Mini Review

Death and Its Significance in Nursing Practice

Tiago Horta Reis da Silva*

Lecturer in Nursing Education, King’s College London, UK

Submission: March 28, 2024; Published: May 29, 2024

*Corresponding author: Tiago Horta Reis da Silva, Florence Nightingale, Faculty of Nursing, Midwifery and Palliative Care; King’s College London, UK Email: tiago.horta_reis_da_silva@kcl.ac.uk

How to cite this article: Tiago Horta Reis da Silva*. Death and Its Significance in Nursing Practice. Palliat Med Care Int J. 2023; 4(3): 555640. DOI: 10.19080/PMCIJ.2023.04.555640

Abstract

Death is an inevitable aspect of human existence, and its implications reverberate across various domains, including healthcare. Within the nursing profession, understanding and addressing the complexities surrounding death are paramount. This article explores the multifaceted nature of death, its significance in nursing practice, and the ways in which nurses can navigate this profound aspect of their profession.

Keywords: Oncology; Death; Holistic Care Nursing Practice; Nature of Death; Oncologist; End-of-life care; Birth to death

Introduction

Death, often regarded as the final frontier of human existence, is a topic that evokes a wide range of emotions, beliefs, and cultural practices. In the realm of healthcare, particularly within the nursing profession, death holds significant importance.

Due to a living organism’s basic need for breathing and consciousness, the United States President Council on Bioethics has classified brain death as human death [1-3]. All diagnostic criteria for human death depend on the proof of the irreversible loss of awareness and breathing ability [3]. The irreversible loss of these two capabilities translates to human death. The brain is a vital organ that cannot be replaced, and every human death is a brain death. Nonetheless, there are other acceptable grounds for determining death outside neurological ones. It is possible to prove the permanent loss of respiration and awareness using three different sets of criteria [1,3]. Neurological criteria are employed in critical care settings, whereas somatic criteria are used in community settings.

The connection between organ failure and death was changed in the 1950s by developments in critical care treatment, such as organ transplantation, mechanical ventilation, and circulatory resuscitation [4]. Vital signs, which were essential for maintaining life, such as respiratory, cardiac, and neurological function, were no longer required thanks to these technologies. When the Harvard Medical School Ad Hoc Committee classified Brain Death as a biological event in 1968, the idea of entire Brain Death was first proposed. This departure from the conventional circulatory determination of death has caused debate among academics, physicians, and ethicists [4]. Whereas Circulatory Death refers to the irreversible loss of circulatory function, which leaves the brain without blood flow, causing brain death. Brain Death refers to the irreversible termination of neurological function. The criteria used by neurology and circulation to determine death differ significantly, despite the fact that death is primarily a clinical diagnosis [4].

The educational background, work experience, personal convictions, and cultural background of nurses all impact how they see disease and death [5]. In addition to receiving training in palliative care and illness management, personal experiences, beliefs, and emotions also have an impact on their emotional reactions [5]. Because of the medicalization of death, nurses now provide care for patients who are nearing death in hospital settings, necessitating emotional self-awareness and support systems. Nurses’ perspectives are significantly influenced by cultural factors as well [5]. For example, many cultures discourage candid conversations about death, which might lead to a communication gap. In order to deliver dignified care, nurses need to have culturally competent communication abilities [5]. Diverse medical traditions provide distinct viewpoints on sickness and demise, encompassing burial customs and beliefs on the afterlife. Nurses should have access to psychological support and support programmes to help them deal with these difficulties. Effective patient care requires both institutional support and emotional management, and nurses need to continuously reflect on their practice in order to give compassionate care and handle the difficult emotional components of their work [5].

Nurses are at the forefront of providing care and support to individuals and their families during times of illness, deterioration, and ultimately, death. This article delves into the nuanced role of nurses in understanding, addressing, and embracing the concept of death within their practice.

