Concept of Dignity and Related Factors among Elderly Patients with Cancer

Context

According to WHO, respecting dignity is a prominent factor in patient recovery [1]. The International Council of Nurses puts a lot of emphasis on the honor and dignity of the patients to be respected by nurses, creating a code of ethics for that reason [2]. Dignity is a complex, fundamental, and ambiguous concept [3]. There has not yet been any clear and acceptable definition for it; however, human dignity has been defined as feeling valued, respect, privacy, and having control in various societies. Human rights, independence, satisfaction, security, and being autonomous are other areas of consideration regarding dignity [4-6]. Respecting human dignity is one of the principal factors of ethics and ethical care. Thus, a thorough study of this concept is essential [7].

Respecting dignity becomes more important for special and vulnerable age groups such as the elderly patients suffering from cancer [8,9]. The hospitalization period is longer for the elderly compared to young people which increases the risk of their dignity being ignored [10]. Although the rise in the number of old people is a victory in health and socioeconomic policies, it is also a 21st-century challenge that calls for all social aspects to maximize the capacity for health, functionality, social contribution, and security in the elderly [11]. According to the estimation of the Population Division of the United States, the elderly population will have soared dramatically by 2050 in developed countries, with the number of old people reaching from the current 739 million to 2 billion in 2050 [1].

Researchers explain nursing and human dignity as followings:

1. A nurse can improve the trust of the patient in the caring team.
2. A nurse can increase a patient’s satisfaction with nursing care.
3. A nurse can decrease dependence.
4. A nurse can reduce the hospitalization duration.
5. A nurse can fulfill the security needs of the patient [11-14].

On the other hand, ignoring the honor and dignity of an elderly patient increase stress, anxiety, depression [15,16]. It can also create negative feelings, uncooperativeness, not following the prescribed diet, and change in sleeping patterns [17,18].

Various studies indicate diverse results about respecting human dignity; nevertheless, there have been few studies addressing dignity and its effect on elderly cancer patients. Studies show that most hospitalized patients are satisfied with their honor and dignity being protected by the nurses [19]. In contrast, Matiti et al. have shown that a high number of patients complained about their honor and dignity being respected in hospitals [20]. A study carried out in Iran in 2010 demonstrated that half of the patients reported their privacy in hospitals to be low or medium and complained about a disregard for their privacy, independence and an experience of disrespect when receiving nursing care [21]. Schopp, et al. (2003) showed that in five European countries the nurses were satisfied with their professional conduct to respect the patients’ privacy, while the patients thought otherwise [22].

This contrast in viewpoints among nurses and patients about respect and dignity is considerable because there is a concern that nurses overestimate their ability to respect patient’s privacy. In other words, although the receivers of the service are not satisfied, nurses still think that they should be. A nurse might consider a conduct proper whereas another nurse or a patient from a different nationality, culture, or age group may consider the same conduct as an insult [23]. Therefore, it is challenging to derive a conclusion from these studies, and one needs to explore dignity from the viewpoints of special groups such as nurses, patients, cultural groups, nationalities, and age groups. Human dignity is a prominent concept in nursing care, but complex and ambiguous at the same time. There needs to be more research about dignity and its various aspects in elderly cancer patients. The viewpoints of nurses and the elderly towards the significance and respecting of dignity must be realized, which will lead to better cooperation among them.

Evidence Acquisition

To this study, researchers engaged in reviewing related papers, resources, and articles published between 2015 and 2021 in English and Farsi from the following websites: Pub Med, Magiran, Iran Medex, Science Direct, Cochran, Proquest, Sid, Web of science. The keywords examined include dignity, nursing, respect, oncology patient, personal respect, elderly, independency, nursing care, decent, privacy, Elderly with cancer both in Farsi and English. It should be noted that to have a better understanding of the nature of current relations, interventional and review articles were examined simultaneously.

Results

The Concept of Dignity

Dignity is a mental and ethical experience that every human being has had it due to human being [24]. Honor is a complex, mental, and dynamic quality [25]. Dignity is a feeling of being important and valuable which forms while interacting with others and can be endangered or developed in those interactions [26]. It has been defined philosophically in the nurse corps code of ethics, being defined as an integral and unique part of an individual. The philosophical aspect is related to the value of uniqueness in people [27]. Dignity has also been defined as a concept of self-importance and respect [28].

