The practice of palliative care prides itself in facilitating complex and uncomfortable conversations around death and dying. One such conversation is sex and intimacy, which healthcare professionals (HCPs) accept as integral to each person's identity. Yet, it remains one of the most difficult subjects to broach with patients (Hjalmarsson and Lindroth, 2020), leading to an unfortunate neglect of one of the most important aspects of person-centred care. Palliative care guidelines are clear that sexuality should be addressed. However, there are differing views and ongoing debates as to whether this is relevant with serious illnesses and when it is most appropriate to enable sex and intimacy for patients/partners. One of the principles of palliative care is to encourage HCPs to ensure people live as actively as they can until they die (WHO, 2020)—this includes sex and intimacy. Indeed, where intercourse is no longer possible, intimacy should be afforded, making it part of the assessment plan. Joint conversation should be had with the patient and their partner to agree upon the best approach.
It is important to recognise detractors and facilitators, but more crucially, for HCPs to have an open mind and be comfortable discussing the topic. Evidence from a systematic literature review of 18 articles by Benoot et al (2018) reported seven themes that hindered/facilitated efforts to enable sex and intimacy within the healthcare setting. Here, I only focus on four as examples of barriers still being encountered:
- Age stereotypes impacting conversation with professionals
- Reprioritising survival over intimacy needs
- Influence of family/friends/carers
- Clinical settings inhibiting expression of intimacy.
The challenge for all of us seems to be attitudes that do not shift; hence, stereotypes are still prevalent. It may also be that HCPs need to continually remind themselves that it is for the patient to prioritise what is important and that support is then provided accordingly. The debate on social dying rages on, and while we can all understand the complexities of families and family units, we have to find a way to let the patients decide how they die, while acknowledging and respecting the input of families/friends and other relatives. We all accept clinical settings (hospitals, in particular) are not conducive for sex and intimacy arrangements. However, different settings such as hospices are finding ways to facilitate this by creating more privacy rooms, family dedicated rooms/spaces, offering bigger beds, and openly discussing with patients when and how they require to be left alone.
Colleagues in palliative care discuss terminology that is suitable, and the recently introduced term of ‘private time’ is not popular, as it is euphemistic, which, like death euphemisms, defeats the very object of being open when discussing sex and intimacy.
The point for consideration is not necessarily terminology, but rather if we can facilitate sex and intimacy for those who prefer it. At such late stages of life, some couples may not have been separate from each other until admission to hospital/hospice, so keeping them close is only natural. More importantly, we need to ask ourselves if we are ready and comfortable supporting people we care for to experience such an important aspect of their identity.