The Object of Gratitude in Palliative Care: A Phenomenological Study

Gratitude, a universal phenomenon, holds particular significance in healthcare, especially palliative care. While previous studies have examined gratitude in this context, a comprehensive analysis of the object of gratitude remains lacking. This study aims to address this gap by investigating the essence of what elicits gratitude from patients, families, and healthcare professionals in palliative care settings. The research utilizes the concept of the 'objective good for the person,' coined by von Hildebrand, which represents a benefit perceived as good in itself and specifically directed towards the individual. This concept bridges the gap between intrinsically important goods and subjectively satisfying ones. By exploring this concept within the context of palliative care, where death and suffering are prevalent, the study sheds light on the fundamental aspects of the caregiver-patient relationship and the profound impact of gratitude in this specific context. The challenging association of palliative care with death and negative perceptions makes the presence of gratitude towards professionals all the more significant, suggesting a potentially beneficial aspect of care rarely explored in such detail.

The literature review examines existing research on gratitude within social psychology and positive psychology. Social psychology often views gratitude as a personality trait, while positive psychology emphasizes its role as a positive emotion fostering well-being. Several studies highlight the importance of exploring gratitude within interpersonal care relationships, particularly at the end of life. However, few studies have delved into the specific nature of the "object" of gratitude in palliative care. This study builds upon the work of authors like McCullough, Emmons, and Tsang who have investigated the concept of the grateful disposition, and expands on Aparicio's work examining gratitude in palliative care settings. The review also considers research on the concept of health as defined by the World Health Organization and other scholars, recognizing the complexities involved in defining health, particularly in the context of terminal illness. The research integrates philosophical perspectives, drawing upon the work of von Hildebrand to analyze the concept of 'objective good' as central to understanding gratitude.

This study employed a phenomenological methodology, prioritizing the analysis of lived experiences over theoretical comparisons. The researchers adhered to Husserl's principle of all principles, focusing on the 'intuition' offered by experience within its presented limits. This method allowed access to the essence of gratitude beyond its subjective dimensions, identifying 'original phenomena' as defined by von Hildebrand. Data collection was multifaceted, incorporating gratitude letters from relatives, personal accounts from families and healthcare professionals, press releases, and relevant literature from both biomedical and philosophical perspectives. International experts in gratitude were also consulted and their insights incorporated into the analysis. This combination of sources enhanced the depth and breadth of the analysis process. The analysis proceeded iteratively, involving a dynamic interplay between clinicians and philosophers. Local examples of gratitude letters were initially analyzed to identify key themes. These themes were then further explored through the analysis of press releases and other experiences, allowing for a cross-referencing and refinement of the initial findings. The research incorporated both social science and philosophical methods. Social science methodologies were used to collect, reflect, and write about the lived experience. Philosophical methods, including epoché-reduction, provided a framework for deeper reflection and analysis. The overall process involved an iterative cycle of data gathering, analysis, reflection, and discussion with both internal and external experts (philosophers and clinicians not part of the main research team), to ensure adequate representation and validity of the experiences being explored.

The study identified "healing or deep relief" as the central object of gratitude from the perspective of patients and their families. This understanding of healing transcends mere physical recovery; it encompasses a profound alleviation of existential suffering—fear of death, loss of meaning, isolation, and other anxieties common in terminal illness. Patients and families appreciated the personal, compassionate care that affirmed them as individuals, acknowledging their unique circumstances. They valued the presence of the palliative care team not just as medical professionals, but as empathetic companions who provided both physical and emotional comfort. From the perspective of palliative care professionals, the object of gratitude was linked to "professional affirmation." Professionals often expressed surprise at receiving gratitude, viewing their actions as part of their duty. However, the expressed gratitude from patients reinforced the significance and meaningfulness of their work, boosting their motivation and reaffirming their vocation. The professionals' sense of gratitude was also linked to a reciprocal recognition with the patients—the professionals acknowledged the patients' humanity, and the patients, in turn, recognized the professionals' compassionate presence. The professionals highlighted the deep connection formed and the privilege of sharing in the intimacy of patient suffering.

The findings highlight that gratitude in palliative care extends beyond simple symptom relief. It is rooted in the affirmation of the person's inherent value and the recognition of their unique journey through suffering and death. The perception of "healing" is broadened to encompass a deep, existential level, involving the alleviation of fears, anxieties, and the profound sense of loss associated with terminal illness. The study confirms that patient-centered care, marked by compassion and personalized attention, significantly contributes to eliciting gratitude. The reciprocal nature of gratitude, as experienced by both patients/families and professionals, underscores the importance of human connection and the affirmation of shared humanity in the face of death and suffering. This mutual exchange of gratitude fosters well-being and validates the unique roles played by both those providing care and those receiving it. The study also confirms that the perceived value of work by the healthcare professionals is heightened by the acknowledgment of the patient and the family, therefore contributing to their work satisfaction and further emphasizing the role of gratitude in sustaining the care system.

This study provides valuable insights into the nature of gratitude in palliative care, identifying "healing/deep relief" for patients and families and "professional affirmation" for healthcare professionals as central objects of gratitude. This understanding has implications for improving the quality of palliative care by emphasizing the significance of person-centered care and the crucial role of human connection in the face of suffering and death. Future research might explore the long-term impacts of gratitude on both patients/families and healthcare providers, and investigate the potential for interventions designed to foster gratitude in palliative care settings. Further research could also explore cultural variations in the expression and experience of gratitude in end-of-life care.

The study's reliance on a phenomenological approach limits the generalizability of the findings. The sample size, while diverse in its sources, is not statistically representative of all palliative care settings. The researchers acknowledge that the interpretation of the experiences is inherently influenced by the researchers' own perspectives, and the subjective nature of phenomenology is a potential limitation in terms of objective measurement. Furthermore, the study did not include quantitative data to directly measure the impact of gratitude on outcomes like patient satisfaction or professional burnout. Future research using mixed-methods approaches could address these limitations.