Background
Concepts and their meanings are common features in healthcare and systematically analyzing them can be seen as an approach to deepening knowledge in palliative care. Although analysis and development of concepts can be considered a part of theory, concepts have a relevance and meaning in their own right (Koort Reference Koort1975; Rodgers et al. Reference Rodgers, Jacelon and Knafl2018). A concept analysis contributes ontological evidence about the meaning of concepts in clinical settings (Eriksson Reference Eriksson2010a). Ontology has to do with existence; thus, ontological evidence concerns truth and reality (Eriksson Reference Eriksson2010b; Nilsson Reference Nilsson, Wiklund Gustin and Bergbom2012). According to Eriksson (Reference Eriksson2010b), nothing is evident until it has been expressed and formulated in words. The development of concepts can facilitate interaction in the meeting between a nurse and a patient (Näsman Reference Näsman2020; Nilsson Reference Nilsson, Wiklund Gustin and Bergbom2012). It is emphasized that people are dependent on others and that it is through relationships with others that people create their existence (Lindström et al. Reference Lindström, Lindholm, Zetterlund, Marriner-Tomey and Alligood2010).
The caritative theory of caring is the theoretical framework of this concept analysis of reconciliation in end-of life care. The theory is characterized by caritas, which means that caring consists of actions based on mercy and love (Eriksson Reference Eriksson1987; Kirkevold Reference Kirkevold2000; Lindström et al. Reference Lindström, Lindholm, Zetterlund, Marriner-Tomey and Alligood2010; Näsman Reference Näsman2020; Robinson Wolf et al. Reference Robinson Wolf, France and Lynn2017). According to the theory, health and suffering are parts of a whole with mutual preconditions (Eriksson Reference Eriksson1987, Reference Eriksson2015; Lindström et al. Reference Lindström, Lindholm, Zetterlund, Marriner-Tomey and Alligood2010). Suffering can relate to care, illness, or life, and a goal of nursing is to relieve or eliminate suffering (Kirkevold Reference Kirkevold2000; Lindström et al. Reference Lindström, Lindholm, Zetterlund, Marriner-Tomey and Alligood2010; Näsman Reference Näsman2020). The alleviation of suffering has been described as an impression of health and being able to express one’s suffering can bring relief (Karlsson et al. Reference Karlsson, Högfors and Johansson2020; Lindström et al. Reference Lindström, Lindholm, Zetterlund, Marriner-Tomey and Alligood2010; Näsman Reference Näsman2020). In the movement between suffering and health, reconciliation can play a crucial role by recreating meaning and wholeness (Karlsson et al. Reference Karlsson, Kasén and Wärnå-Furu2017; Lindström et al. Reference Lindström, Lindholm, Zetterlund, Marriner-Tomey and Alligood2010). Thus, reconciliation is identified as a main concept in caritative caring theory and as a prerequisite for caritas (Lindström et al. Reference Lindström, Lindholm, Zetterlund, Marriner-Tomey and Alligood2010).
Serious illness poses a threat to identity, which may cause suffering (Ekman and Norberg Reference Ekman, Norberg, Edberg, Ehrenberg, Friberg, Wallin, Wijk and Öhlén2013; Gustafsson Reference Gustafsson, Gustin and Bergbom2012). However, people struggle to alleviate suffering (Gustafsson Reference Gustafsson, Gustin and Bergbom2012; Lindström et al. Reference Lindström, Lindholm, Zetterlund, Marriner-Tomey and Alligood2010). Supporting patients in achieving reconciliation can be perceived as rewarding and meaningful (Gustafsson Reference Gustafsson, Gustin and Bergbom2012). Based on the patients’ life story, the nurse can acknowledge personal experiences and support reconciliation (Ekman and Norberg Reference Ekman, Norberg, Edberg, Ehrenberg, Friberg, Wallin, Wijk and Öhlén2013; Gustafsson Reference Gustafsson, Gustin and Bergbom2012).
