Nurses_Perspective_on_Death_and_Dying

The Student Nurse's Perspective on Death and the Dying INTRODUCTION Much has been written about death because it is a subject that touches everyone of us. The following is the culmination of all that I have learnt about Death and the dying patient from my own research and my own experiences as a student nurse. My research has highlighted that I share many of my perspectives on death and dying with other student nurses. V. Ruth Gray states that "For all mankind, living becomes dying: death is the inevitable consequence of living." (1) " Death is the ultimate touchstone of human endeavours. It is the ultimate organiser of time. It is the ultimate enemy of self. It is the ultimate leveler of all persons. It is the ultimate uncertainty, the ultimate event, the ultimate negator of passions and personal growth. " (2) Mosby's medical Nursing and Allied health Dictionary defines ' death' as: "The cessation of life as indicated by the absence of activity in the brain and central nervous system, the cardiovascular system and the respiratory system as observed and declared by a physician." The above criteria applies in most cases of expected death. However, in modern society where many people are kept alive on life-support machines ,the exact moment of death is harder to establish. It's also worth noting that although most Western societies have a clear distinction between being alive or being dead , this is not the case for all societies. Rosenblatt ( 3 ) points out that some societies view the person as still being alive for a considerable length of time after the period that most Western societies would describe the person as dead. There are also some cultures that start to grieve for the dying person as if they had already died during a time when they are technically still alive. Whichever way the individual perceives death, it is not easy to define the exact time when the process of dying begins. Phil Russell says, "We are all dying until we reach that ill-defined point we cal death, or, put in a more positive way, life continues until a decision is made that we have reached that end-point we call death." (4) The technological advances of this century in the field of medicine have enabled many patients to be kept alive for longer. Bramstedt pointed out that though this may be the case, the patient's health may not improve and there may not be a total recovery. As a result, more and more people find themselves in the care of nurses at the end of their life. It is no longer the norm for families to share in the care of the dying at home and as a result, the majority of young people are not exposed to seeing or talking with the dying. The reaction of many young people is to want to get away from a fearful situation because it is a reminder of their own death in the future. Phil Russell suggests that we are a death denying society. Factors such as the increase in the average lifespan in the West and the minimising of funeral rituals and mourning have led to what Phil Russell describes as a "death denying society". (5) This denial however, can not prevent the inevitable and as Morgan states, 'death refuses to die'. (6) Although many see death as a far off event which is best forgotten, death can strike quickly at any moment when we are not prepared for it. "When you are strong and healthy, You never think of sickness coming, But it descends with sudden force Like a stroke of lightning. When involve in worldly things, You never think of death's approach: Quick it comes like thunder Crashing round your head." ( Milarepa, in Rinpoche , 1992 ) Sogyal Rinpoche (1992) suggests that man is fully aware of their immortality even if this knowledge is kept deep within us. He suggests that we aquire more freedom to live once we accept the impermanence of life. Many , including Collick (6), suggest that our attitudes to death and to life would be less riddled with fears and anxiety if people recognised death and talked about it as part of the human experience. If this is the case, then the student nurse must apply this concept and talk openly with colleagues to equip them to deal with death and the dying. The student nurse is confronted with another person's dying or death throughout their training and must learn how to cater for the patient's welfare as well as dealing with their own emotional needs. It is vital that the student nurse is able to differentiate between the process of dying and the act of dying. The process of dying may be filled with pain and anxiety and nurses are able to relate on an emotional level to this. Death is a state of physical non-being and beyond human experience or understanding. Consequently, the psychiatrists Weisman and Hackett maintain our fear of the process of dying rather than the state of death by saying, "The fear of death is a specific attitude towards the process of dying and is not related to the fact of death." (7) As previously stated,dealing with terminally ill patients is something that all nurses will experience throughout their training and during the course of their nursing career. Much of their knowledge on how to do this comes from hands on experience and much of their understanding of how to cater for the patient's needs comes from listening and looking. It is then that the one in the professional role can gain more understanding of each patient's unique experience. The student nurse in the 21st century is presented with a curriculum designed to how to better cater to the patient's physical and emotional. This area is known as Death Education. Death Education is defined as : " .. .the movement to study the social phenomenom of Death and the caring processes for those who are dying." (8) Death Education is a relatively new concept and dates back to Dr Feifel's talks about Death at the American Physiological Association meeting in 1956. Among the pioneers of this concept in the sixties, Quint and Kubler-Ross stand out because their work had a significant impact on leading Daath Education to be seen as a crucial part of the student nurse's straining. Kubler- Ross made it clear that a nurse's own attitudes to death would have a significant impact on the way they administered palliative care to dying patients. The need for good quality care of dying patients has been highlighted as a national priority in the UK and has