Terms like hopefulness, self-excellence, self-confidence, quality of life, and self-respect overlap with dignity [29-32]. Dignity is a judgment on people’s respectful conduct, it is a behavior that indicates respect, and people who respect themselves and others are honored [33].

Classification of Dignity in the Elderly

Dignity has a philosophical aspect related to human being, meaning that every individual is special and possesses intrinsic and unique characteristics [29].

Two types of dignity can be defined regarding the elderly:

a) Human or absolute dignity: Since human is an image of God, this dignity is an intrinsic right for all humans disregarding gender, race, age, and religion, to have the same value and rights. This dignity is unchangeable, is built upon theology and law, and exists because of human characteristics such as responsibility, speech, logic, love, and morality.

b) Social, relative, or locational dignity: Social dignity reflects human dignity, but arises from culture and society, changing and evolving in relation to others. Therefore, it can be influenced by the level of education, context, and social networks and is dependent on interactions [34].

Effective Factors in the Maintenance and Improvement of Dignity in Elderly Cancer Patients

Individualized care, integrity, and excellence: Respecting the dignity of the elderly patients means giving individualized care, with an awareness of their needs, hopes, and habits in physical, mental, spiritual, and social levels [35]. Paying attention to the life story, experiences, and beliefs of an old person and modifying the care can lead to a feeling of being valued and an acceptance towards depending on the care correctly. Individualized care means encouraging the old person to have activities and make decisions about his/her care, which can be carried out based on the nurse’s understanding [36,37]. The elderly patients evaluate themselves by their ability to perform daily activities [37]. Nurses must identify the abilities of the patients and manage their expectations according to their abilities.

Therefore, the old patient will recognize his/her abilities and will adapt accordingly [38]. This will help reduce the feeling of being a burden to others and prevent unnecessary dependence of the elderly cancer patients on others. Being a good listener and emphasizing the individuality of elderly cancer patients is a pivotal principle of individuality and giving value to them, indicating their importance from the perspective of their nurses [38,39]. What follows is paying attention to their excellence and integrity, which is related to the unique characteristics of the elderly, focusing on being, existence, and individual rights [40]. Thus, it defines respecting old people with regards to their integrity as special people with numerous life experiences. Therefore, nurses must identify the personality and habits of elderly cancer patients and respect them.

Retrieving self-control and authority: this means being able to make decisions free from threats or coercion [41]. The goal of elderly care is to maintain their control in the status and improving new capabilities. When an elderly person faces a health crisis, supporting self-control and focusing on health becomes important [40,42]. At this stage the elderly cancer patient improves his/her self-esteem to regain control and authority over life, by accepting the new level of capabilities; moreover, in many cases regaining selfcontrol is achieved by modifying the conditions of the environment and situations to rehabiliate the elderly person [43-45].

Independence: The focus on the old person’s independence and capabilities to make choices and important personal decisions is based on that person’s individual interests [37]. One of the rights of an elderly person is to make decisions for themselves and have authority [36]. This will show the nurse’s respect for their rights. Nurses must refrain from labeling elderly cancer patients as useless and incapable people. They must be aware of the patients’ history to become familiar with their abilities and needs and to be able to manage an adaptation to their needs in accordance with their values and goals [36,38].

Respect: The honor of an old person depends on respect [24]. Respecting the elderly gives them a sense of value. Self-respect develops in an old person according to the respect received from others [39]. Of course, this respect must be given based on the cultural viewpoint of the old person. Respect can be sometimes formed by giving some space to the old person to keep symbols or other things that define his/her individuality or give him a sense of tranquility (like paying attention to the old person’s personal belongings). It should be noted that even the body of an elderly person must be respected [40]. Physical disabilities might be a threat to the honor of an elderly cancer patient [41]. In many cases, being nude in front of others can be a threat to the honor of an individual. For instance, the elderly feels their honor is threatened and damaged by wearing hospital clothing with open backsides [42]. On the other hand, respect forms by interaction, communication, and attention. When an old person feels that the nurses are worried about him/her or acknowledges their altruism, he/she will find faith, trust, and hope in nursing care and speak more freely about sensitive issues with their nurses [43-45].

