manifestations of the disease. To ensure the effectiveness of the measures applied, it is necessary that nurses have the right at any time to vary the dosage within acceptable limits so that it matches the needs of the patient “[12]. The program outlined here needs to be projected onto the goals and objectives of the Russian nursing reform and, in accordance with this, to solve specific tasks in the field of nursing education, and nursing research, while expanding the legally enforceable professional rights and responsibilities of nurses. In the solution of the latter task, the role of independent professional nursing associations is particularly important.

In the domestic literature on palliative medicine, the ethical aspects of the treatment of chronic pain proper, from our point of view, are not sufficiently discussed. Take the earlier ethical imperative of modern palliative medicine: terminal patients should receive painkillers as much as their clinical condition requires. The Statement on Policies for the Treatment of Deadly Ill Patients Experiencing Chronic Pain (World Medical Association) states in part: “The appearance of iatrogenic drug dependence should not be considered as a major problem in the treatment of severe pain against neoplastic diseases and can not be the reason for refusing strong analgesics in patients with whom such analgesics can help … “[5]. In general, we, of course, agree with the above ethical recommendation of the “medical Olympus” – (WMA, 1990): it is impossible to make terminal patients “hostages” to the struggle of doctors and society with drug addiction. However, it should be noted: that this ethical setting requires physicians, and medical personnel of the highest professional, and clinical competence.

Errors in the prognosis of the outcome of the disease, even in the oncological IV clinical group, can not be ruled out. For example, a Norwegian journalist, telling on the pages of one of the WHO magazines, an instructive story of the illness, dying, and death of his wife, who suffered from breast cancer for more than 20 years, in particular, stressed that when the tumor has already given extensive metastases and, according to surgeons’ forecasts, the patient left to live for several months, she lived after that for more than 10 years [14]. How can we not recall here the position of E. Kubler-Ross (Elisabeth Kiibler-Ross), sharply negatively related to the propensity of some doctors (and we add – and nurses) is too easy to predict how much life is left for the patient [8]. Of course, in the treatment of chronic illness in the vast majority of terminal patients, the risk of iatrogenic drug dependence is almost zero. At the same time, this risk can not be ruled out a priori absolutely in all patients on palliative care. This is the first objective moral and ethical dilemma in the practice of treating chronic pain syndrome in terminal patients.

Another moral and ethical dilemma, generated by modern tactics of treating chronic pain in terminal patients, is associated with the risk of shortening the lives of such patients from the use of high doses of anesthetic. It is only about cases where the use of high doses of analgesics does not have a clinical alternative. According to WHO experts, such clinical situations should not be assessed as “death from an overdose”: “Some acceleration of the death due to measures aimed at suppressing pain should be regarded in such a way that the patient could no longer tolerate the therapy that is necessary for that to make his life bearable and dignified “[12].

Unfortunately, in the professional medical press in Russia, ethical dilemmas of anesthesia in palliative medicine, as well as the ethical dilemma of stopping, stopping extraordinary treatment in terminal patients with mandatory palliative care are not discussed at all on clinical material. And the wide popularity among the bulk of Russian doctors and nurses, these new ethical ideas of modern medicine do not have. The only exception is the problem of brain death, which was debated in the philosophical and scientific medical literature in the late 70s. [11], and since 1984 this state is recognized as the equivalent of a person’s death. At the same time, this is the only clinical condition which a hopelessly sick patient is allowed to stop life-saving treatment in Russia. “Fundamentals of the RF legislation on the protection of public health” (Article 45. Prohibition of euthanasia) prohibit not only active euthanasia but also “cessation of artificial measures to maintain life.” Ethical committees in hospitals and hospitals, where doctors and nurses would have acquired the experience of finding the best moral choice in dealing with such ethical dilemmas, in Russia yet. Ethical committees appeared in the early ’90s. in many scientific and research medical centers, but only from the point of carrying out an ethical examination

biomedical research involves a person as an object.

