Palliative care and grief: a bibliometric study

Analyze the scientific production published on online journals about palliative care and grief. This is a bibliometric study, conducted with 48 articles, published between 2005 and 2014, selected in the databases LILACS, IBECS, MEDLINE, PubMed, SciELO and DOAJ. The years 2012 and 2013 presented a greater quantitative of publications. Were identified 37 vehicles of which the Palliative Medicine Journal was the one that most published on the subject, and the American Journal of Psychiatry showed the highest impact factor. Most of the publications were produced by medical researchers and predominated authors with PhD. It is expected to have contributed to stimulate scientific production in this thematic and subsidize the dissemination of this specific knowledge and assist in the preparation and training of professionals for patient care under palliative care in the confrontation of grief.


INTRODUCTION
In the context of contemporary health, discussions about human finitude are gaining emphasis in society, especially when it comes to technological innovations, the possibilities to prolong life and the cure of illnesses.However, the cure, in some cases, is impossible, and death, therefore, inevitable.Given this reality, palliative care emerged, spread around the world as a form of care that strives for the patient's well-being and is promoted in the early stages of the course of certain progressive disease, advanced and incurable 1 .
In palliative care, the limit of life is accepted and the goal is to care, not cure.Aims for the respect of human dignity and must be started from the diagnosis of serious diseases, progressive and incurable, assigning to promote comfort and well-being for the person.It is noteworthy that, in the practice of such care, assistance is inserted in the whole process of human finitude and mourning phase experienced by the patient and its family.Grief is presented as a normal and expected reaction to the breaking of a bond, an emotional tie with significance set in an individual way, experienced in contextual and subjective form 2 .
Grief can be anticipatory, which is qualified by the expected loss experienced by the patient and its family, in the phase between the diagnosis and death; normal, or grieving at the right time, which is characterized as the event after death; and complicated or pathological when anguish and mourning at the loss may vary from the pain of absence until a devastating sadness that may appear associated with suicidal ideations and psychotic symptoms 3 .Mourning is essentially a response to an indeed potentially deconstructive and inevitable fact, that all human beings will experience at some point in the course of their lives 4 .
The attention to grief varies according to the needs of each person and family affected.Although most individuals have sufficient internal resources and informal to adapt to this life transition, some are more vulnerable and may be at risk of developing physical or mental problems and seek emergency medical services and hospitalization, as mentioned in study 5 .For that reason, it is undeniable the relevance of palliative care as a form of care that alleviates physical and spiritual symptoms, and gives psychosocial support, since the diagnosis of a disease without cure until the end of life and throughout the grieving process of the patient and the family.Therefore, considering that palliative care and grief have been making a growing theme at the national level, urges the need to explore the knowledge produced on this theme available in online journals, with the undertaking of a bibliometric study.
The correct choice of the subject is essential to the research carried out is, in fact, representative of the existing knowledge on a topic.Thus, the use of keywords enhances access to the content of documents 6 .With regard to grief, this becomes important in the philosophy of palliative care and establishes the object of its action.In this context, it is highlighted the importance of using grief a keyword because present as mediator between the recorded information as faithfully as possible and the contents of this research.
In this setting, this study seeks to answer the following question: What is the scientific production available in online journals addressing palliative care and grief?In this perspective, this research aims to analyze the scientific production on palliative care and grief published on online journals.