Reconciliation can be one way of moving toward health and quality of life for a person living with an incurable illness. In palliative care, it can be important to understand what reconciliation as a concept can mean for a patient (Gustafsson Reference Gustafsson, Gustin and Bergbom2012). According to the World Health Organization (WHO 2020), the definition of palliative care is an approach that improves the quality of life of patients – adults and children – and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, impeccable assessment and treatment of pain and other problems, whether physical, psychosocial, or spiritual. Being confronted with end of life can become a wish to achieve reconciliation and for patients with an incurable illness, reconciliation can make a peaceful death possible (Tornøe et al. Reference Tornøe, Danbolt and Kvigne2015). Achieving reconciliation can mean that quality of life and well-being can be established at the end of life (Gustafsson Reference Gustafsson, Gustin and Bergbom2012). The form of reconciliation can depend on who the patient is as a person (Eriksson Reference Eriksson2015; Lindström et al. Reference Lindström, Lindholm, Zetterlund, Marriner-Tomey and Alligood2010).
Therefore, it is important to broaden the analysis of the meaning of reconciliation by adding a caring context in order to gain a deeper understanding of the concept. Hence, the aim of this study was to gain a deeper understanding of the meaning of reconciliation in palliative care.
Methods
This literature study used Schwartz-Barcott’s and Kim’s (Reference Schwartz-Barcott, Kim, Rodgers and Knafl2000) hybrid model for concept analysis as it is appropriate for nursing practice and found valuable for determining the relevance of a concept in a specific context (Hupcey et al. Reference Hupcey, Morse, Lenz and Gift1997; Schwartz-Barcott and Kim Reference Schwartz-Barcott, Kim, Rodgers and Knafl2000). The concept analysis consists of three phases: a theoretical phase, a fieldwork phase, and an analytical phase.
Methods in the theoretical phase
The theoretical phase, the first phase, was initiated by the choice of concept (Schwartz-Barcott, Kim Reference Schwartz-Barcott, Kim, Rodgers and Knafl2000). Reconciliation was chosen due to its nuances in caring science and palliative care. Next, a literature review of the concept of reconciliation was conducted to gain an understanding of its use in different fields of science over time.
The literature search took place during spring 2021 in the CINAHL and MEDLINE databases, which were selected due to their caring sciences connection (Polit and Beck Reference Polit and Beck2021). The search terms were reconciliation, palliative, and end of life. Boolean operators were applied and truncation was used in order to include different forms of the search terms. Inclusion criteria were peer-reviewed, full text, English-language articles with keywords after the abstract. Initially, 20 articles were selected, of which 12 were included (Figure. 1). A further search in the Digital Scientific Archive (DiVA) revealed a doctoral thesis in caring science by Gustafsson (Reference Gustafsson2008). Eriksson’s theoretical work “The Suffering Human Being” (Reference Eriksson2015) was also included. The studies included in the theoretical phase are presented in Table 1.
Flow diagram of the search process (Page et al. Reference Page, McKenzie and Bossuyt2021).
Presentation of the studies included in the theoretical phase
Similarities and contrasts in the material were determined in accordance with Schwartz-Barcott and Kim (Reference Schwartz-Barcott, Kim, Rodgers and Knafl2000, p. 137). The analysis focused on identifying explicit and implicit meanings of reconciliation, in the literature. Examples of organizing and analyzing the literature are presented in Table 2.
Example of the format for organizing and analyzing the literature
The theoretical phase ended with a suggested working definition for the forthcoming fieldwork phase in accordance with Schwartz-Barcott and Kim (Reference Schwartz-Barcott, Kim, Rodgers and Knafl2000). The working definition is presented in the Results section.
Methods in the fieldwork phase
The fieldwork phase is intended to confirm or disprove the working definition and, in order to do so, the hybrid model recommends observations such as interviews with patients (Schwartz-Barcott and Kim Reference Schwartz-Barcott, Kim, Rodgers and Knafl2000). However, in line with the focus and the ethics of this concept analysis, autobiographies were considered an alternative to interviews with patients at the end of life. In order to ensure the relevance of the autobiographies based on the selected palliative care perspective, the inclusion criteria were authors’ own description of experiences associated with incurable illness until the end of life, written in the Swedish language and published since the year 2000. Inclusion criteria were formulated to ensure the relevance of autobiographies in the palliative care perspective. The Swedish-language autobiographies had to contain descriptions of the persons’ own experiences associated with incurable illness until the end of life. The autobiographies by Ingesson and Ekblom Ystén (Reference Ingesson and Ekblom Ystén2016), Gidlund (Reference Gidlund2013), and Lindquist (Reference Lindquist2004) were selected.