led to the production of the End of Life (EOL) strategy by the Department of Health.The EOL gives advice on how nurses can deliver a "good death" experience. Despite there being significant developments in the nursing curriculum during the last ten years., the amount of EOL is still regarded as being insufficient. ( ) It is widely acknowledged that nurses are working in an environment where medicine primarily emphasises the cure of illness . Nurses may see death as a failure because life has not been extended. Consequently, nurses have to be prepared to see beyond this view of failure and recognise the value of providing good palliative care In 1984 the Alberta Association of Registered Nurses described palliative care as "...representing a philosophy of care for he dying individual for whom treatment aimed at cure and prolongation of life is no longer appropriate." During the course of their career the student nurse embarks on a journey that not only brings them into situations where they are dealing with the dying patient and their family, but also into situations where they must address the emotional needs of themselves and their work colleagues. At such times the student nurse has to deal with one of the most intensely emotional periods of life, namely the move progression from the familiar world of being alive to the unfamiliar world of death. Nurses may encounter death in any medical area but these encounters are more likely in some areas than others. In the early days of their training student nurses spend time in several medical areas where they are particularly likely to meet dying patients. DEALING WITH THE PATIENT Student nurses' training must educate and equip them to deal with all the needs of the dying patient. In order to meet these needs , it is therefore crucial to be understand both the physiological and psychological needs of the patient. In 'Dealing with Death and Dying', V. Ruth Gray affirms that although every patient's experience of death is unique , there are similar physiological stages of dying that they all pass through : . The patient loses the sensation and power of motion as well as his/her reflexes in the legs first and then gradually in the arms. . There is a "drenching sweat" as the patient's peripheral circulation fails and the body surface cools, regardless of room temperature. . As sight and hearing fail, the dying patient always turns his/her head toward the light. . Touch sensation decreases but the dying patient is aware of pressure. . The dying patient may seem in pain . . The dying patient may remain conscious to the moment of death. . Spiritual needs may increase at night time. . There seems to be an interval of peace before death. Being aware of these stages helps the nurse give planned, purposeful physical care, for example when the patient's sight and hearing fail, indirect lighting should be provided, shades in the room should not be drawn and visitors should sit near the patient at the head of his/her bedside. Once a patient is aware that their illness is terminal they have the psychological response of grief. A nurse who understands the characteristic stages of grief is able to anticipate and cater for the psychological needs of each patient. The pyschological response of grief is displayed by both the dying patient who has just been informed he/she has a terminal illness , and the loved one of the patient who is dying. Dr George Engel describes three stages that the loved one passes through. ( 9 ) Engel's stages are an initial shock and disbelief; then an developing awareness and anger and finally acceptance. In 1970 Dr Elizabeth Kubler -Ross pointed out that when patients are diagnosed with a terminal illness both they and their close ones experience anticipatory grief. These are the five stage s that she says everyone passes through: 1. Denial and isolation 2. Anger 3.Bargaining 4.Depression 5.Acceptance Many student nurses experience these stages themselves when working with dying patients. This is perhaps because it is the nurse who has most contact with the dying patient in hospital and because this is often on a 24 hour basis , a relationship between nurse and patient often develops. This support extends to the patient's family. The expectation to provide safe, humane, effective care to a dying patient and family places huge responsibility on all nurses regardless of their speciality. Consequently, an understanding of these stages assists the student nurse in providing good palliative care ,helps them to relieve the patient's loneliness, depression and fears, as well as helping them to stay patient and calm when the dying person responds in a negative way. The nurse is also more prepared to help relatives and friends with their own emotions so that they can support the dying patient instead of the patient getting more disturbed by them or having to offer them support. Student nurses need to be aware that many dying patients are fearful. Jane C . Williams says, "From my experience, these patients have three levels of fear-fear of pain, fear of loneliness, and fear of meaninglessness." ( 10 ) Allaying these fears in turn makes the process of dying easier for the patient. D.Clark pointed out that even though pain is not inevitable with life threatening illnesses, it still remains patients greatest fear . ( ) Faul et al's research in 1998 said that 75% of patients with advanced cancer and 65% of patients dying from other causes experience pain. Student nurses need to be aware of 'the concept of pain' where emotional , social, spiritual and physical elements all have an impact on the patient's experience of feeling pain. In order for pain to be controlled in terminally ill patients the student nurse must have a thorough understanding of the potential etiology of pain, how to use medication and how to use non-pharmocologic methods. For dying patients the pain is often severe and is a constant reminder that it is part of the disease that will ultimately kill them. It is therefore vital that the student nurse is not only capable of assuring the patient that medication will keep him/her comfortable but also that they are able to comfort the family by informing them that the final act of dying is usually painless. Each dying patient's experience of pain is unique and as such requires an individualised programme delivered by the nurse. Nurses