METHODS
Bibliometrics is a method that has been used by different areas of knowledge, in order to combine and synthesize research findings on a theme delimited or a guiding question, in a systematic and orderly manner, which contributes to the construction and improvement of the knowledge on the subject investigated 7 .
For the development of this research, a search was made in the following databases: Latin American and Caribbean Literature (LILACS), International Literature (MEDLINE), Spanish Bibliographical Index in Health Sciences (IBECS), Medical Publications (PubMed) Online Scientific Electronic Library (SciELO) and Directory of Open Access Journals (DOAJ).
It is appropriate to point out that the search for articles in these databases was conducted using the available health terminology among the Medical Subject Headings (MeSH) and the keywords available in the Health Sciences Descriptors (DeCS).The data were collected in the period from July to October of 2014.Using the keywords: "palliative care and grief" or "palliative care and bereavement" or "terminally and mourning" and "cuidados paliativos e luto" or "termilidade e luto".This set of descriptors has been extensively revised to remove as many studies that did not meet the proposed criteria and to focus on the selected theme.
To select the sample, were adopted the following inclusion criteria: publication in article form, available in full on online collection, in any language, in the period from 2005 to 2014, which addressed palliative care and grief in its title or keywords for the study.In that way, it was possible to identify 79 articles.Were excluded 22 studies whose title or descriptors did not present the relevant keywords, and nine repeated studies.Thus, the sample of the study consisted of 48 articles.
The time frame was based on the assumption that one can infer with more security on the evolution of the theme, starting from the research of a longer-term situation, seeking to show the trajectory of a given phenomenon 8 .In this way, it has the purpose of covering the most widespread studies in the literature on palliative care with emphasis on grief.Thus, it is necessary to adjust the temporal delimitation of ten years (2005-2014).
After reading the selected studies, they were analyzed using an already validated instrument 9 , evaluating information from the database; year of publication; data relating to periodicals; professional qualification and titling of the authors; authors'

Palliative care and grief
Fernandes MA, Costa SFG, Morais GSN, Duarte MCS, Zaccara AAL, Batista PSS binding to the institution; data from studies concerning the mode, the approach, the research site, the group of participants, the analysis of data, the techniques and data collection instruments and the reference to ethical aspects; and used descriptors.
In relation to the descriptors, it was employed the methodology of concept map.The conceptual maps are schematic structures represented by a set of ideas and concepts, since the most extensive to the less inclusive, organized with the purpose of presenting more clearly the knowledge and organize it for simplicity and for order of the content that will be covered, displayed and analyzed in depth and at length, with the use of Cmap Tools ® software 10 .
Therefore, with the data of this research, it was proceeded to the descriptive statistical analysis, with frequency distribution in absolute numbers (n) and relative frequency (%), arranged in graphics, tables and figures.