A qualitative content analysis was used, with focus on the latent content in the reading of the autobiographies (Graneheim et al. Reference Graneheim, Lindgren and Lundman2017; Graneheim and Lundman Reference Graneheim and Lundman2004). The autobiographies were read several times in order to gain a sense of the whole and 2 of the authors individually selected meaning units in the form of quotations, while keeping the working definition of reconciliation in mind. The latent content is presented in the form of subthemes and themes to reveal latent messages. Examples of the analysis process in accordance with Graneheim and Lundman (Reference Graneheim and Lundman2004) are presented in Table 3.
Application of qualitative content analysis in the analysis of the autobiographies with meaning units, interpretation of the latent content based on the working definition, subthemes, and themes
Methods in the analytical phase
In the analytical phase, the third phase, the analyses continued with inquiring into what had emerged about reconciliation in the theoretical- and fieldwork phases based on the following questions: How much is the concept applicable and important to nursing? Does the initial selection of the concept seem justified? To what extent do the review of literature, theoretical analysis and empirical findings support the presence and frequency of this concept within the population selected for empirical study? (Schwartz-Barcott and Kim Reference Schwartz-Barcott, Kim, Rodgers and Knafl2000, p. 147)
Results
The theoretical phase, fieldwork phase and analytical phase are presented in the result section. Reconciliation as a concept is highlighted from different perspectives in order to formulate a working definition. Content from the autobiographies of Ingesson and Ekblom Ystén (Reference Ingesson and Ekblom Ystén2016), Gidlund (Reference Gidlund2013), and Lindquist (Reference Lindquist2004) that corresponds with the working definition is presented, as are the results of the final analysis of the previous phases.
Results from the theoretical phase
The different reconciliation perspectives revealed by the literature were reconciliation in theology – peace and conflict studies, reconciliation in a semantic analysis, reconciliation in health sciences, and reconciliation in palliative care.
Reconciliation in theology
As a concept reconciliation has a clear foundation in theology as well as in peace and conflict studies. The original Swedish meaning of reconciliation was to settle a fight. In Judaism and Buddhism, suffering is considered an inescapable part of life and destiny. Therefore, reconciliation can only be achieved if people accept suffering. According to Islam, reconciliation can involve finding meaning in life events by trusting God (Gustafsson Reference Gustafsson2008). In Christianity, reconciliation can be described as a feeling of God’s fellowship and love (Eriksson Reference Eriksson2015; Gustafsson Reference Gustafsson2008). In research on peace and conflict, reconciliation has been described as the creation of good relations between conflicting parties. Achieving acceptance can be seen as a central attribute of the concept. In sociology and criminology, reconciliation is considered an ongoing process between people (Gustafsson Reference Gustafsson2008).
Reconciliation in a semantic analysis
In a semantic analysis by Gustafsson (Reference Gustafsson2008), reconciliation has several meanings including establishing, overcoming, unifying, enduring, and purifying. Reconciliation as establishing can concern the self, life, and suffering. Through reconciling, a new wholeness can be formed, which can enable people to see meaning in their suffering. Clearing away what is immaterial with confidence in the future provides a clearer picture of the whole, including the self and the outside world. Absorbing suffering while facing it can lead to acceptance of suffering as something bearable. Overcoming through reconciliation can mean moving from what is to what will be. Overcoming suffering can inspire feelings of freedom and control over one’s own life. Reconciliation with suffering can therefore be seen as a survival strategy (Gustafsson Reference Gustafsson2008).
Reconciliation in health sciences
In health sciences and caring contexts, reconciliation is linked to acceptance. The acceptance of life experiences involves healing through self-knowledge and knowledge about suffering to become whole. In order to become whole, parts of life that have been experienced as negative need to be seen as part of the whole. Feelings of clarity, peace and harmony were found by reconciling with death. Achieving reconciliation can therefore mean a life of hope and the belief that better days will come regardless of life’s uncertainty (Benzein et al. Reference Benzein, Norberg and Saveman2001; Gustafsson Reference Gustafsson2008).