It should be noted that giving ample information and explanation and informing the elderly person of the treatment-care status is itself considered a form of respect in caring methods; a practice that prevents confusion and unawareness [46]. It is part of an elderly patient’s right to be consulted about the treatment and care procedures [40]. It is especially important to observe personal hygiene and a good appearance for elderly people [47]. An elderly cancer patient expects to be seen dressed up and tidy to gain special statuses like excellence and honor, and these factors can also affect the judgment of others about the elderly person [39]. Therefore, in caring for such patients, attention to a tidy appearance and the cleanliness of their clothes and sheets can help with the creation and maintenance of dignity and show a kind of respect and attention to the elderly person.

Privacy: This mostly means the rights of a person with regards to their individual aspects (private and physical space) or psychological (regarding values, beliefs, and mindset) aspects [48]. Respecting a person’s privacy is one of the pivotal parts of holistic care in meeting the needs of patients [48,49]. This conduct gives honor to the elderly cancer patient and provides grounds for mutual trust [50]. Consequently, a secure environment leads the elderly patient towards physical and mental well-being [9]. Moreover, it should be noted that the limits of private space vary for different individuals. Most elderly patients prefer to have nurses of the same gender as themselves and complain about being asked private questions in the presence of others [51]. This respect can also be formed in relation to social networks around the old person [6].

Discussion

Honor is a quality that leads to happiness and vigor and is a mental experience of judgment towards others [52]. Paying attention to a person’s honor and dignity in nursing care is extremely significant and is one of the needs in the Maslow hierarchy of needs, being one of the human rights which leads to personal transcendence and improving spiritual well-being and the quality of life [33,52]. Evidence shows that feelings of value, respect, being involved in decision-making in care issues, and creating a positive viewpoint in patients, constitutes the most effective health outcomes in care systems [11,12]. As soon as personal honor becomes stained and a type of moral abuse occurs, there will be disorder and instability in caring for patients.

To define the antecedents to the maintenance of dignity and honor for the elderly, their characteristics for them must be recognized. Professional awareness about the elderly includes studying and being aware of the history of elderly health, and how to communicate with them, which is impossible without an understanding of the personality and individuality of the elderly person. Nurses can never fully understand an elderly cancer patient with complete confidence. To provide and maintain dignity, a nurse must be committed to the elderly patient. For that reason, the nurse needs to be aware of the potential capabilities of the patient. Professional nurses must be able to care elderly cancer patients professionally. Therefore, coordination and adaptation can help to create a suitable environment for them. To encourage individuality, the nurses’ attitude towards each patient must be individualized and unique. This approach consists of nurses’ awareness of limitations, physical and mental abilities, cultural sensitivities, helping to maintain and regain values, supporting and facilitating their self-control. Thus, personal characteristics, the type and extent of relations, environmental situation, and social relationships are all effective in the creation and maintenance of the dignity of elderly cancer patients. This approach depends on the behavioral feedback of the elderly person to nurses. Nurses depend on the operational and behavioral feedback of the old person to create coherence in their thoughts, feeling actions and solve issues. Without considering a reflexive relation, dignity will be accidental, which is illogical for the position of a professional nurse. Therefore, the environment must allow nurses to become close to patients; an effort that is impossible in vertical organizations. It is of dire importance that the organization providing the services emphasizes on holistic and patient-oriented care as opposed to economic priorities and routine physical care.

Regarding the high importance of maintaining human dignity in elderly cancer patients and its gripping impact on mental and physical well-being, and the diverse results of previous studies about dignity-oriented relationships in hospitals; it is recommended that clinical interventional studies be conducted to develop this matter.

Conclusion

Dignity is a significant and fundamental concept in nursing and constitutes the core of caring. Respect for human dignity is pivotal in the field of nursing, and one way to maintain and develop dignity is for the person to be able to control the behaviors and the environment around them or be able to receive information and make decisions. Therefore, the maintenance and improvement of dignity result in self-respect and self-esteem. Dignity is highly significant for all age groups. This increases dramatically for the elderly cancer patients, and they expect special attention from nurses at the time of their hospitalization, due to their longer period of stay in the hospital compared to younger patients, and their possible need to help in performing daily routines. The security and dignity of these patients are the responsibility of the nurses in the relevant section, because of the long period of hospitalization. Therefore, the nurses need to know their patients to keep an effective relationship and meeting their needs.

