Death and Dying
Coping with death, one’s own or a loved one’s, is considered the ultimate challenge. The idea of death is threatening and anxiety-provoking to many people. Kubler-Ross stated, “The key to the question of death unlocks the door of life. . . . For those who seek to understand it, death is a highly creative force.” Com-mon fears of dying people are fear of the unknown, pain, suffer-ing, loneliness, loss of the body, and loss of personal control.
In recent years, the process of dying has changed as advances have been made in the care of chronically and terminally ill pa-tients. Technological innovations and modern therapeutic treat-ments have prolonged the life span, and many deaths are now the result of chronic illnesses that result in physiologic deterioration and subsequent multisystem failure.
Preparation for an impending death can precipitate the expe-rience of anticipatory grieving. Although anticipatory grief can have positive effects on later grief, this does not hold true for all people. For some family members, anticipatory grief is seen as a risk factor for poor early bereavement adjustment (Levy, 1991). The nurse must be aware of the uniqueness and individuality in-herent in the grieving process and work to meet the needs of those involved in the best way possible.
Various frameworks for understanding the concept of grief and the stages of death and dying may be useful to the nurse. The stages of bereavement described by Bowlby (1961) are protest, disorganization, and reorganization. Kubler-Ross (1975) con-ceptualized five stages of grieving: denial, anger, bargaining, de-pression, and acceptance. Often, the dying person and the survivors do not experience these responses in an orderly or lin-ear fashion; rather, there is random movement between all the stages for differing periods of time. Another model for successful grieving, proposed by Engel (1964), is shock and disbelief, de-velopment of awareness, and restitution. The themes common to almost all models of grieving are periods of avoidance, con-frontation, and acceptance (Cooley, 1992).
Another framework for understanding the individuality of the dying process is provided by the “patterns of living while dying” de-scribed by Martocchio (1982). There are four identified patterns of living based on the clinical trajectories of dying people. The first is referred to as peaks and valleys or periods of hope and periods of de-pression. Despite the hopeful times, there is still an overall move-ment toward decline and death. The second pattern is one described as distinct but descending plateaus. This course also reflects a downward trend with progressive debilitation and eventual death. The third pattern is a clear downward slope with many physiologic parameters indicating that death is imminent. This pattern is often observed in the critical care unit when people and families have no time to prepare for the death. The last pattern is a downward slant that reveals a crisis event, such as a severe cerebral hemorrhage with almost no hope of recovery. Often, a patient in this pattern is being maintained on life support systems. The nurse should recognize that a person may experience one or more of these living–dying patterns.
Nursing care involves providing comfort, maintaining safety, addressing physical and emotional needs, and teaching coping strategies to terminally ill patients and their families. More than ever, the nurse must explain what is happening to the patient and the family and be a confidante who listens to them talk about dying. Hospice care, attention to family and individual psy-chosocial issues, and symptom and pain management are all part of the nurse’s responsibilities. The nurse must also be concerned with ethical considerations and quality-of-life issues that affect dying people. Of utmost importance to the patient is assistance with the transition from living to dying, maintaining and sus-taining relationships, finishing well with the family, and accom-plishing what needs to be said and done.
The nurse is the consistent link in promoting understanding of the patient’s disease and the dying process and in making the event more manageable for the patient and family, who will re-quire assistance to resolve problems and proceed through the grief work. Retaining as much control as possible during the process of dying allows the patient and family to make as much sense as possible out of an overwhelming situation. In the hospital, in long-term care facilities, and in home settings, the nurse explores choices and end-of-life decisions with the patient and family. Referrals to home care and hospice services, as well as specific re-ferrals appropriate for the management of the situation, are initi-ated. The nurse is also an advocate for the dying person and works to uphold that person’s rights. The use of living wills and advance directives allows the patient to exercise the right to have a “good” death or to die with dignity.