Experiencing a sense of wholeness leads to health. Unifying the past and the future inspires a sense of control and perfection in life. Regardless of context, the experience of wholeness leads to an impression of community in the world and contributes to a transition from loneliness to community, thus enhancing a person’s ability to discover new things in life (Gustafsson Reference Gustafsson2008).
Reconciliation may be achieved in a changed reality (Gustafsson Reference Gustafsson2008) and provides new strength to overcome suffering (Eriksson Reference Eriksson2015). Failure to reconcile with suffering can lead to a sense of futility, while reconciliation can give meaning to life despite illness. Reconciliation might mean a shift from something that has been to something new. Through acceptance of one’s life story, the true self can be shown without the need to hide behind a constructed ideal self-image (Gustafsson Reference Gustafsson2008).
Reconciliation in palliative care
In palliative care, reconciliation is linked to other concepts and contexts. Experiencing reconciliation between life and death is a prerequisite for living in hope. Emotional and practical preparation for acceptance of death is described as central to living a hopeful life (Benzein et al. Reference Benzein, Norberg and Saveman2001; Mok et al. Reference Mok, Lam and Chan2010a). As a terminally ill person, being able to reconcile with life and its changeability can mean an existence in well-being. Reconciliation, on the other hand, is not seen as a condition per se but as something that goes hand in hand with illness (Axelsson et al. Reference Axelsson, Randers and Jacobsson2011).
Achieving reconciliation concerns gaining inner harmony, but also mutual forgiveness among relatives (Chao et al. Reference Chao, Chen and Yen2002). Reconciliation can be expressed by planning for death together with relatives (Durepos Reference Durepos, Sussman and Ploeg2019). Achieving reconciliation means that relatives are able to talk about the person who has died without being overwhelmed by pain and sadness (Gustafsson Reference Gustafsson2008). Reconciling with the impending death of a family member means embracing life and precious memories while they remain (Tan-Ho et al. Reference Tan-Ho, Choo and Patinadan2020). Reconciliation in the form of conflict resolution may be important in the final conversation between relatives and the person who is dying. By resolving conflicts and rebuilding relationships, loved ones do not need to be remorseful about the past. In palliative care, the nurse can help patients achieve reconciliation by trying to resolve conflicts (Keeley Reference Keeley2007; Mok et al. Reference Mok, Lau and Lam2010b)
For patients with serious illness, the connection between reconciliation and forgiveness means the restoration of broken relationships (Ho et al. Reference Ho, Leung and Tse2013). The awareness of a limited life span evokes a need to reconcile thus achieving reconciliation may lead to a peaceful death (Keeley Reference Keeley2007; Renz et al. Reference Renz, Bueche and Reichmuth2020). The nurses’ support in a patient’s reconciliation could be seen as a form of spiritual care (Koper et al. Reference Koper, Roeline and Pasman2019; Tornøe et al. Reference Tornøe, Danbolt and Kvigne2015).
The working definition of reconciliation in palliative care
Reconciliation means striving to settle a conflict and in palliative care the concept can be described as striving for acceptance, living in a truthful way, as well as to forgive and be forgiven. People wish to create meaning and to reconcile as a whole in body, spirit, and soul. At the end-of-life people strive to reconcile by uniting suffering, life, and death, as well as their relationship with their loved ones. Reconciliation is something ongoing; a force in what has been, what is, and what will be.
Result from the field work phase
Two themes emerged: “achieving reconciliation” and “not achieving reconciliation.” The first theme has 3 subthemes: reconciling with life, reconciling with death, and reconciling with a changed self-image. The second theme has three subthemes: not reconciling with life, not reconciling with death, and not reconciling with a changed self-image.
Achieving reconciliation
Reconciling with life
To be reconciled to life is accepting the situation and life as it is including the fact that life and illness cannot be controlled. It can be challenging to let go and accept what is, but by doing so, people have the opportunity to reconcile with existence.
Sometimes it makesno sense to analyse mistakes and decisions. Sometimes things do not go your way. Somehow you must accept it as both a coach and a player and move on. Anyone who thinks he can control everything that happens will ultimately not be able to control anything, (Ingesson and Ekblom Ystén Reference Ingesson and Ekblom Ystén2016, p. 185)
To reconcile with life entails the creation of meaning in life, which is achieved by a change of perspective. Becoming ill is life changing and affects everyday life. Reasoning works as a way of coping with change and seeing meaning in life.