References

• http://www.who.int/mental_health/policy/quality_rights/en/
• (2012) The ICN Code of ethics for nurses. ICN 1-10
• Jollaee S, Bakhshandeh B, Mohammad Ebrahim, M, Asgarzadeh M, Vasheghani Farahani A, et al. (2010) Nursing code of ethics in Iran: the report of a qualitative study. Medical Ethics and History of Medicine 3(2): 45-53.
• Ciolek CH, Lee SY (2020) Cognitive Issues in the Older Adult. Guccione’s Geriatric Physical Therapy pp.425-452.
• Sulmasy DP (2013) The varieties of human dignity: a logical and conceptual analysis. Med Health Care Philos 16(4):937-944.
• Valentini L (2017) Dignity and human rights: A reconceptualisation. Oxford Journal of Legal Studies 37(4): 862-885.
• Lewis M (220) A Conception of Human Dignity: A study about human dignity as a guiding moral principle in the implementation and conflict of human rights.
• Ounalli H, Mamo D, Testoni I, Belvederi Murri M, Caruso R, et al. (2020) Improving Dignity of Care in Community-Dwelling Elderly Patients with Cognitive Decline and Their Caregivers. The Role of Dignity Therapy. Behav Sci(Basel) 10(12): 178.
• Pergolizzi D, Monforte Royo C, Balaguer A, Porta Sales J, Rodriguez Prat A, et al. (2021) Older Age: A Protective Factor Against Perceived Dignity-Related Distress in Patients With Advanced Cancer?. J Pain Symptom Manage 61(5): 928-939.
• Gazarian PK, Morrison CR, Lehmann LS, Tamir O, Bates DW, et al. (2017) Patients' and Care Partners' Perspectives on Dignity and Respect During Acute Care Hospitalization. Journal of patient safety.
• Šaňáková Š, Čáp J (2019) Dignity from the nurses’ and older patients’ perspective: a qualitative literature review. Nurs Ethics. 26(5): 1292-1309.
• Mullen RF, Kydd A, Fleming A, McMillan L (2019) Dignity in nursing care: What does it mean to nursing students?. Nurs Ethics 26(2): 390-404.
• Simões Â, Sapeta P (2019) The concept of dignity in nursing care: a theoretical analysis of the ethics of care. Revi Bioét 27(2): 244-252.
• Lindwall L, Lohne V (2020) Human dignity research in clinical practice-a systematic literature review. Scandinavian Journal of Caring Sciences.
• Parpa E, Kostopoulou S, Tsilika E, Galanos A, Mystakidou K (2019) Depression as a mediator or moderator between preparatory grief and sense of dignity in patients with advanced cancer. Am J Hosp Palliat Care 36(12): 1063-1067.
• Julião M, Barbosa A, Oliveira F, Nunes B, Carneiro AV (2013) Efficacy of dignity therapy for depression and anxiety in terminally ill patients: early results of a randomized controlled trial. Palliat Support Care 11(6): 481-489.
• Amininasab SS, Lolaty HA, Moosazadeh M, Shafipour V (2017) The relationship between human dignity and medication adherence in patients with heart failure. Journal of medical ethics and history of medicine 10: 5.
• Singh OP (2016) Dignity and Death: Psychological wellbeing in death.
• Östlund U, Brown H, Johnston B (2012) Dignity conserving care at end-of-life: a narrative review. Eur J Oncol Nurs 16(4): 353-367.
• Matiti MR, Trorey GM (2008) Patients’ expectations of the maintenance of their dignity. J clin nur 17(20): 2709-2717.
• Nayeri ND, Aghajani M (2010) Patients’ privacy and satisfaction in the emergency department: a descriptive analytical study. Nurs Ethics 17(2): 167-177.
• Leino Kilpi H, Välimäki M, Dassen T, Gasull M, Lemonidou C, et al. (2003) Perceptions of autonomy, privacy and informed consent in the care of elderly people in five European countries: general overview. Nurs Ethics 10(1): 18-27.
• Karimi H, Ajorpaz NM, Aghajani M (2019) Older adults' and nurse’s perception of dignity in the setting of Iranian hospitals: A cross-sectional study. Central European Journal of Nursing and Midwifery 10(4): 1134-1142.
• Rosen M (2012) Dignity: Its history and meaning. Harvard University Press.
• Steinmann R (2016) The core meaning of human dignity. PER: Potchefstroom Electronic Legal Gazette 19(1): 1-32.