need to be able to assess both the physical and non-physical aspects of pain in order to provide good pain management for the patient. Being aware of and following the three-step analgesic ladder advocated in 2005 by The WHO ( ) usually enables them to keep the patient's pain levels down to a minimum. It dictates that at Step 1 medication is first taken orally. At Step 2 the medication is given at regular timed intervals . Step 3 advises following the directions on the ladder. The following is the Three-step analgesic ladder adapted from WHO ( ) For moderate to severe pain Opiod Step 1 + non-opiod + adjuvant ( adjuvant is a substance included in the prescription to help the other drugs work) For mild to moderate pain Opiod Step 2 + non-opiod + adjuvant For mild pain If pain is not Non-opiod controlled Step 3 + adjuvant This model is accepted as the most valuable method of keeping the patient as pain free as possible if that is what they so wish. Nurses do not have to have a detailed understanding of pharmacology but need to understand that starting the steps early and then reviewing the given drugs regularly is crucial to controlling the patient's pain. Edward Clark's words support this . " One of the most common errors is the notion that pain and death are inseparable companions. The truth is, they rarely go together. Occasionally the act of dissolution is a painful one, but this is the exception to the general rule. The rule is that unconsciousness, not pain, attends the final act. to the subject of it death is no more painful than birth... Nature kindly provides an anesthetic for the body when the spirit leaves it." ( 11) The second fear of loneliness often expresses itself as hostility to others including, family, staff and God. Nurses can support the patient by understanding the reason for such behaviour , allowing the dying to express their rage and by not taking it personally. The third level of fear is one that is often difficult to relate to and deal with. People seem to have a need to feel that there was meaning in their life otherwise life itself seems pointless. To suffer for nothing is too hard a concept for many of us to take on. Without a sense of meaning to their lives, many people fall into a deep depression. For a person to have purpose and meaning in their life they need to have a will that works and an imagination that keeps functioning. Therefore a nurse must learn how to keep a person's will working and stimulate their imagination to help them find some value in life. An awareness of spirituality and spiritual care can assist nurses who have to support dying patients deal with the depression they often experience. These terms are difficult to define especially as they are open to change and are often challenged. In 1989 Stoll ( ) wrote: " Spirituality is my being; my inner person. It is who I am- unique and alive. It is me expressed through my body, my thinking, my feelings, my judgements and my creativity. My spirituality motivates me to choose meaningful relationships and pursuits. Through my spirituality I give and receive love; I respond to and appreciate God, other people, a sunset, a symphony and spring. I am driven forward, sometimes because of pain. Spirituality allows me to reflect on myself. I am a person because of my spirituality- motivated and enabled to value, to worship and to communicate with the holy, the transcendent." Kellehear's discussions suggest that mankind has an innate desire to understand suffering in order that they might transcend and make sense of something that challenges them. Dying is the ultimate challenge that we all must face. Kellehear believed that there are three different areas make up a person's spirituality and they share a common goal of trying to explain a meaningful purpose from a life crisis that a person may encounter. Many people use the prayer, meditation and ritual that the religious dimension offers to provide the understanding they seek. Nurses need to be aware of the patient's culture because religion is an integral part of a person's culture. Each patient's grieving experience is influenced by their religious and cultural beliefs. Trainee nurses need to be aware that a dying patient's culture affects their "thinking and doing, and becomes patterned experiences of who" they are. ( 12) Their culture affects what health information a patient may report, who they ask for help and what remedies they choose to take" ( 13 ) It is important that student nurses are aware that Great Britain is a multi-cultural society and as such requires nurses who understand and are sensitive to the cultural needs of their patients and families. Training should ensure that all negative stereotyping is addressed and that nurses should be non-judgemental and respectful of the attiudes to death from different cultures. Although student nurses need to have an awareness of their own religious beliefs and attitudes to death , these need to be set aside so that the nurse is able to respect the patient's wishes . In 2006 Collins affirmed that, "providing culturally competent care means recognising and appreciating that each individual is part of a cultural group that will colour the individual's response to illness. (14) nurses need to be aware that a dying patient's culture affects their "thinking and doing, and becomes patterned experiences of who" they are. ( 12) Their culture affects what health information a patient may report, who they ask for help and what remedies they choose to take" ( 13 ) For many individuals religion is an integral part of their culture and it is therefore beneficial for the student nurse to understand which practices are being adhered to. Many religious and cultural groups have strict dietary rules and these include preparation requirements as well as excluding forbidden foods. ignoring theses rules is seen as sinful and will therefore hinder the patient's recovery. Many Muslims believe that following the dietary rules set out in the Quran is necessary to prevent illness. Muslims are forbidden to eat pork, raw meat, foods containing alcohol, pork products and foods with animal fats in them.The animal eaten has to be halal (killed in a certain way) and has to be soaked in water to ensure it has no blood in it before it is cooked. Orthodox Jews follow kosher rules and have similar dietary restrictions on