That I have cancer. That I am dying. That I am not even 30 years old. That is how I wake up every day. That is what it feels like. Then I will be there for a while. Then I realise that every day is like a birth. I breathe deeply, time and time again more than ever and get up. Thinking I just have to bite the bullet. And get back in the game. Then I put my pants on, one leg at a time, to try and do something sensible with the time that is left. (Gidlund Reference Gidlund2013, p. 46)
Reconciling with life involves creating new goals and seeing the positive in what is in the situation; it can be achieved by accepting suffering as a part of life. The awareness that death is near entails a need to live for the moment, without thinking about what will happen in the future.
I am going to die of Amyotrophic Lateral Sclerosis (ALS) unless something unexpected happens. There are two ways of looking at it. One is to lie down, be bitter and wait. The second is to try to make sense of the misery. To look at it positively, no matter how trivial it may sound. My path is the second one. Logically, therefore, I have to live in the here and now. In fact, there is no bright future for me. But one brilliant here and now. That is how children live. For the moment. Nothing is coming next. That is why I laugh like a child. Uncontrollably. (Lindquist Reference Lindquist2004, p. 84)
Reconciling with relatives can be meaningful in order to reconcile with life. Sometimes there has already been a reconciliation with relatives and loved ones so no further apologies, explanations or words are necessary. The relationship with loved ones continues as before without conflicting interests.
One late afternoon, my two lives meet in bed. Ulrica and Carin are here. Their father has come here with his daughter from a marriage before his and mine. [..] There is no need for any conciliatory words because we have never been enemies. (Lindquist Reference Lindquist2004, p. 177–178)
Reconciling with death
To be reconciled to death at the end of life means that death is accepted as part of life even though the urge to live is strong. Acceptance of death enables a person to say goodbye to relatives, which can be seen as important at the end of life. Reconciliation may therefore arise as a result of final conversations with relatives.
I am ready, but I am not done. I sense you never will be in these situations: no matter how much time the doctors give you, it will still be too little. [..] At least now I have done what I was supposed to do: said goodbye to my loved ones, said goodbye to my friends, reconciled with the thought of dying. (Ingesson and Ekblom Ystén Reference Ingesson and Ekblom Ystén2016, p. 214)
Reconciling with death means that a person reflects on funeral arrangements. Thinking about one’s own funeral makes death something that can be controlled. Even though death itself is uncontrollable, the funeral preparations can be an expression of reconciling with death.
This morning I was standing in the place where I want to be buried. I get caught in the sentence, because I understand it is a sentence to get caught in. But for me, it does not hurt. I made up my mind a long time ago. You can see the roof on our house from there. My brother’s upstairs window. (Gidlund Reference Gidlund2013, p. 76)
Reconciling with death means the acceptance that life has an end. Reconciling with death brings people closer to life. Impending death contributes to a reformulation of the meaning of life and endows life with a greater value than before.
It is amazing - I do not actually want to be without this part of my life! I have a very limited time left here. But it is only now that I feel present. Death brings me closer to life. (Lindquist Reference Lindquist2004, p. 199)
Reconciling with a changed self-image
To be reconciled to a changed self-image means accepting the self as it was and as it is today. It can be difficult to accept a changed self-image. On the other hand, accepting who you have been and who you are leads to inner power and strength. Being fully reconciled to oneself means accepting deficiencies so that one’s self-image gains a new and unexpected form.
You would think that such an insight makes you pause a little in life - that it would make you think again and be a little nicer to yourself. But it is what it is. You can learn to understand why you do what you do, but at the end of the day you are who you have always been. You learn to live with it. (Ingesson and Ekblom Ystén Reference Ingesson and Ekblom Ystén2016, p. 182)
Reconciling with one’s own changed body is a source of well-being. The body is important for achieving reconciliation with the bodily part of the self and with an altered self-image.