• Gilabert P (2016) Labor human rights and human dignity. Philosophy & Social Criticism 42(2): 171-199.
• Roghayeh Ismaili, Jila Abed Saeedi, Tahereh Ashkotrab (2013) The concept of dignity of the elderly from a nursing perspective: a regular review of studies. Journal of Medical History 5(17): 11-36.
• Hall J, Mitchell M (2016) Dignity and respect in midwifery education in the UK: a survey of Lead Midwives of Education. Nurse Educ Pract 21: 9-15.
• Martin Ferreres ML, Pardo MÁ, Porras DB, Moya JL (2019) An ethnographic study of human dignity in nursing practice. Nursing outlook 67(4): 393-403.
• Adib Hajbaghery M, Aghajani M (2015) Patients dignity in nursing. Nurs Midwifery Stud 4(1): e22809.
• Rodriguez A, Smith J, McDermid K (2018) Dignity therapy interventions for young people in palliative care: a rapid structured evidence review. Int J Palliat Nurs 24(7): 339-349.
• Hosseini A, Rezaei M, Bahrami M, Abbasi M, Hariri H (2017) The relationship between dignity status and quality of life in Iranian terminally ill patients with cancer. Iran J Nurs Midwifery Res 22(3): 178-183.
• Farrell C, Heaven C (2018) Understanding the impact of chemotherapy on dignity for older people and their partners. Eur J Oncol Nurs 36: 82-88.
• Caldeira S, Vieirac V, Timmins F, McSherry W (2016) From the struggle of defining to the understanding of dignity: A commentary on Barclay (2016) In sickness and in dignity: A philosophical account of the meaning of dignity in health care. International journal of nursing studies 67: 1-2.
• Er RA, Incedere A, Öztürk S (2018) Respectful care of human dignity: how is it perceived by patients and nurses? J Med Ethics 44(10): 675-680.
• Colloca G, Tagliaferri L, Di Capua B, Gambacorta MA, Lanzotti V, et al. (2020) Management of the elderly cancer patients complexity: the radiation oncology potential. Aging Dis 11(3): 649-657.
• Slettebø Å, Sæteren B, Caspari S, Lohne V, Rehnsfeldt AW, et al. (2017) The significance of meaningful and enjoyable activities for nursing home resident's experiences of dignity. Scand J Caring Sci 31(4): 718-726.
• Balducci L, Fossa SD (2013) Rehabilitation of older cancer patients. Acta Oncologica 52(2): 233-238.
• Suparno A, Arofiati F (2021) Adaptive Response of Colorectal Cancer Patients with Stomas on Quality of Life and Body Images: A Literature.
• Cooper EB (2015) The power of dignity. Fordham L Rev 84: 3.
• Bauer C (2018) Dignity in Choice: A Terminally Ill Patient's Right to Choose. Mitchell Hamline L Rev 44: 1024.
• Halliday S (2016) Protecting human dignity: reframing the abortion debate to respect the dignity of choice and life. Contemporary Issues in Law 13(4): 287-322.
• La Esperanza Oy. The Meanings of Cancer Survival: From Loss of Self-Control to Optimism and Hope.
• Kennedy G (2016) The importance of patient dignity in care at the end of life. Ulster Med J 85(1): 45-48.
• Seglow J (2016) Hate speech, dignity and self-respect. Ethical Theory and Moral Practice 19(5): 1103-1116.
• Gewirth A (2019) Human Dignity as the Basis of Rights. InThe Constitution of Rights pp. 10-28.
• Bluethmann SM, Foo W, Winkels RM, Mama SK, Schmitz KH (2019) Physical activity in older cancer survivors: what role do multimorbidity and perceived disability play? J Aging Phys Act 28(2): 311-319.
• Floridi L (2016) On human dignity as a foundation for the right to privacy. Philosophy & Technology 29(4): 307-312.
• Van der Geest S (2017) The toilet: Dignity, privacy and care of elderly people in Kwahu, Ghana. InAgeing in Africa pp. 227-243.
• Dai WD, Lu S (2108) The “Socialization of Elderly Hospitalization” in China: Development, Problems, and Solutions. Journal of Social Service Research 44(4): 518-528.
• Papastavrou E, Efstathiou G, Andreou C (2016) Nursing students’ perceptions of patient dignity. Nurs Ethics 23(1): 92-103.
• Quintavalla A, Heine K (2019) Priorities and human rights. The International Journal of Human Rights. 23(4): 679-697.