pork. Animals must be killed in line with Jewish law regulations. dairy products are not allowed to be eaten with meat products and certain fish and birds are forbidden to be eaten. The majority of Buddhists are vegetarian. They believe that what they eat affects their health as what happens to them after they die. they are forbidden to eat onions, scallions, chives and garlic believing that they will be rejected by the gods and saints if they do. Consequently, the student nurse needs to be aware of the patient's beliefs in order to provide the correct food for them. Communicating with the patient or their relatives allows the nurse to find out in good time if they want their spiritual leader to visit them. Communicating with relatives allows the nurse to ascertain if any specific practices will be required during the terminal stages of the illness and after the patients death. Sikhs may wish prayers to be said for them during the final stages of death . Muslims have strict guidelines including the requirement that only Muslims are allowed to touch the dead body. Sometimes the student nurse's inexperience with dying patients makes them feel awkward or uncomfortable or communication between patient and carer may be hindered by a language barrier,or the patient being unresponsive or difficult. Sometimes patients are reluctant to communicate with someone of a different sex because of religious boundaries and restrictions. In the Situational dimension the dying patient tries to discover hope and meaning in the location they find themselves in whether that be the hospital, hospice or their family home. They need the help of others to bring connection and to offer affirmations that there is hope. It is in the Moral and biographical dimension that patients reflect on their lives and then seek reconciliation and forgiveness from loved ones . with a view to securing an inner peace.The nurse can help them bring some closure to their life and listen as they try to find an answer to what their life has been about, by giving them care and attention, allowing them to get angry and by providing privacy for visits. The three dimensions of Spirituality are complex and in order for the nurse to provide the patient with maximum support , they demand not only a a developing knowledge of spirituality but also a developing ability to listen,to build trusting relationships and to ultimately provide hope. In order to give the patient who is dying the best possible care , the student nurse must take into account that there are many aspects concerning death and dying that are not hard and fast black and white areas , in fact they are grey, uncertain areas. It is not only the patient who has to face uncertainty but also the nurse who sometimes has to deal with ambiguous circumstances. It is therefore crucial that the student nurse is aware of the importance of focussing on the fact that the patient is living until they are dead and as such it is the role of the nurse to enable the patient to have the best quality of life possible. Nurses are in a position to regard the care they give to the dying as being part of a health promotion project for each individual patient. The White Paper 'Our Healthier Nation' (DoH, 1999) focusses on helping all people lead a healthier , more satisfying life from the start of their life till the end of it. Good health is not only concerned with living as long as possible , but also with having a life where dignity and independence are respected. Having this quality of living is everyone's right regardless of their clinical health status. The process of dying can be seen in a more positive way by patient and nurse if a health promoting perspective is taken . Also this view allows the patient the right to choose how they experience their dying . The philosophy of caring for the dying is known as palliative care and the ideas expressed in the White Paper fit with what the student nurse is trying to provide for the dying patient. Student nurses are able to provide palliative care for patients whose condition is unable to be cured .Although the patient's condition usually leads to their death the length of time involved will differ from patient to patient. In 2004 NICE defined palliative care as: "the active holistic care of patients with advanced, progressive illness." The World Health Organisation states that it is the active, total care of patients whose disease is not responsive to curative treatment. Management of pain and other symptoms and provision of psychological, social and spiritual support is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with other treatments. " ( ) Palliative care is a relatively recent concept growing out of Dame Cicely Saunder's work after she opened St. Christopher's Hospice in Sydenham in 1967.Her work as a nurse brought her into contact with many patients who received little care as they were dying and consequently became very distressed and distraught. Her goal was to have dying patients die painfree and to have all their needs including psychological and spiritual ,provided for. Dame Cicely's vision inspired many countries across the world to address the needs of the dying and according to the Hospice Information Service by 2001 over 93 countries across the world had established hospice and palliative care interventions. Hospices are establishments that are either funded by the National Health Service or on a voluntary basis with a view to provide palliative care for patients in the final stages of their illness. They also provide services to support the dying patient's family. Often hospices not only provide symptom control for patients but also provide counselling and complementary provisions. Palliative care should be offered by nurses at the start of the patient's diagnosis and not reserved for their final days. Even when an illness is not curable and will result in death, nurses need to refrain from describing the care associated with it as terminal care. as this term has very strong negative connotations and can be very distressing for he patient. Nurses reserve the term "terminal care" to describe the care given in the patient's final days, weeks or months of their life. The student nurse must understand the aims of palliative care in order to best help the patient. Phil Russell ( ) cites five aims . The first thing the student nurse must