I saw my slightly tanned face. And felt right there and then that I looked pretty good after all, for the first time since hell started for the second time. (Gidlund Reference Gidlund2013, p. 35)
Emotionally separating what feels healthy from what feels ill is a way to create a self-image in which a person feels well. Focusing on the spirit when the body feels ill is a form of reconciling with the self. By focusing on what is perceived as good and beautiful, reconciliation becomes a constructive force in which suffering is processed.
I am not my body. I am in it. It is ill, but my spirit is healthy. My self is my soul and it is strong. Suffering can be my strength. The primal force. Like when the baby’s head rotates out of the womb. I know how it is going to end. Makes me strong. Calm (Lindquist Reference Lindquist2004, p. 90)
Not achieving reconciliation
Not reconciling with life
To not reconcile with life may be due to not wanting or being able to see life as it is. At the same time, a person may choose not to acknowledge certain events in life as a way to reconcile with what is happening.
I think everyone felt the same way. Like me, they knew the cancer would kill me, but somewhere along the way we had probably all begun to imagine that it would not happen. You fool your brain to live in the present. (Ingesson and Ekblom Ystén Reference Ingesson and Ekblom Ystén2016, p. 193)
Not reconciling with death
To not reconcile with death may come from an inability to accept death as part of life. Not reconciling with death is influenced by a strong will to live. Living an existence threatened by incurable illness brings feelings of sadness and pain. Even though death is present, it is denied.
I even think the silent man is here at the motel. In the same house, death sits with a cigarette. On the edge of the bed. Fully clothed. I put the latch on the door. Make sure it is locked. Close the curtain. In my loneliness, I might be safe. I will give it a try. One more time. And another one. In my head, reality continues to burn. (Gidlund Reference Gidlund2013, p. 34)
Not reconciling with a changed self-image
To not reconcile with a changed self-image, no longer being who you once were can result in spiritual agony and thoughts about how to accept the new self. It can be difficult to achieve bodily reconciliation when the body has changed and affects the self-image. There is a wish for everything to remain the same.
How is a middle-aged person who has always celebrated independence going to learn how to accept having to be looked after like a child? How is a woman who still wants to be attractive to her husband going to learn to accept that she probably is not anymore? (Lindquist Reference Lindquist2004, p. 134)
Feeling attractive is important for reconciling with one’s self-image.
Results from the analytical phase
Based on the analytical questions described in the method, the analytical phase is a continued adaptation and interpretation of what emerged about reconciliation in the theoretical- and fieldwork phases (Schwartz-Barcott and Kim Reference Schwartz-Barcott, Kim, Rodgers and Knafl2000).
The concept of reconciliation is applicable to and important for palliative care nursing. The choice of reconciliation as a concept can be justified by its original meaning in the Swedish language, which was to settle a fight. Gustafsson (Reference Gustafsson2008) has shown that reconciliation is essential in nursing. In addition, reconciliation is an important anchor in Eriksson’s theory (Eriksson Reference Eriksson1987, Reference Eriksson2015). Reconciliation is considered a concept of relevance in palliative care (Gustafsson Reference Gustafsson2008, Reference Gustafsson, Gustin and Bergbom2012).
Comparing what emerged about reconciliation in the theoretical and the fieldwork phase largely supported our working definition of reconciliation in palliative care. Reconciliation as a quest for acceptance, to live in a truthful way with oneself and be able to forgive and be forgiven has been mentioned both in the scientific literature (Chao et al. Reference Chao, Chen and Yen2002; Durepos et al. Reference Durepos, Sussman and Ploeg2019; Eriksson Reference Eriksson2015; Gustafsson Reference Gustafsson2008; Ho et al. Reference Ho, Leung and Tse2013) and in the autobiographies (Gidlund Reference Gidlund2013; Ingesson and Ekblom Ystén Reference Ingesson and Ekblom Ystén2016; Lindquist Reference Lindquist2004). The literature on palliative care emphasizes that reconciliation can mean resolving conflicts in human relationships, for which forgiveness is a prerequisite (Keeley Reference Keeley2007; Mok et al. Reference Mok, Lau and Lam2010b; Tornøe et al. Reference Tornøe, Danbolt and Kvigne2015).