Interconnectedness and Holistic Care

The uniqueness of older adults highlights the necessity of an integrated approach. For instance, dehydration [6] and poor nutrition [7] can exacerbate physical frailty, increasing the risk of falls and mobility issues [8,9,10], long-term conditions, for example, Chronic Kidney Disease [11]. Similarly, loneliness and social isolation [12] can lead to mental health problems [7,12], which in turn may affect dietary habits and overall physical health. By understanding and addressing these interdependencies, nurses can develop comprehensive care plans that cater to the multifaceted needs of older adults [13,14].

Holistic nursing care emphasizes the importance of treating the whole person rather than just the symptoms of a disease. This approach requires collaboration among healthcare providers, patients, and their families to create a supportive environment that promotes health, independence, and dignity [13]. By integrating care for ageing, moving and handling [14], loneliness, social isolation, nutrition, mental health, and death, nurses can significantly enhance the quality of life for older adults, ensuring they receive compassionate and effective care throughout the ageing process and at the end of life [7-14].

The Nature of Death

Death is a complex phenomenon that extends beyond the biological cessation of vital bodily functions to include psychological, emotional, social, and spiritual dimensions [15]. Individual experiences and perceptions of death are influenced by factors such as caregiving and preparations for death [16,17]. Preparedness for death has been identified as a crucial factor affecting family caregiver bereavement outcomes [18]. Suffering in the context of cancer highlights the importance of providing opportunities for patients to express their suffering and acknowledging the psychological aspect of death [19].

Death anxiety, characterized by concerns of existential origin, significantly influences individuals’ attitudes towards death [20]. The impact of caregiving at the end of life on grief, quality of life, and general health underscores the need for comprehensive support services for caregivers [21]. Studies on PTSD, ASD, secondary traumatization, and death anxiety emphasize the psychological outcomes of ongoing wars and military operations [22]. The relationship between death anxiety, religiosity, and culture sheds light on coping mechanisms and implications for therapeutic processes [22].

Understanding death requires acknowledging its multidimensional nature, as highlighted in studies exploring the quality of dying and death [23]. The concept of a ‘good death’ involves addressing physical, psychological, social, and spiritual aspects, emphasizing the complexity of endoflife experiences [24]. Death anxiety among older adults during the COVID19 pandemic underscores the need for tailored nursing practices to address anxiety and uncertainty surrounding death [25]. Nurses’ experiences facing death in intensive care units reflect personal encounters with loss, influencing their actions and responses to death and dying [26].

The prevalence and assessment of pain and dyspnea in acute exacerbations of COPD emphasize the importance of exploring symptoms in clinical states, recognizing the multidimensional impact of these conditions on patients [27]. The Multidimensional Mortality Awareness Measure and Model provide insights into mortality awareness, supporting a more integrative approach to understanding this aspect of human existence [28]. Factors associated with cancer patients’ death-preparedness states highlight the importance of accurate prognostic disclosure, symptom management, and empathetic patient-family communication in facilitating preparedness for death [29].

Religious factors affecting death anxiety in older adults practicing Hinduism demonstrate the role of religiosity in shaping attitudes towards death and coping mechanisms [30]. The effects of mortality awareness on attitudes towards dying and death underscore the role of heightened awareness in influencing perceptions of life and death [31]. Wisdom as a mediator in the relationships between meaning in life and attitude toward death highlights the intricate interplay between existential meaning and acceptance of mortality [32]. The association between preoperative frailty and myocardial injury after noncardiac surgery emphasizes the impact of frailty on mortality outcomes [33].

In conclusion, death is a multifaceted phenomenon that encompasses psychological, emotional, social, and spiritual dimensions. Understanding the multidimensional nature of death is crucial in providing holistic and tailored support to individuals facing the end of life.