be conscious of doing is to affirm life and understand it as a normal process. Secondly the student nurse must offer pain relief and ease distressing symptoms. Thirdly they must provide for the psychological and spiritual needs of individual patients. Fourthly the support system they offer the patient should allow them to live as actively as possible until their death. The fifth and final duty of the nurse offering palliative care is to support the dying patient's family both during the illness and after the death. The skills needed to be a good nurse and offer high quality palliative care are not easy to define. However, Saunders tried to clarify this situation by talking of good nurses 'being with' people when they were in distress. ( ) The four characteristics that Saunders says are the essentials of a good nurse demand skill and expertise. These are being able to be sensitive to the needs of others and able to accept their values without criticising them; to respect the identity and integrity of each individual;to know when to listen and when to speak; to be aware how to provide the best quality of life as defined by the patient. In 1990 Davis and O' Berle interviewed dying patients and their families to ascertain what they needed most at this challenging period of their life. Their answers helped them extend Saunder's ideas and provide a useful , more in depth framework for those offering palliative care. This framework focusses on six areas that help improve the nurse - patient relationship. Rogers believed that VALUING the patient is vital if nurses are going to establish a relationship with the patient that is therapeutic. The element of CARING is essential as it conveys the message that the patient is important. For dying patients who are losing control, allowing them to make decisions for themselves as much as possible is particularly beneficial and EMPOWERING. Many dying patients seek help to help them with FINDING MEANING to the experience of life and death. The element described as DOING FOR relates to the provision of care for the dying patient and this includes controlling pain and symptoms. The team approach used makes it easy to take control away from the patient and family so it is essential to negotiate freely with them. The challenge of caring for the dying can lead nurses to doubt their own ability and self worth, so PRESERVING INTEGRITY by getting good support from other colleagues is very important. Cassen (1991) work suggests that nurses must be able to demonstrate seven crucial features when managing dying patients. 1. Concern: compassionate, empathetic involvement is vital. 2.Competence: patients can be reassured with skill and knowledge. 3.Communication: developing a relationship where patients feel secure enough to share their fears and thoughts. 4.Children: Patients wishing to see children should be allowed to do so as they can bring consolidation to the dying. 5.Cohesion:Family cohesion is reassuring for both patient and family. 6.Cheerfulness: a gentle ,caring sense of humour is often beneficial 7.Consistency: patients often fear they are a burden and will be abandoned.These fears can be removed with continuing involvement from the medical team. Nurses must be able to liasise with the other specialised professionals who are involved with delivering paliiative care to the dying patient. These include clinical nurses who have specialised in palliative care , such as the Macmillan nurses, consultants in palliative care, social workers, clinical psychologists and other professionals such as physiotherapists and occupational therapists. In the early days of palliative care , the professionals involved worked mainly with those dying with cancer. Komaromy suggested that this care should be extended to patients dying of any other other illness for example dementia and respiratory diseases. In 1996 NHSE supported the view that all patients suffering from any terminal illness should receive care not only from specialist palliative care teams , but also from all the health care professionals they encountered. In 2004, the National Institute for Clinical Excellence recognised that not all terminally ill patients' needs had been met and they addressed the shortcomings in their document Improving Supportive and Palliative Care for Adults with Cancer. This document highlights the rights and needs of both the patient and their family. It recognises the importance of face to face communication and strives to establish and maintain the patient's right to be involved in decisions made concerning their care. The NICE document offers information on how to support the needs of the patient and their family in thirteen topic areas. The main recommendations can be accessed at www.nice.org.uk The practice of palliative care exposes the student nurse to several ethical issues that must be considered. The patient's right to refuse Life sustaining treatment may result in death ad it is therefore vital that they are not only able to understand the risks and benefits from the available options, but also that they can think rationally and express which treatment they prefer. Consequently the patient must be provided with sufficient information before making an informed decision and freedom from coercion must be ensured. ( ) The numbers of patients dying in hospitals or hospices rather than having home deaths has increased dramatically and it is therefore vital that the trainee nurse understands and is sympathetic to the individual wishes of the patient regarding their end of life care. Some cultural groups do not want anyone to die at home , for example, many West indians beleve it will bring bad luck. Muslims on the other hand , prefer to die at home. Of course, there are always some individuals who do not strictly adhere to all the beliefs of their cultural group. According to a report by Demos, of the 500,000 people who die each year in the UK, the majority would prefer to die at home. However, less than 20% of patients achieve this. The report entitled 'Dying For Change' predicts that by 2030 65% of people will die in hospital and only 1 in 10 people will die at home. The following statistics provided by the ONS England and Wales in 1997 show that a substantial number of patients suffering from cancer and non-cancer related conditions die in either NHS hospitals or nursing and