Noting that such ethical aspects of palliative medicine as the refusal of extraordinary treatment in terminal patients, and the risk of shortening their life with modern tactics of anesthesia (“indirect, indirect euthanasia”), while insufficiently realized in the Russian professional medical community, we will turn to the problem of truthful information such patients. In prerevolutionary (before 1917) Russia, most of the coryphaeus of Russian medicine (GA Zakharin, SP Botkin, and others) occupied here an orthodox position, which still goes back to Hippocrates: to conceal “much from the patient in his orders” and not to inform the “sick of what comes or has come, for many patients for this very reason, that is, through the presentation of predictions about what comes or after will happen, was brought to an extreme state” [3]. At the same time, the founder of Russian therapy, M. Ya. Mudrov said in 1820: “To promise healing in an incurable disease is a sign of either an ignorant or dishonorable doctor” [10]. Evidence that many Russian doctors were aware of this most difficult moral problem of healing as an ethical dilemma is that the dying doctor after AS Pushkin twice said that his injury was hopeless.

In Soviet medicine, it is precisely the attitude to the problem of truthfully informing patients in general, and in oncology in particular, that has become an expression of paternalism. One of the founders of domestic oncology, N. N. Petrov in the book “Questions of surgical deontology” (first edition in 1944, the fifth – in 1956), largely determined the approaches to ethical problems in Soviet medicine until the ’80s., wrote: “It is better to avoid the terms” cancer “,” sarcoma “completely, replacing them with the words” swelling “,” ulcer “,” constriction “,” infiltration “, etc.” [15]. NN Petrov allowed the communication of the diagnosis of cancer, and even then as a presumptive, only in the situation of refusal of the patient from surgical treatment. This approach in the following decades was followed by all other oncologists [1].

In modern Russian medicine, many doctors and nurses, especially those working in oncology, in general, are aware of the “ethical revolution” in the field of informing patients that occurred first in the US, and later (though not everywhere in such a radical form) in other Western countries, when, as a result of criticism of the paternalistic model of medicine, in many clinical situations this model began to be replaced by a partner model, based on the ethics of respect for the rights of the patient. At the same time, Russian doctors and nurses are largely unaware of the relevant international ethical standards – the Lisbon Declaration on the Rights of the Patient (WMA, 1981, 1995); The Declaration on Patient Rights Policies in Europe (WHO, 1994); Convention for the Protection of Human Rights and Dignity in connection with the use of the achievements of biology and medicine; Convention on Human Rights and Biomedicine (Council of Europe, 1996).

A few sociological studies of this problem in our country have shown the following. When polling the population of Moscow in 1992, 47% of the respondents answered,

that hopelessly sick people have the right to know the whole truth about their state of health, and 41% say that the doctor should decide this question. When asked by doctors: “Do you inform patients about the diagnosis and prognosis?” – 40% of them answered – “almost always”, 30% – “often”, 19% – “sometimes.” To the question: “Do you think that the patient should know about the hopeless forecast?” – 27% answered affirmatively, and negatively – 46% of doctors. Finally, 61% answered the question of actual, actual informing of hopelessly sick people “usually not”, 11% – “sometimes”, 2% – “often,” 3.5% – “almost always” [21]. Thus, 27% of the polled domestic doctors in the soul for truthfully informing the hopelessly sick (we are convinced that among oncologists this indicator is much lower). However, only about 5% of doctors adhere to this position in their clinical practice.

The main peculiarity of the problem of truthful information of patients by their doctors in our country is that customs, and norms of medical deontology come into sharp contradiction with the current Russian legislation. “Fundamentals of the RF legislation on the protection of public health” (Article 31. The right of the citizens of the Russian Federation to information about the state of health) prescribe: “Every citizen has the right, in an accessible form, to obtain available information about his state of health, including information on the results of the survey, the availability the disease, its diagnosis and prognosis, the treatment methods, the risk associated with it, the possible options for medical intervention, their consequences and the results of the treatment … In cases of unfavorable prognosis of the disease development info The statement should be reported in a delicate form to a citizen and members of his family if the citizen has not forbidden to inform them about it and (or) has not appointed a person to whom such information should be transmitted “[13]. From our point of view, these prescriptions are too categorical. After all, a similar problem in the Lisbon Declaration on the Rights of the Patient of the WMA (edition of 1995) is solved more gently, compromise: “Exceptionally, some information can be hidden from the patient in those cases when there is good reason to assume that, being informed to the patient, this information may pose a threat to his life or health “[23].