Death and Nursing Practice

In the context of nursing practice, death is not merely an endpoint but a complex process that demands compassionate care, empathy, and ethical consideration. Experts in delivering tailored care and assisting patients in finding purpose in dying, nurses support patients at a pivotal juncture in their lives [34-37]. This role encompasses various aspects, including pain management, symptom relief, emotional support, and facilitating end-of-life discussions and decision-making [38]. Nonetheless, a lot of nurses emphasize the value of undergraduate nursing education for endof- life circumstances since they feel unprepared to deal with dying patients [34,36-37,39]. Through clinical practice, nursing students observe patients with a range of illnesses and nurses giving end-of-life care in a transitional setting [13,14,37,40,41]. It is essential to comprehend the profound emotions and convictions that nursing students have towards dying and patient death [37,40,41]. The relevance of life and death philosophies in the nursing education process is emphasized by the American Association of Colleges of Nursing, and nursing schools in many other nations offer end-of-life teaching [37,42]. Nevertheless, not enough study has been done to examine what death means from the perspective of nursing students who have seen a patient pass away while participating in clinical practice [37,40,41].

Because nursing students lack experience caring for dying patients and their families, previous research has shown that nursing students exhibit lower understanding of end-of-life care and greater ethical standards than registered nurses [37,39,43,44]. Nursing students experienced emotional distress when caring for dying patients and feelings of inadequacy when communicating with patients and their families during clinical practice due to a significant gap between nursing education and practice [36,37,39,41,43,44]. When confronted with patient families, student nurses frequently feel helpless and unsure of how to respond. Including service users in simulation within the nursing curriculum is crucial for preparing students to deal with death, as it provides realistic and immersive experiences that enhance empathy, communication skills, and emotional resilience [13,45]. Engaging with service users in simulated scenarios allows students to practice end-of-life care in a controlled environment, fostering confidence and competence in managing the complexities of death and dying [13]. They also frequently report feeling unprepared, abandoned, and experiencing reality shock [37,39].

The use of ideas by nurses has strengthened their practice and helped to systematize care in recent years [46]. A growing amount of nursing care is predicated on theoretical frameworks, which provide its knowledge and expertise social and scientific significance and qualify it for use in a multidisciplinary setting. It is required of nurses to acquire the skills necessary to care for patients at every stage of life, including death [46,47]. Nonetheless, it is possible that nurses are not always ready to deal with people’s limitations, which might cause unpleasant emotions and behaviors while a patient is dying [46].

Hospital environments are seeing an increase in deaths, which has resulted in an impending technological practice that encourages a sense of failure [46]. Unfragmented, broader approaches are necessary to solve this problem because they offer a careful examination of all the aspects that affect people, including death [46,48].

There are overt references to death and the dying process in several nursing ideas [46,48]. Nursing, according to Virginia Henderson [49], is the care given to people who are ill or well, with the goal of promoting health, healing, or a peaceful end of life [50]. The goal of Imogene King’s nursing is to assist people in achieving, maintaining, and regaining their health via an interpersonal process of action, response, interaction, and transaction [51]. The study of human life processes and the promotion of adaptation is at the heart of Callista Roy’s nursing science [52]. Her research focuses on assessing the behaviors and circumstances that affect people’s capacity to adjust in four ways: physiological-physical, role-playing, group self-concept identity, and interdependence [52]. Body, soul, and spirit harmony are promoted by Jean Watson’s Human Caring Theory [53]., whereas Madeleine Leininger’s nursing is concentrated on human care occurrences and actions [54]. Care practice has shown signs of struggling to reconcile nursing theories with the meaning and goal of care, particularly when it comes to the setting of death and the dying process [46].

Raingruber and Wolf [55] found three primary themes emerged from the nurses’ discussions: the significance of patients’ vulnerability and gratitude; the spirituality and grace connected to cancer practice; and the relevance of living in the present and setting priorities as significant facets of oncology nursing. Patients’ vulnerability and gratitude inspire nurses to give cancer patients the best care possible [55]. Patients with cancer react as though the nurse is a gift, while nurses experience personal growth, gratitude, and continuous learning from their work [55]. Patients in oncology are grateful for all that staff members do, and there is a distinct gratitude in oncology.