residential homes. Place of death for cancer and non-cancer patients ( ) Cancer (%) Non-cancer (%) NHS Hospitals 48.3 55.0 Voluntary Hospices 13.3 0.2 Psychiatric Hospitals 0.3 1.0 Own home 25.8 19.9 Nursing home 7.3 10.9 Residential home 3.6 9.6 Other home /places 1.6 3.4 The magnitude of the Aids epidemic has had and will continue to have an effect on nurses' health care experiences. Aids no longer affects only haemophiliacs and homosexuals and consequently the numbers of people dying from Aids will increase. The World Health Organisation states that it occurs mostly within the teenage group so it is vital that nurses receive adequate education and appropriate training if they are to deliver supportive and humane care to this group of dying patients. In 1987, Priest pointed out that because of the increasing " number of young, dying Aids sufferers, the importance of making high quality palliative care accessible to all in need becomes very real." ( ) Many people are only admitted to institutional care when it is no longer practical to care for them at home. Dr Keri Thomas established a system of care called The Gold Standard Framework which was designed to help people die at home if they so chose. This system was taken on by Macmillan Cancer Relief and then endorsed by the National Health Service. After identifying those in the community who need palliative care, the patient and their family are catered for by a multi-disciplinary team . This is particularly beneficial when attention is needed during out of hours. Despite the religious/cultural beliefs about death and dying being complex , Andrews and Boyle believe that they all share one common theme, they all want to die with dignity. (15) The dramatic increase in the numbers of patients dying in hospitals and hospices rather than having home deaths has made it even more important that the student nurse understands and is sympathetic to the individual patient's wishes regarding end of life. Student nurses are taught that there are three stages that the body goes through when death has occurred. These are 1. Rigor Mortis, 2.Algor Mortis and 3. Livor Mortis . For many student nurses , their first experience of these stages of death comes when they are involved in giving the Last Offices. This term describes the final acts of care that a nurse gives to someone who has died and for many is an opportunity to bring closure to a relationship they had with their patient. Although the procedures for Last Offices depends on whether the patient died in a home, a hospice or a hospital, the nurse must be aware of and follow the principles outlined by Cooke in 2000. These include following the relevant legal requirements , communicating promptly with other relevant staff and treating the dead person with respect. Several important ethical and legal issues have arisen with the rise of palliative care .Student nurses must be aware of each patient's rights. If a patient can comprehend the available choices together with the associated risks and benefits, and can express their desired choice of treatment rationally, they can choose to refuse life sustaining treatment even if death is the result of this choice. (Stanley 1992) ( ) Legally the patient must be provided with adequate information , be competent enough to decide for themselves and be free from co-ercion from others. ( ) Some cultures ,including African and Asian believe that informing the patient burdens them and they should not have their feelings of hope destroyed . DEALING WITH THE FAMILY During their training, student nurses become aware that their role not only involves learning about and dealing with the needs of the dying patient, but also with providing support for the grieving family. The student nes aware that they can influence at the outset the way a family will begin coping with their loss, their grief and their inevitable guilt. Helping the family is ultimately helping the dying patient. Nurses are not born being able to assess, understand and empathise. The best way of cultivating theses skills is to listen for clues. Most people usually make it known what they need to discuss. Listening not only offers direct support and comfort but also allows the nurse to plan a personalised caring approach for the patient and family. it's worth noting that non-verbal communication conveys a more authentic indicator of a person's emotional status than words do. Recent teaching skills have focussed primarily on "doing" and consequently, some would argue that this has resulted in many nurses feeling uneasy or guilty for listening to patients instead of carrying out a tangible task , especially when a head nurse or supervisor is near. Student nurses need to remember that when a person is admitted to hospital, the family's need for communication, contact and security is often increased in an unfamiliar, impersonal environment. Taking time to understand the individuals in the dying person's family during the interim between diagnosis and death is beneficial to all parties involved. It sets the foundations for a trusting, caring relationship which builds rapport and aids communication. A stable relationship supports the family members in acknowledging the loss they must face. It also eases the family riddled with guilt and provides clarity for those who are unfamiliar with the treatments being offered. For many family members, sitting around just watching their loved one dying intensifies their feelings of helplessness. The student nurse is in a position to reduce this feeling by involving them in some of the caring duties the patient needs, for example, feeding the patient. Such involvement is not only comforting but also helps relieve anxiety and guilt. The student nurse is able to offer comfort to the family by assuring them that their loved one will receive pain relief and that all that is possible to do will be done to promote their physical comfort. It is vital that family know this because even though many family members can admit that death is very close and can not be avoided, the suffering it may entail is too much for them to cope with. The inevitable death of the dying patient can evoke many unexpected emotions from family members and being aware of and having a clearer understanding of the nature of bereavement can help the nurse better support the grieving individual. Freud offered