RESULTS
In this section, are presented the results from the selected scientific productions, considering the bibliometric indicators.After applying the selection criteria, were collected 48 articles relating to the range of 2005-2014, which constituted the sample of this research.
With regard to databases, 48.92% of the articles published were available in LILACS, and 20.83%, in MEDLINE.The virtual libraries SciELO and PubMed presented the amount of 18.75% publications, each.About the publications, 10.41% were in IBECS, and 2.08%, in DOAJ.
As for the articles considered in this study, Graphic 1 shows the distribution in relative numbers of the production of articles, according to the year of publication.
Graphic 1 represents the temporal dynamics of the production of articles.It is seen that in the distribution of studies, by years, there was a certain homogeneity during the selected period researched, although with the largest number of articles in the years 2012 and 2013, which concentrated about 29.2% of the total number of publications.Considering the fact that, for the year 2014, it was only possible to insert published studies until the month of September, the curve of publications on palliative care and grief seems to float upwardly, since 49% of the studied journals are monthly.This demonstrates a quantitative growth in research in this area.
Table 1 shows in which journals the studies were published on.Thus, were identified 37 dissemination periodicals.Of these, the one that has most published on the subject palliative care and grief was the Medicina Paliativa Journal, which presented 10.4% of all surveyed items, followed by Supportive Care in Cancer, with 8.3%.
In relation to the language used by journals to disseminate its scientific content, 40.54% of them adopt English, followed by periodicals that disseminate their studies in Portuguese and Spanish.
Table 1 also presents the impact factor of publishing vehicles considering the base year of 2013.The American Journal of Psychiatry showed an FI of 13,559, followed by the CMAJ journal, with an FI of 5,808.
With regard to academic and professional qualification, researchers have been identified from different areas of knowledge.According to the data obtained, stood out Medicine among the authors, with 45.8%; Psychology, with a considerable percentage among the other professions, with 35.4%; Nursing, with 12.5%.The lowest indexes were presented by the areas of Biology, Social Sciences and Theology, with 2% each.
Regarding the degree of the researchers, the data indicated that 37.5% are doctors; 27%, PhD; 25%, masters; and 10.4%, specialists or residents.About the number of authors per article, there was an ascendance in studies with a single author, representing 37.5% of the studies.Articles with two authors add up to a quantity of 16.6%; scientific productions, three authors 12.5%; studies with four authors, 10.4%; and those with five or more authors, 23.9%.
In relation to the institutional link of the authors, Brazil stands out with the participation of 31.4% of educational institutions that publish researches about palliative care and bereavement.The United States are represented by 14.1% of universities; Spain, by 11.4%; and Australia, by 8.6% of the institutions.
As for the data concerning the methodological approach used in each of the articles that composed the sample of this research, there was variety in relation to the mode of studies, with prevalence for the original study, with 72.9% of articles published.The modality, case studies, presented 14.6% of sampling and review, a percentage of 12.5%.
Regarding the approach of the 37 original articles, prevalence of studies was for the qualitative approach applied in 48.6% of articles; quantitative, 20.0%, and to 14.3%.Not mentioning any, 17.1%.
As for the location of the survey, 42.8% of the work had as scenario Oncology Units, and 28.5%, Palliative Care Units.The group of participants that predominated in most studies were bereaved families, represented by 22.8% of the sample; bereaved patients, 20%, and bereaved children and children/adolescents, 17.1%.Note: * Journal that showed no record of impact factor.
Palliative care and grief Fernandes MA, Costa SFG, Morais GSN, Duarte MCS, Zaccara AAL, Batista PSS With regard to the ethical aspects of research, in short, the study sample revealed that 31.4% did not mention the ethical aspects of research with humans and/or the Protocol for Approval by CEP, Resolution 196/96, and international protocols.As for data collection, the scales were the instruments most used, with 34.3%.In relation to the data collection technique, the interview stood out, with 28.5% of these studies.Regarding to the data analysis technique, the thematic analysis of content was the one that stood out with a percentage of 17.1%, while 14.3% of original studies have not made any reference.
For discussion under the prism of scientific production on palliative care and grief, it will be contextualized with the analysis of the keywords of the items shown in Figure 1, represented by a conceptual map constructed linearly.

DISCUSSION
With regard to scientific communication, are highlighted the journals of health sciences, whose primary characteristic is its regularity and speed in the dissemination of knowledge.These journals provide a continuous flow of information on the results of studies and enable the dynamics and the evolution of the process of knowledge in a particular area in the ambit of care.
Considering the prevalent journals in publications on the theme "palliative care and grief", there are three important vehicles responsible for disseminating the knowledge, namely: "Medicina Paliativa Journal", with five publications, and the "Supportive Care in Cancer", with three.Both are scientific journals that address the focused subject in this study.In addition to these, stands out the Ciência & Saúde Coletiva journal, with three articles related to the topic investigated.It is worth pointing out that each of the other journals included in the study presented a publication.
The "Medicina Paliativa Journal" is a quarterly publication of Sociedade Espanhola de Cuidados Paliativos, which are published studies from all areas related to palliative care, particularly the multidisciplinary character 11 .The journal "Supportive Care in Cancer" addresses mainly, medical, surgical and therapy themes related to technical support and care that can complement or replace the basic treatment for cancer at all stages of the disease 12 .The scientific journal "Ciência & Saúde Coletiva" is a periodical of Associação Brasileira de Saúde Coletiva (ABRASCO), published monthly.Its mission is to publish debates, analyses and results of research on a specific theme considered relevant to the collective health 13 .
Regarding language, the results show, in this study, the hegemony of English on the theme "palliative care and grief", considering that even countries whose official language is not English, like Brazil, also publish in that language.In this sense, the study 14 in palliative care area corroborates this finding, which emphasize that for most of the publications surveyed the predominant language is English, which indicates the importance of this language in the dissemination of knowledge produced.
Among the journals of highest impact factor, the American Journal of Psychiatry and the Canadian Medical Association Journal (CMAJ) prevailed.The impact factor (FI) of a scientific journal is the average equation of citations of scientific articles published in a specific journal indexed in a database 15 .American Journal of Psychiatry is the most widely read psychiatric journal internationally, published monthly, and of fundamental importance for psychiatrists and other mental health professionals committed to keep the field of Psychiatry on the rise, when publishing the latest advances regarding the diagnosis and treatment of mental illness 16 .As for the journal CMAJ, it is a medical journal that publishes original clinical