The nurses also emphasized the spirituality and grace that permeate their work and enable them to see that what makes a successful patient is one who is able to find comfort or serenity [55]. They are inspired and sustained by the grace and compassion of oncology nursing, where they acquire newfound appreciation for life’s little moments, gratitude, and compassion [55].

Being an oncologist is a compassionate, calling, and passionate field that transforms people’s lives while also improving one’s own. Every individual who comes into contact with a patient makes a distinct effort to improve their quality of life. Cancer is a blessing that extends life, gives one the opportunity to experience several lifetimes, and fosters personal growth [55].

For nurses to be fully present in the moment, recognize what matters most in life, and provide compassion to others, they must be in the present moment. Being an oncologist means accepting that mistakes might happen. Cancer patients have aided nurses in realizing the need of self-care and developing empathy for oncology patients, among other essential life goals [55]. It can be difficult to remember that being fully present and in the moment is necessary for nurses to be able to support their patients and guide them through life’s journeys.

End-of-Life (EOL) Care

End-of-life care represents a crucial aspect of nursing practice, emphasizing the provision of comfort, dignity, and quality of life for patients nearing death [56]. Palliative care, a specialized approach to care focused on alleviating suffering and enhancing quality of life, underscores the importance of holistic support for patients and their families [57]. Through effective communication, symptom management, and psychosocial support, nurses contribute significantly to ensuring a peaceful and dignified endof- life experience [57-58].

The way nurses feel about the end of life affects the quality of care they provide to patients who are dying. As patients approach the end of their lives, nurses stress the significance of attending to their spiritual needs since they encounter both physical and spiritual challenges [56,58]. EOL care requires a holistic approach, and nursing spirituality plays a significant role in this care. Symptom management is the main emphasis of the majority of EOL therapies as opposed to holistic care [56,58]. Family of patients, contact with family, and their unwillingness to accept a bad prognosis are all barriers to EOL treatment. Because caring for very sick patients requires more time to meet the patient’s bodily demands and less time to respond to the patient’s and family’s spiritual and psychological needs, nurses also noted a shortage of time to discuss with patients about their wishes for end-of-life care [58].

When continuing aggressive treatment, continuing therapy, or stopping life-supporting measures, clinical variables should be taken into account. Nurses’ opinions on direct patient care are unwelcome, discounted, or irrelevant, and doctors are the primary decision-makers when it comes to initiating, continuing, or ending treatment. A significant obstacle to delivering highquality treatment may also be the differing perspectives that doctors and nurses have about end-of-life care [58,59].

Nurses recommend volunteers to assist nurses and assess the nurse’s performance in order to enhance end-of-life care. They also recommend educating patient families on how to care for a critically sick patient. Enough time for family members to say farewell to the deceased, support from volunteers or social workers in providing care, acceptance by family members that the patient is dying, and emotional time are all factors that would aid in end-of-life care [58].

Ethical Considerations

Navigating ethical dilemmas surrounding death is an inherent aspect of nursing practice. Nurses grapple with issues such as autonomy, beneficence, non-maleficence, and justice in the context of end-of-life care, resuscitation decisions, and organ donation [60]. Upholding ethical principles while respecting the values and preferences of patients and families is essential in promoting compassionate and culturally sensitive care during times of death and dying [60].

Coping with Death

The emotional toll of witnessing death and supporting grieving families can be profound for nurses. Self-care strategies, debriefing sessions, and access to emotional support resources are vital for nurses to process their own grief and maintain their well-being [61]. Cultivating resilience, empathy, and mindfulness can help nurses navigate the emotional challenges inherent in caring for patients at the end of life [61].

Emotional Intelligence in Caring for End of Life

Nursing practice is paying more attention to emotional intelligence (EI) since it is seen to be important for building compassionate connections and comprehending patients’ needs, feelings, and moods [62]. Emotional intelligence (EI) is crucial for decision-making, problem-solving, and patient management of unpleasant emotions. It is the foundation of nursing education and may reduce workplace stress and promote team cohesion [62,63].