a model that suggested grief was a process that needed to be worked through. ( ) This model has been taken and adapted by several psychologists including Parkes , Worden and Kubler- Ross. Studies in recent years have criticised these models of grief maintaining that they do not adequately recognise an individual's unique response to the death. They point out that family units are unique and as there is no stereotype for grief, family memnbers will be affected by death in different ways according to their own personality, their relationship to the dying person, their age, their own cultural and religious beliefs about death and their own previous experience with death. Stroebe and Schut's model (1999) takes into account gender and cultural differences and is by its nature more individualised. It suggests that people move back and froth between the area of being emerged in their grief and the area of being distracted from it in their everyday life. Nurses therefore need to take this on board and focus on the individual rather than dwelling on the theoretical aspects of bereavement when supporting grieving family members. Goodall ( ) suggested Ten ways to help the bereaved and Phil Russell adapted this to offer some guidance to student nurses. His chart laid out the following suggestions: . Be there . Listen in an accepting and nonjudgemental way . Show that you are listening and understanding something of what they are going through . Encourage them to talk about the deceased . Tolerate silence . Be familiar with your own feelings about loss and grief . Offer reassurance about the normality of grief . Do not take anger personally . Recognise that your feelings may reflect how they feel . Accept that you can not make them feel any better ( ) Jane C Williams believes that after the patient has died the nurse should try to reaffirm the lives of the grieving family . She ends her thoughts on Stages in bereavement (16 ) by saying, "...if we really believe and "live" our vocation, our deep investment of compassion and empathy will be communicated to the bereaved.It can help them find the inner strength in each of us but which, in their despair, they're blind to or have forgotten. " These words clearly reinforce the belief that the student nurse is learning how to become a valuable instrument of healing both in life and in death. CARING FOR OTHER NURSES The qualitative research methods used in recent years have given nurses a chance to express their needs and concerns .The results have provided important information that reveals if and how nurses are affected by working with dying patients. . After analysing theses results , it was found that many nurses in similar clinical situations shared a common response . Having a deeper understanding of student nurses needs is useful in identifying and providing the support and training they need. During 2005 and 2009 the results from the surveys done were put on the following database:MEDLINE, LILACS, BIREME, SCIELO and BDENF. After analysing the results three main categories were identified: 1. Nursing students and contact with death; 2.Nursing faculty living with Death and teaching skills; 3.Academic education providing support for a critical reflexive view on the theme "Death-dying The abilitiy to provide a relevant curriculum ultimately benefits both nurse and patient.These responses highlighted a need for extra theory input on the areas of nurse/ patient relationships ;communication difficulties; ethical dilemmas related to sudden death situations; sudden detioration; mechanistic care and resuscitation policies. Johannon and Lalley (1991) say that student nurses often find it hard to manage the stress that caring for a dying patient brings. ( ) Research suggests that this affects first year undergraduate Nursing students more than other groups because their pre-existing socio-cultural views may prejudice their attitude to Death. These students believed that they would feel better equipped to provide better care and support by the end of their training. In one study the results showed that emergency room nurses exhibit greater fear and less acceptance of death than hospice nurses. (Payne, Dean and Kalus 1998) ( ) Hospice nurses continually update their training on caring for the dying unlike emergency nurses who do not. This could therefore be seen as evidence to support the view that both a nurse's experience in clinical settings as well as the course work they undertake, infulences their perceptions and attitudes about death and dying. Research has shown that it is not only individual factors such as age ( ) and level of education ( ) that influence a nurse's attitudss to death and dying, but also the individual's cultural background. For example, survey results indicate that Swedish and Iranian student nurses hold different attitudes towards death and their consequent care. This is accounted for by the fact that Sweden is part of the European culture where the majority of people are Christians whereas Iran is part of the Middle Eastern culture and Islam is the primary religiion. The adult mortality rate is higher in Iran than in Sweden so the student nurses there are more likely to be more familiar with death than Swedish nursing students. The results of the questionaire given to student nurses from both countries indicated that although they both saw palliative care as a positive approach, Iranian students were less likely to interact and discuss matters of dying and death with the dying patient. Swedish student nurses feared death less than the Iranian nurses who were concerned about death because they believe it is the gateway to a happy life or eternal judgement. Younger students who saw death from a religious perspective held a more negative outlook on death than older ones who had a more natural view of it. Ultimately, the student nurse needs to have their Nursing theory incorporated into everyday experiences in the clinical environment. Loftus believes (1998) that "developing an understanding of the meaning of student nurses' experience when caring for dying patients will help both teachers and clinical staff by (influencing) both nursing theory and practice." Caring for dying patients inevitably has an emotional effect on nurses and many experience feelings of anger, depression, frustration,hurt, and sadness. Sheila Lelly Blake