The literature, theoretical analysis, and findings support the presence and frequency of reconciliation within the autobiographies selected for empirical observation. Acceptance has been highlighted as an important meaning of reconciliation. It is clear in both the scientific literature and the autobiographies that reconciliation means acceptance of what has been, what is, illness, death, and an altered self-image (Benzein et al. Reference Benzein, Norberg and Saveman2001; Eriksson Reference Eriksson2015; Gustafsson Reference Gustafsson2008; Mok et al. Reference Mok, Lam and Chan2010a). In the subtheme reconciling with death, based on the interpretation of the autobiographies by Ingesson and Ekblom Ystén (Reference Ingesson and Ekblom Ystén2016), reconciliation with death can be achieved even when the will to live is strong. Lindquist (Reference Lindquist2004) outlined the difficulty of accepting oneself physically and spiritually since becoming terminally ill.
The wish to create meaning in life and existence is an important understanding of reconciliation. Reconciliation creates meaning, which has been emphasized in caring science as a way of overcoming experienced suffering (Eriksson Reference Eriksson2015; Gustafsson Reference Gustafsson2008). In the interpretation of the autobiographies dealing with constructing meaning by changing one’s perspective on life, as described by Gidlund (Reference Gidlund2013), reconciliation involves the construction of meaning in relation to peoples’ existence. Therefore, in the working definition “People wish to create meaning” can be reformulated as “People wish to create meaning in their existence.” This modification of the working definition is based on what emerged in the fieldwork phase and the analytical phase.
To reconcile as a whole in body, soul, and spirit means striving towards health. Reconciliation as an experience of wholeness entails feelings of hope and fellowship despite illness (Benzein et al. Reference Benzein, Norberg and Saveman2001; Gustafsson Reference Gustafsson2008; Mok et al. Reference Mok, Lam and Chan2010a). The feeling of being a whole consisting of different dimensions emerged in the subtheme reconciling with a changed self-image; the bodily dimension of the self feels ill, while the spirit and soul feel healthy.
At the end of life, struggling to reconcile through unifying suffering, life and death, as well as reconciling with relatives, emerged as an essential meaning of reconciliation both in the scientific literature and the autobiographies. Reconciliation is a way of unifying what has happened, what will happen and what has caused suffering and death. By considering suffering, life and death as united, people reconcile their existence with an incurable illness; a limited life span brings the person closer to life and makes her/him feel more alive than before.
That reconciliation is an ongoing force in what has been, what is, and what will be can be seen in relation to peoples’ ever-changing existence. Whether reconciliation touches on life, death, or a changed self-image, the meaning of the concept is dynamic and changeable in the same way as people’s existence (cf. Axelsson et al. Reference Axelsson, Randers and Jacobsson2011). The wish to reconcile has been confirmed by analyzing the working definition of reconciliation in palliative care. The need for reconciliation in palliative care is strengthened by the notion of a limited life span (Keeley Reference Keeley2007).
“Not achieving reconciliation” did not emerge to the same extent as the theme “achieving reconciliation.” Finding a rebuttal to the elaborate working definition of a concept can be seen as confirmation of the definition (Schwartz-Barcott and Kim Reference Schwartz-Barcott, Kim, Rodgers and Knafl2000). Therefore, the theme not achieving reconciliation and the subthemes not reconciling with life, not reconciling with death, and not reconciling with a changed self-image, may be seen as proof of the relevance of the working definition within the chosen perspective, namely palliative care.
A final definition of reconciliation in palliative care
Reconciling means striving to settle a conflict, and in palliative care reconciliation can be described as striving for acceptance, to live in a truthful way, to forgive, and be forgiven. People wish to create meaning in their existence and achieve reconciliation as a whole in body, spirit and soul. By striving to unite suffering, life and death as well as a peaceful relationship with relatives, people can achieve reconciliation at the end of life. Reconciliation is something ongoing and can be a force in what has been, what is, and what will be.
