The concept of death and dying is a subject that has fascinated mankind from the beginning of our evolution. We have sought answers to its purpose and being from virtually every aspect of science e.g. biological, psychological, sociological, anthropological etc. The concept of death also has political and legal significance. For example the subject of death by suicide, euthanasia, and cessation of hospital treatments for terminal patients. Statistics in Canada have shown that life expectancy has increased from the early philosophy of ‘ three score years and ten (70 years)‘ to that of 75.3 years for males and 81.3 years. Statistics have also indicated a decline in mortality rates for epidemics, primarily due to advances in medicine and pharmacare (Marshall, V.W. 2012).
From around 1867 the actual cause of death has significantly changed. Prior to this time wars, starvation, epidemics and limited medical treatment accounted for a large proportion of deaths. Since 1867 the shift has changed with about 37% relating to chronic conditions like heart related disease, 28% by cancer related illness 5% for Pneumonia and 1:10 is attributed to death by violence, accident, poisoning or self-abuse i.e. drug related. Despite our best efforts in medical advancements we have still not eliminated the potential threat of pandemics ( the potential to cause the death of millions of people). The biggest threats in our time are mutations of viral threats of influenza and social diseases such as HIV Aids.
Nurses have to deal with the concepts of death, dying and grief as the result of losses of a loved one. This can be extremely difficult particularly for young nurses who are new to the profession and are focused on patient care and saving lives. It is however a reality of life and only practical experience together with certain training i.e. grief counselling procedures, can prepare you for this experience.
Psychology of Death
The passing of a loved one in Adult life, particularly after a long period of togetherness in marriage, brings on a strong sense of bereavement. This tends to go through a number of stages. In the stage at the time of death it brings about a sense of numbness and shock with a great deal of distress. This can last for hours or days. The second phase is one of pining for the lost person and a sense of grief at the loss. These intense pangs of anxiety are a direct result of trying to come to terms with the loss. These conditions are transient but see the individual trying to cope with everyday life in an apathetic or clumsy way. This period can last from weeks to several months dependent upon the strength of the bonding. The final stage is reconciliation or coming to terms with the loss and trying to continue with your life. Often this starts to resolve by the person finding another social relationship. We are not meant to be sol The Doctor / Nurse Patient Relationship
As Doctors are faced with the concept of mortality on a regular basis they become somewhat hardened to the condition. Very often this takes on a clinical perspective and somewhat cold perspective on the harsh realities of life. The interface with the patients often occurs with life threatening conditions like Cancer. Most patients want to know their chances of survival and possibility of a cure. Doctors on the whole tend to be pessimistic and deal with trends or statistics. The real patient care being passed on to the Nurses who are at the sharp end of dealing with patient care and often the transition of dying patients providing them with the help and dignity of coming to terms with death. The nurses are greatly undervalued in Society for the significant role that they play here. Studies of patients with small cell lung cancer often showed the patients to be more optimistic about their potential for recovery than the Doctors who were treating them. In Hong Kong the Doctors and Nurses are receiving more advanced training programs to learn how to approach and deal with terminally ill patients. (Wong, Lee, & Mok, 2001).
Reaction to death
The main human reaction to death is one of fear. It is the sense of the unknown – a voyage or passage that we must all face alone. Nobody gets to cheat death – it is something that we all have to face. Religious people with faith console themselves in the belief of an afterlife, as opposed to the scientific biological explanation that like any other creatures on the planet when we die we simply cease to exist – that’s it period. It is unlikely that science will ever fully comprehend the meaning of death or provide a rational explanation for it. Consequently we will continue to live our lives in fear of it. One thing seems certain and that is everyone’s experience of death is both personal and unique. Each of us travels the journey alone and deals with it in our own terms.
Psychological characteristics of Aging
In our younger and formative years the concept of death seems alien and confined to older people, a different generation who are estranged. As we ourselves get older we become much more aware of our frailty and approach towards death. This becomes more so as we deal with illness, lose mental faculties and generally see a decline in our physical appearance through ageing. This can be a traumatic period for some people and we seek means to halt the ageing process and perpetuate our youth. Equally our roles change in later life, particularly at retirement and we get to spend more time with our spouses. Often a time of self-discovery but equally dealing with loss of status and self-esteem where Society no longer needs our services. The most dramatic changes in life are that of retirement and the dilemma of leaving social status and contacts behind (Cohen, H.J. 2012)
Finally circumstances of death will greatly change our reaction and perception to it. For example, someone taken suddenly without warning in a car accident, someone who takes their own life in a suicide and the trauma of mass murder like Holocaust victims. In the latter the families had long lasting psychological scars with eternal memories of horror.
Training for Nurses
Nurses are often at the sharp end when it comes to preparing a patient for death and dying. Equally they are often the first contact with the bereaved persons who are grieving over the loss of a loved one. With the patient it is the comfort of not feeling alone or abandoned and that someone is there to help and comfort them through this passage with the minimum of discomfort and pain. With the bereaved family it is the ability to come to terms with the loss. Death is not something that they will recover from but something that has to be accepted as part of life and the ability to come to terms with this. Those that are unable to make this adjustment can equally put their own health and wellbeing at risk.
The nurses and Doctors have to carry out this facilitation function whilst conditioning them to remain relatively detached from the mental anguish involved. This period can create many mixed and varied emotions including distress, anger, sadness, separation, aspects of denial and loss of interest in social functions and potential isolation. In order to advise the bereaved the nurses require a background of each families personal circumstances as advice can vary differently for each person. Very often, after preliminary advice is given, this needs passing over to a specialist grief councillor. Depending upon religious persuasion spiritual guidance can be provided and most hospitals have a chapel and a Priest that will be prepared to assist in this process. Equally the nurses can gain spiritual guidance and support from the priest in the best determination of how to deal with specific situations.
Training needs to be provided in order to help nurses assist in solving the problems caused by emotional responses and the families of terminal ill patients. There are certain consistent stages that each patient and family passes through. It is important to both recognise and have an understanding of these stages in order to be able to deal with them. Only in this manner can you progress through this in a logical manner . This provides a learning experience and a degree of competency over the process. There have been many psychological models that have been produced that nurses can become familiar with. These include such theoretical models from the likes of Kubler-Ross, Pattison, Cor, Buckman and Copp etc. Each offer different psychological perspectives on death and dying. Whilst useful background reading these can be somewhat restrictive when facilitating someone’s transition from life to death.
Most nurses in hospitals recognise the important need for training in this area. Doctors can be somewhat more detached in the final analysis but the nurses are at the sharp end. Whilst to an extent a lot of experience is gained over time by exposure to different practical experiences, nevertheless, training helps in putting together a suitable framework that will help all nurses engaged with having to deal with transition experiences. This will help the nurses to gain confidence in their approach and help to reduce some of the levels of personal stress in the provision and facilitation of these services.
Cohen, H. (2012, 8 1). Health Aging. Retrieved from Psychological and Social Issues : http://www.healthinaging.org/agingintheknow/chapters_ch_trial.asp?ch=
Marshall, V. (2012, 8 1). Death and Dying. Retrieved from Canadian Encyclopedia: http://www.thecanadianencyclopedia.com/index.cfm?PgNm=TCE&Params=A1ARTA0002191
Wong, F. K., Lee, W. M., & Mok, E. P. (2001). Educating Nurses to Care for the Dying in Hong Kong: A Problem-Based Learning Approach. Cancer Nursing, Vol 24(2), 112-121.