‘‘Being altruistic is how patients show that they're alive and not just sick bodies in beds”: A constructivist approach to illuminate palliative nursing professionals' experiences of patient altruism

Altruism is a complex phenomenon largely described in literature through the expression of certain behaviours or actions, a description which does not easily address the altruistic potential of people in palliative and end-of-life care (PEOLC) contexts who are living with increasing frailty. Whereas nurses' altruism is considered foundational to nurse-patient relationships, this study inverses the narrative and investigates how nurses experience patient expressions of altruism in palliative and end-of-life care (PEOLC) contexts. Informed by constructivist principles to explore a complex phenomenon based within interpretation and subjective experiences, we conducted a qualitative descriptive study using semi-structured interviews with 31 nursing professionals in Switzerland. Their reflections revealed multi-directional expressions of altruism between patients, relatives, and professionals in PEOLC contexts, shedding light on the interplay of patient agency and caregiving roles. One nurse posited that being altruistic is how palliative patients can show they are "still alive" and are "not just sick bodies in beds," even in the vulnerable state of approaching death. We analysed nurse depictions of patient altruism within a moral-interpretative framework, showing how nurses experienced it positively, negatively, and sometimes with ambivalence. The boundaries between positive and negative were crossed when altruistic expression had clinical implications, elicited dilemmas, or contested traditional nurse-patient relationships. Certain altruistic acts transgressed traditional patient-nurse roles, particularly when patients prioritised the needs of others to their own detriment or minimized their own care needs to lighten nurses' workloads. Although patient altruism sometimes led to awkwardness, discomfort and ethical dilemmas, some altruistic gestures increased job satisfaction and motivation. Nurse strategies for navigating negative or ambivalent altruism included setting boundaries and having discussions with colleagues to determine appropriateness. Findings show how patient altruism in palliative contexts contests characterised views of nurses as the altruistic actors and patients as passive recipients of care.