Few studies depict emotions, communication, and behavior from a humanistic perspective [64], while the majority of EIrelated research is based on a natural science approach [63]. Emotional acuity and cognitive sensitivity are two ways that emotions are linked and reinforced during the knowledgegenerating process. The interconnection of emotions, judgements, thoughts, and behaviors makes it easier to show sensitivity and compassion when thoughts become more intense and vice versa [63]. The ability to comprehend other people as embodied, intentional human beings is facilitated by our emotions and ideas. If a carer is to make the best choice at the appropriate moment, emotions must be taken into consideration. Emotions are shaped by societal conventions and personal experience therefore it is critical to consider how we apply our emotional intelligence to nursing practice [63].

Some researchers [64-66] challenge prevailing norms about what constitutes a decent death, asking if acceptance of one’s own mortality is a goal for dying people or if knowledge and honest, open conversation are necessary when facing death. This danger is reinforced by the standardization of care content and a biassed perspective on knowledge that ignores emotions. In surgical wards, existential issues might be raised by patients, family members, and nurses during the meeting between life and death. In these kinds of circumstances, nurses’ emotional intelligence is essential since it is caring that patients and their families can get. The goal of this study was to characterize and analyze nurses’ emotional knowledge in order to show how it manifests itself in day-to-day work and what kinds of feelings, ideas, and behaviors this knowing encompasses [62].

Sustainable Development Goals:

The Sustainable Development Goals (SDGs), established by the United Nations in 2015, are a universal call to action to end poverty, protect the planet, and ensure prosperity for all by 2030 [67]. These 17 goals encompass a wide range of global challenges, including health and well-being (Goal 3), which directly intersects with the field of nursing. The focus on health aims to ensure healthy lives and promote well-being for all at all ages, thereby implicitly addressing the care and management of death and dying [68].

In nursing practice, particularly in the context of end-oflife care, the SDGs emphasize the importance of comprehensive healthcare that respects the dignity of individuals [68]. Death, as an inevitable part of the life cycle, requires a humane approach that encompasses physical, emotional, and psychological support for both patients and their families. Nurses play a crucial role in this process, providing palliative care, pain management, and emotional support, thereby aligning with SDG 3’s targets of reducing mortality rates and ensuring access to essential health services.

Furthermore, SDG 10, which focuses on reducing inequalities, is highly pertinent in nursing practice related to death [68]. Ensuring equitable access to quality end-of-life care regardless of socioeconomic status, race, or geographic location is vital. Nurses advocate for and implement policies that aim to eliminate disparities in healthcare access and outcomes, striving to provide compassionate and equitable care for all individuals at the end of life.

Additionally, the principles underpinning SDG 16, which promotes peaceful and inclusive societies, resonate with the ethical responsibilities of nurses [68]. Providing end-of-life care involves upholding the rights and dignity of the dying, fostering an environment of peace and respect, and supporting families through the grieving process. This goal highlights the need for robust healthcare systems and legal frameworks that protect patient rights and ensure that end-of-life care is delivered with compassion and respect.

In summary, the SDGs provide a framework that enhances the role of nursing in managing death and dying, advocating for comprehensive, equitable, and ethical end-of-life care. Nurses are pivotal in achieving these goals, ensuring that patients receive dignified and respectful care, thereby contributing to the broader agenda of sustainable development in healthcare.

Conclusion

Death is an inevitable aspect of human existence, and its significance in nursing practice cannot be overstated. By embracing a holistic understanding of death, advocating for compassionate end-of-life care, navigating ethical dilemmas with integrity, and prioritizing their own well-being, nurses fulfill their essential role in providing comfort, dignity, and support to patients and families during times of loss and transition. In doing so, they exemplify the essence of nursing: caring for the whole person, from birth to death.

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