Discussion
A broader and deeper understanding of the concept reconciliation in palliative care contributes to the nurse’s ability to listen, see, and understand patients’ suffering in their pursuit of reconciliation. In caring, nurses encounter patients in their wholeness as people, consisting of body, soul, and spirit (Lindström et al. Reference Lindström, Lindholm, Zetterlund, Marriner-Tomey and Alligood2010). The person at the end of life strives for reconciliation with suffering, life and death to gain meaning, wholeness, and a peaceful death. Facing one’s own death can evoke a need to reconcile, while achieving reconciliation can contribute to a peaceful death (Ho et al. Reference Ho, Leung and Tse2013; Keeley Reference Keeley2007). Not achieving reconciliation at the end of life was less prominent in the autobiographies than achieving reconciliation. However, it illustrates peoples’ striving for a peaceful end of life. To forgive and be forgiven can be of importance for reconciliation at the end of life. Forgiveness can be understood as an act and is the outer dimension in striving to reconcile, while reconciliation is the inner striving to reconcile.
The final definition of reconciliation in palliative care is the most important result of this study. It has been demonstrated that the definition originates in philosophy, literature, and peoples’ experiences. From a research ethics point of view, it is important that the definition has been shown to have a theoretical and empirical basis, as this can be considered confirmation that the study contains valuable knowledge about reconciliation in palliative care.
Because of its meaning and relevance within several care contexts, the present final definition of reconciliation in palliative care may be transferable to other contexts. Contributing knowledge about palliative care is important for society due to people living longer, even with chronic diseases (World Health Organization 2020). As the connection between reconciliation and life, death, and an altered self-image is also a philosophical and spiritual issue, this concept analysis may be relevant for people who do not live with a life-threatening incurable illness.
Strengths and limitations
The theoretical phase consisted of 1 dissertation on reconciliation from a health science perspective, which can be seen as a limitation. On the other hand, the dissertation provided a good basis for an initial understanding of the concept within caring science.
The autobiographies included in the fieldwork phase were written by 2 men and 1 woman, which ensures gender equality in the concept analysis. The use of autobiographies instead of interviewing people at the end of life may be seen as a limitation. However, researching experiences of reconciliation in an empirical manner was not considered justifiable from an ethical perspective. The hybrid model recommends 3 to 6 participants for the fieldwork phase, therefore justifying the inclusion of 3 autobiographies. Nevertheless, this can affect the transferability of the result. Furthermore, the selection of quotations was limited in agreement with the publishers. On the other hand, these published autobiographies can be regarded as a strength, as all 3 narrate experiences of palliative phases and describe being seriously ill with an incurable disease.
An understanding of reconciliation facilitates conversations about its meaning in palliative care. Patients who strive to achieve reconciliation can be more easily identified and supported. An understanding of one’s own reconciliation regarding life, death, and self-image contributes to personal and professional development in caritative caring. Clarifying what reconciliation means in palliative care can lead to more sustainable care of patients with incurable illness.
Practical implications
A broad and deep understanding of the concept of reconciliation in palliative care can be seen as a tool for nurses, which can help them to think differently when meeting patients and their relatives at the end of life. Thanks to the deeper understanding of reconciliation, conversations can be held about the meaning of the concept with both personnel and patients in palliative care. For instance, by using the themes and subthemes that emerged from the empirical phase; achieving reconciliation based on the subthemes reconciling with life, reconciling with death, and reconciling with a changed self-image; and not achieving reconciliation based on the subthemes not reconciling with life, not reconciling with death and not reconciling with a changed self-image, such conversations could guide nurses when caring for people in palliative care. Patients striving to achieve reconciliation can be identified and supported to a greater extent. This conceptual analysis can also be useful as a basis for supervision of nursing students and personal in palliative care to increase the understanding and knowledge of reconciliation.
Acknowledgments
We would like to thank Norstedts, Offside Press and Forum publishers for their friendly reception. We gratefully acknowledge Klas Ingesson, Kristian Gidlund and Ulla-Carin Lindquist for choosing to write about life with an incurable condition. We acknowledge Monique Federsel for reviewing the English language in this paper. We are grateful to the Department of Health Sciences, University West, for financial support.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.
Competing interest
The authors declare no conflicts of interest.
Ethical approval
The ethical principles contained in the World Medical Association (WMA) Helsinki Declaration (2013) were adhered to. The ethical aspects of including participants in the form of autobiographies were taken into consideration. Permission to quote from the autobiographies was obtained by electronic mail from the relevant publishers and one of the author’s relatives. The autobiographies were read, interpreted and analyzed with the utmost respect for the content and authors.
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