believes these feelings of grief help nurses to connect with their patients. She goes on to ask " ...how can we expect to share deep emotions with a patient or family one minute if we reject our own tears of joy or sadness the next'" ( ) Many student nurses reported that despite feeling emotionally drained and exhausted , the caring for a dying patient helped them identify strengths they did not know they possessed. it is widely accepted that if nurses are working in an environment where death is a frequent event then no-one can afford to stand alone emotionally. Support from other staff is essential to prevent nurses feeling emotionally debilitated. Each death experience is unique and no-one can totally prepare one's feelings in advance to cope with it. However, a willingness to discuss and share feelings with others benefits all concerned . Nurses need to feel secure enough to expose their feelings and not have their fears interpreted as failures. Time set aside where they can vent their feelings also provide an opportunity to share new approaches to their problems. Nurses do not always have access to theses meetings at the moment they need them so it is important that they are able to deal with their troubling emotions on the spot to prevent them from having a negative effect on the way they relate to other patients, other staff members or even their relationships outside of work. This requires that all learn to recognise the signs that indicate another nurse needs emotional support and that a nurse who is feeling "up" is ready to reach out to another nurse who is feeling " down". Working in an environment where one can get things off their chest not only allows the nurse to relieve some of the fears and anxieties they face but also provides clues to feelings they will probably encounter when a patient is dying. Being aware that the feelings such as guilt, insensitivity , inadequacy and helplessness are prevalent and are seen as a normal , healthy reaction, may in fact help nursing staff mentally prepare themselves before these feelings actually arise. Guilt is probably the hardest feeling for nurses to deal with and can be brought on by countless different situations. It is difficult to take a specific action to rid the feeling and often can only be resolved through time , understanding and acceptance. Nurses must allow themselves to feel the uncomfortable feelings they experience during the care of the terminally ill so that when they make a mistake they can analyse the situation and learn from the experience so that they know better what to do in the future. It is easy for nurse to become insensitive to the problems of family and friends outside the hospital. Their problems may seem trivial compared to the problems their patients are feeling. It is important however for the nurse to try extra hard to keep their perspective and remember that those problems are very real for the people involved. Feelings of inadequacy and helplessness are particularly common and nurses often experience these feelings when they do not how to say the right thing or when they are unable to assist a patient medically. Setting small , achievable targets when facing hopeless situations every day can help nurses make the day bearable and purposeful for the patient and nurse. It is very important for a nurse to have interests outside of work to act as diversion from the pressures of work and to help uplift their spirit. Elizabeth Kubler -Ross urged nurses to "live every day to the fullest....You have to learn early to switch gears , to enjoy the garden, a boyfriend, whatever makes you happy. You owe that to yourself, your family, and- not least of all- your patients. hoard the sunshine things in life. You will then be able to spread some of that sunshine in those hospital rooms where it's so desperately needed." ( ) In conclusion , my work on the student nurse's perspectives on Death and Dying have highlighted that although the survey results indicate nurses require more education on communication skills, pain and symptom management and psychological support,the current health and social policy documents are not fully addressing the shortfalls. Some would argue that in the future nurse educators an in higher education and practice must work alongside each other to implement guidelines at a local level. Others maintain that only a national inter-professional curriculum will prepare nurses to cater for the needs of dying patients and their families. I find that I share many of the thoughts and feelings of fellow student nurses. I have experienced fear of making mistakes and feeling anxious about not knowing what to do.I have feared doing something I didn't want to do when faced with touching a dead body for the first time. I have felt sadness when I have come into contact with grieving families as I can empathise how I would feel in a similar situation. My feelings of compassion have been stirred as I have built up a relationship with a dying patient and i have felt upset at losing them after becoming attached to them. i have felt frustration with some of the medical responses of some doctors because some of the aggressive treatments they have authorised seem futile when the patient is nearing death. I have felt stressed when I haven't been able to communicate to patients and families in a supportive way. Despite all these negative feelings I have felt, I have also experienced, along with many of student nurses, the positive feelings of satisfaction and joy that caring for and developing a close relationship with a dying patient brings. My communication skills have developed as I have had more experience of caring for dying patients. My own thoughts about death have become clearer and I no longer fear the stage of life we call death. Ultimately, i seek to care for my patients to the best of my capability and be the best nurse I can be. Consequently , i intend to be led ny the words of Fritz Williams : "Suffering and joy teach us, if we allow then, how to make the leap of empathy, which transports us into the soul and heart of another person. In those transparent moments we know other people's joys and sorrows and we care about their concerns as if they are our own." © 2013 MicrosoftTermsPrivacy & cookiesDevelopersEnglish (United Kingdom) © 2013 MicrosoftTermsPrivacy & cookiesDevelopersEnglish (United Kingdom)