Palliative care and grief
Fernandes MA, Costa SFG, Morais GSN, Duarte MCS, Zaccara AAL, Batista PSS researches, reviews, analyses of clinical topics, health news, updates of clinical practice and editorials 17 .
In relation to the area of knowledge of the publications included in the study and training of authors, most come from the Medicine, Psychology and Nursing.This demonstrates that the topic under the study is a multidisciplinary research theme.The investigation 18 revealed that there is significant production of articles on palliative care in recent years, which shows that this type of care comes deserving attention by researchers, with positive probabilities to be inserted palliative care under assistance and academic training of professionals from different areas.Based on this premise, the investigation showed that, despite Medicine being dominant in developing work focused on the theme in question, other areas have shown interest in developing studies on palliative care, such as Nursing, Psychology, Physiotherapy, Nutrition and Social Services, which results in stimulating the creation of a multidisciplinary team to assist patients and families who need such care.
Regarding the authors' title, it is understood that health professionals are seeking mechanisms aimed at sophistication and improvement of scientific research.Proof of this is that most authors are doctors, making it possible, in such way, to add reliability and relevance to the knowledge that these researchers desire to publish.The originality of a study determines scientific progress through the dissemination of research findings that enhance the understanding of certain subject.Thus, the large number of original articles found from this research demonstrates the interest of authors in deepening the understanding of palliative care and grief of which intervention and research themes are of great importance, in addition to being contemporary themes of discussion 4 .
It should be stressed, however, that despite the importance of original articles, the reviews have an important role in the dissemination of information, in particular regarding grief, a subject still little discussed nationally and internationally.Because of this, it is essential to update the knowledge about certain content, in this case, the process of grieving, because it requires a careful evaluation of the subject available in the scientific scenario.Furthermore, any knowledge produced begins with a comprehensive review of the literature, in order to identify gaps on a particular topic, which results in an investigation 19 .
As the prevalent approach among the manuscripts included in this research, it can be said that the result meets the suggesting of the mourning theme, which is its in-depth understanding, possible through qualitative studies, because they contribute to the investigated be more involved, learn the process and the results obtained and act as an ally in the process of knowledge construction, which promotes a deepening of the reality studied.
Whereas this investigation involves a bibliometric analysis of scientific production about palliative care and grief, the predominance of studies in cancer services is understandable, since cancer is a disease that, in advanced stages, threats life, therefore, requires a palliative approach.However, it is important to note that palliative care and the experience of grief are experienced by any family and individual affected by a pathology without healing therapy possibilities.For this reason, it is necessary to draw the attention of researchers to undertake studies involving cancer patients and their families who experience the process of finitude and that, regardless of the diagnosis, suffer physical, social, psychological and spiritual pain.
Understanding grief requires the reflection of the person who experiences the phenomenon.This explains the large number of scientific articles conducted with human beings and requires compliance with ethical rules, with regard to research involving human beings.Thus, it should be evident in the methodology of the manuscripts, because the Brazilian and international legislation about the ethical rules to conduct research with people aim to protect "the subject of the investigation and contribute to the quality of the research that has the ambition to be scientifically reliable, methodologically correct, morally acceptable and socially relevant" 20:567 .However, it is clear, in this study, a significant quantity of research that make no reference to the ethical aspects of research involving human beings, which requires efforts of journals to pay attention so that researchers comply with the ethical provisions, when submitting their researches with human beings through a careful evaluation.
The fact that most of the inserted studies in this research, used the interview as data collection instrument shows that it is one of the main techniques to obtain information about a particular topic, because it allows the seizure of categorical information and in-depth data collection 21 .
Also exploring the data of the articles included in this research, it is possible to infer about the current trend with regard to the use of the technique of content analysis, to interpret data from qualitative research, more prevalent among the manuscripts, as shown.The analysis of content, such as a data-processing technique in scientific research, aims to "[...] obtain, by systematic procedures and objectives description of contents of messages, indicators (quantitative or not) that allow the inference of knowledge of production/reception conditions (inferred variables) of these messages" 22:47 .Based on this definition, it is possible to understand the reason that technical analysis is being increasingly used among the thematic related research palliative care and grief, since it allows to understand the characteristics related to the phenomenon and behind the speeches of the investigated.
The study examined if the descriptors used in the search in the databases were present as keywords in the articles.For this, a frequency count of these descriptors in the sample of keywords was performed.Were identified 76 terms in 48 publications, and the most frequent descriptors were "palliative care", with a representation of 33.4%, and "grief" with 28.2%, among the articles selected for this study.