Of course, most of today’s Russian oncologists solve the problem of informing their patients as before, traditionally, that is, conservatively paternalistic. Of course, the diagnosis of “cancer” today is reported to the patient (especially with greater chances of success of therapy) much more often than in the days of N. N. Petrov. But when informing patients about the unfavorable prognosis of the outcome of their disease, usually doctors (not all but the vast majority) adhere to the “optimistic legend” [19], and truthful information about the patient’s condition is necessarily reported to the patient’s relatives (usually without the knowledge of the latter, that is, violating medical secrecy, which is prohibited both by medical ethics and by Law – Article 61. The medical secret is “Fundamentals of the RF Legislation on the Protection of Citizens’ Health”).

The emergence of hospices in our country in the 90s. made significant adjustments (at least in the hospices themselves) in solving the problem of informing patients with a fatal prognosis, since the initial preparation of the first domestic

Specialists in palliative medicine passed either abroad, or in Russia with the invitation of teachers from abroad. The first printed manuals on palliative medicine in Russian were translations of the corresponding English manuals. For example, in the First Moscow Hospice, whose work the authors of the article are well acquainted, the question of truthfully informing his patients about the state of their health is solved as follows: every patient, who wants it, who is ready for this, has the right to know the whole truth. This ethical setting is necessarily supplemented by another ethical setting: the patient also has the right not to know the truth. A few publications, summarizing the experience of Russian hospices, relate to this problem. For example, LA Zelnitsky, analyzing the work of the Hospice service in St. Petersburg in 9 months of 1992 and noting that 504 people were covered by all forms of hospice care, further emphasizes: “In 100% of cases, patients received full information about his condition and disease. Cases of inadequate response to additional data on their disease and its name were not “[6].

Analyzing the experience of the formation of the hospice service in Russia in the early 90s, AV Gnezdilov draws attention to the paradoxically small number in our hospices of volunteers (volunteers), where it is counted as a whole, while in the West “for 20 patients there are 100-150 volunteers “[4]. The role of volunteers in the hospice movement has profound philosophical overtones. Let us turn again to LN Tolstoy’s novel The Death of Ivan Ilyich: “Ivan Ilyich at some time, after much suffering, wanted most, as he would not have been ashamed to admit it, – he wanted that he, like a child, be sick, someone would have pity. He wanted to be petted, kissed, wept over him, how to caress and console children. ” Servant of Ivan Ilyich Gerasim seems to express the whole meaning, the whole philosophy of the hospice business: “If you are not sick, why not serve? .. We will all die, why not work?” [18].

Volunteers in hospice are another civil initiative, akin to environment. Many of the volunteers have had survived the loss of a loved one, having already gone through the “way to death” with him once already. The death of man is the collapse of the universe, the microcosm of the human personality. The volunteers in the hospice are Tolstoy’s “collective Gerasim”, whose words can be exhaustively defined by their moral position: “We will all die, why not work?” The movers, protest as if by their labor against the total medication of death in our time, preventing the transformation of dying humans in a simple biotechnological process. A small number of volunteers in Russian hospices is another serious problem in today’s Russian society, of course, beyond the health sector.

The modern reform of nursing in our country is the most advanced in nursing education. Since 1991, the country has begun training nurses with higher education. This was the first step toward creating a system of multi-level nursing education: a basic level, an advanced level, higher education, residency, and postgraduate study. It is natural to domestic nurses of the new formation are increasingly occupying a “niche” of qualified nursing teachers in hundreds of Russian secondary medical schools (10 years ago there were almost no nurses here among the teachers). Further development of the reform in nursing practice and nursing studies will largely be determined by the fact that the leaders of the healthcare system, the nurses themselves will find other professional “niches” for the career development of nurses of the new formation.

It is logical that another such professional “niche” was management activity in the medical and preventive institutions of the country.

From our point of view, another such professional “niche” in which the goals and tasks of modern nursing reform in our country could be successfully realized is the system of palliative care. In the professional training of nurses working here, many scientific achievements in clinical medicine in general (which, for example, are increasingly oriented toward studying the quality of life of patients) and palliative medicine itself, with its experience in solving ethical dilemmas, effective treatment of chronic pain syndrome, solving social problems of terminal patients, providing them and their loved ones with psychological support, etc. While society does not create an effective system of palliative care for all patients who need it, this society can not be considered sufficiently civilized. Nurses who will link their lives, and their professional growth with palliative medicine, already deserve respect, and they will be the first builders of this important line of modern healthcare in our country.



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