Palliative care and grief
Fernandes MA, Costa SFG, Morais GSN, Duarte MCS, Zaccara AAL, Batista PSS Both terms are indexed in Descriptors of Health Sciences (DeCS).DeCS is a structured and trilingual vocabulary (English, Portuguese and Spanish), created by Bireme to be used for indexing scientific journal articles, dissertations, theses, books and other documents.It is used also in the process of search and recovery articles in the databases Lilacs, SciELO, Medline, among others.
DeCS was developed from the Medical Subject Headings (MeSH) by the Latin American and Caribbean Center of Information in Health Sciences (Bireme), with the objective of promoting the use of common terminology for research and a safe and unique environment to index and internationalize the information in order to facilitate a uniform dialogue between 600 arranged online libraries across countries 23 .
It should be mentioned that the keywords were organized and displayed schematically in a systematic order, from the correlation and the meaning between the terms, presented through a conceptual map, as shown in Figure 1.In this map, there is a variability of approaches with scope of expressions that form four areas interconnected with each other.It may be noted that the descriptors of the first axis highlight aspects of palliative care in anticipatory mourning, which starts from the moment it is received a diagnosis of a potentially deadly disease, for concrete or symbolic losses that might cause the person who is receiving hospice and their family 23 .
It is possible to understand, therefore, that the concepts of palliative care and grief involve the assistance of the patient and its family, both considered a unit of care, and that effective communication is paramount to the relationship of those involved in this action (professional, patient and family).This allows the management of care related to death and the grief and enhances the conducting and the adaptation in the therapeutic project to individual needs 24 .
The second class of words refers to the promoters of palliation.In palliative care, multidisciplinary activities are essential for the patient to have a good quality of life and a dignified survival.Respect, ethics, sensitivity and sincerity should always guide the team during the treatment.Ideally, such assistance should be provided by an interdisciplinary team that includes doctors, nurses, social workers, psychologists and chaplains 25 .They should promote coordination and continuity of actions.
With regard to bereavement, nurses and psychologists are the professional with more skills to provide the necessary support.The nurse because accompanies the patient and their families daily, throughout the process of palliative care, and for being a professional whose communication is sensitive and empathic, and able to listen to the complaints of the patient and their families, to identify the real needs the patient and perform effective actions 26 .In addition, the psychologist's intervention in this process of alleviation is particularly important because conflicting and unconscious behavioral reactions arise in the patient and their families, which leads to a state of distress and reinforces feelings of uselessness of effort, existential meaning and life project 27 .
The third class relates to the great theme of the cultural aspects of death and dying, the attitude towards finitude and its interference in the quality of life of the patient and the possible complications of a bereavement in the family.In the meantime, it should be consider the values and beliefs in the face of death and the dying process of the patient and their families.The suffering that the awareness of finitude has caused in humans, over time, is so intense that, for the bereaved, the acceptance of death is a painful process, especially in Western culture 27 .It is important to note that, these aspects have reinforced the need to implement actions for a more humane practice in that respect the rights of users and preserve their family relationships and socio-cultural values across the finitude process in palliative care 24 .
The death of a loved one is a painful event and can be even more suffered depending on the bond the person have with the one who is dying.An example of this is the loss of a son, considered a risk factor for the development of a complicated grief, by the bond between parents and children -complex and intense.Therefore, the multiprofessional team develop mechanisms through which enhance its interventions to understand and accompany those who face the finitude and grieving process, in order to improve the quality of its life, the main objective of palliative care 24 .
The study 28 performed indicates that a substantial part of the caregiver family of patients under deceased palliative care are developing complicated grief post-loss reactions or depression and a group of bereaved people still suffering from high levels of anxiety over a considerable period of time.Based on these findings, the research suggested that due to the high prevalence of complicated grief and its severity, early identification of families at risk can be beneficial.However, one needs approaches to identify prospectively people at risk and indicate the need to use scales to assess risk, which can safely identify and benefit the people involved in the care of loved one.
Finally, as the schematic drawing suggests, the fourth thematic class exposed in Figure 1, present palliative care as an assistive mode that is intended for patients with diseases without therapeutic possibility of healing and terminals in any age group (children, adolescents, adults and the elderly).
The proper practice of palliative care advocates an individualized attention focused on those who suffer from diseases that threaten the continuity of life and seeking excellence in control of all the symptoms and prevention of pain.For this reason, it is important that each member of the team develop its specific role, but acting in an integrated manner, in harmonic and convergent work, identifying problems and decisions taken together.This is, therefore, a way of contributing to the dyad patient/family can continue to have a good quality of life and well-being.

CONCLUSIONS
This bibliometric review enabled the discussion of 48 references on the subject of palliative care and grief.It is worth mentioning that, in the practice of palliative care, grief is an experience linked directly to the patient and its family, however, for health professionals, it is a great challenge to work with care on the border of the possibilities of life.It can be stated that the main questioners centers of this thematic are concentrated in Brazil and the United States of America.Among the journals, which published most on the subject was the Palliative Medicine Journal.
From the characterization of the analyzed publications, it was considered that the scientific articles on the subject, although they have grown numerically in recent years, show that the research is not yet consolidated, showing gaps in the production of knowledge, for example, not contemplating research that emphasize training in health in the context of palliative and bereavement care and not being considered by most researchers, the ethical aspects of research involving human beings.It is necessary to meet the observances of rules, laws and ethical recommendations to safeguard the protection of research subjects.The discussion on the ethics of research should be instigated and be present in the academic field as well as in scientific events and journals.
With the analysis of the bibliometric aspects of scientific production, health professionals and teachers researchers can understand the characteristics of the disseminated articles on the subject investigated.Further investigation on this subject can contribute to the expansion of the discussions about palliative care and grief directed to all involved in the process of a disease without curing possibilities and on completion of life.In addition, the contribution that the study presents is an indication of the need for health professionals to develop more researches considering interdisciplinarity and training in health, which will help professionals to develop better teamwork in order to deal with patient care under palliative care in the confrontation of grief.

Graphic 1 .
Distribution of studies on palliative care and grief, according to the year of publication, in the period 2005-2014 (n = 48).Palliative care and griefFernandes MA, Costa SFG, Morais GSN, Duarte MCS, Zaccara AAL, Batista PSS

Figure 1 .
Figure 1.Elaborated conceptual map, from the descriptors of the studies on/about palliative care and grief, in the period 2005-2014 (n = 48).

Table 1 .
Distribution of studies on palliative care and grief, as for the journal, in the period from 2005 to 2014 (n = 48)