Learning Objectives
1. Explain death’s relationship to the process of growth and development.
2. Discuss how culture, ethnicity, and religion influence attitudes toward death.
3. Describe the ways in which religious beliefs and spirituality can help individuals cope with death.
4. Define what is meant by the stages of grief and loss.
5. Identify the five stages of coping with impending death.
6. Explain ways in which the death of an individual affects the family unit and how families grieve.
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IMPORTANT TERMINOLOGY |
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acceptance denial |
stages of grief and loss |
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anger depression |
terminal illness |
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bargaining detachment |
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Understanding death as a normal part of life is a fundamental concept. Despite great advances in technology, medicine cannot cure every illness, and science has yet to be able to stop the aging process. All people eventually deal with the death of a loved one. As humans age, they also must face their own impending mortality. Nurses are likely to find themselves caring for dying individuals in many situations, including acute care, in a hospice program, in a nursing home, or in a client’s home.
Basic human needs are a priority for the dying person. Families have special needs as they deal with loss and grief. This topic examines death as the final stage of growth and development.
Death is part of life, an extension of birth. Everything that lives in this world will someday perish. Naturally, some people develop a fear of dying because what comes after death is unknown. When healthy and active, most people think of themselves as immortal. Although people can imagine others dying, they often have trouble imagining their own death.
Death is one of the most profound emotional experiences humans encounter. Because Western medicine and beliefs are based on preserving life, admitting that a person cannot be cured or revived is often difficult. Resolving feelings about the reality of death is a continuing challenge for many individuals.
Key Concept Death is a natural part of life.
How you feel about it will influence how helpful you are to dying individuals and their families. Fear and anxiety are natural. By confronting your feelings and reaching out to support others in meeting death with dignity you will become more comfortable with the concept of death.
INFLUENCES OF CULTURE, ETHNICITY, AND RELIGION
Cultural, ethnic, and religious beliefs help to shape people’s attitudes toward death. How one dies and how one responds to death vary greatly, depending on the cultural context. In many cultures, death is a social event with great meaning for the whole of society, whereas in others, death is considered a private, hidden occurrence. Some cultures celebrate when a person dies, believing that he or she is in a better place. Others mourn for extended periods. Some cultures view death as an intensely personal experience, with families keeping most of their emotions and feelings within a private circle. Other cultures grieve openly.
Religion and spirituality play a large role in the client’s and family’s responses to death and dying. Death often forces people to consider profound questions: the meaning of life, the existence of the soul, and the possibility of an afterlife. Individuals faced with death, their close friends, and family often rely on ingrained belief systems that help them meet the challenging concepts related to dying and death.
For those whose spirituality does not include beliefs rooted in organized religion, support may take the form of compassionate care and the acceptance of personal beliefs. For those whose spirituality includes an expression of a specific religious practice, the availability of rituals can bring comfort and support. Many religions have specific laws regarding death, and ceremonies for commemorating the dead person’s passage from life. Table 14-1 lists some approaches of various religions to death and dying.
TABLE 14-1. Traditional Religious Beliefs and Practices Related to Death
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RELIGION |
PRACTICES |
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Amish and Mennonite |
Family cares for the body; funeral is often at home |
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Baptist |
Prayer; communion; call pastor |
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Buddhist |
Priest performs last rites and chanting rituals; cremation is common |
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Christian Science |
Reader is called; no last rites; autopsy is forbidden |
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Episcopal |
Prayer; communion; confession; sacrament of the sick |
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Friends (Quakers) |
Individual communicates with God; no belief in afterlife |
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Greek Orthodox |
Prayer; communion; sacrament of the sick; mandatory baptism |
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Hindu |
Priest performs ritual of thread around neck or wrist, water is put in mouth; family cares for the body; cremation is common |
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Judaism |
After death, a rabbi or designate cleanses the body |
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LDS/Mormon |
Baptism required (adults); body is dressed in temple garments; call bishop/elder |
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Lutheran |
Prayer; communion; call pastor |
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Muslim |
Imam performs specific procedures for washing and shrouding body, with assistance of the family; body is buried facing Mecca |
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Pentecostal |
Prayer; communion; call pastor |
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Presbyterian |
Prayer; communion; call pastor |
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Roman Catholic |
Prayer; sacrament of the sick; communion; mandatory baptism |
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Russian Orthodox |
Prayer; communion; sacrament of the sick; mandatory baptism |
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Scientologist |
Confession; visit with pastoral counselor |
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Seventh-Day Adventist |
Baptism; communion |
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Unitarian |
Prayer; cremation is common |
Nursing care includes consideration of whatever supports your client’s spiritual dimensions. You do not have to be a specialist or expert in this area to feel comfortable and competent. Meeting basic human needs is an expression of caring that dying individuals will appreciate, even if they can no longer communicate with you verbally. In other words, you honor the process of dying. Gifts that you can bring to clients and families are interaction, attention, and concern. A return benefit of this gift is a lessening of your fear of death.
KÜBLER-ROSS’S STAGES OF GRIEF AND LOSS
Dr. Elisabeth Kübler-Ross, among other authors, has described certain phases through which a person may pass in an attempt to cope with impending death. Formerly referred to as the stages of death and dying, Kübler-Ross’s traditional stages are more commonly associated with the stages of grief and loss. This is because the idea that grief, loss, and death have been identified as separate topics having similar phases of human behavior.
Grief is common to all individuals; however, not all individuals experience grief in the same way. Nurses must be aware that there is no correct or right way to grieve; that is, there is no right or wrong way to experience the pain of grief, loss, or death. Nurses must also be aware that coping with the physical and psychological pain of this experience has the potential to be healing and to strengthen those going through this process.
Loss can include grief, but does not necessarily have to include death. Loss can be related to any emotional suffering, such as the loss of health, the breakup of a relationship, or the loss of employment. Loss also includes the realization that one’s personal ambitions will not or cannot be achieved. Maslow’s hierarchy of needs discusses the stages of life and potential losses. Chronic illness, such as depression, unrelieved pain, or diseases such as Alzheimer’s, are also associated with grief and loss.
Terminal illness is a state in which an individual faces a medical condition that will end in death within a relatively limited period.
All terminally ill people pass through some of these stages, unless death is instantaneous or the person is unable to resolve conflicts. The family, to complete the grieving process, also may pass through the same basic stages. These stages can overlap, and a person can go back and forth from one stage to another.
Key Concept The Kübler-Ross stages of grief and loss typically also occur in individuals who are close to the person who has died or is expected to die. These stages have also been identified and used for many of life’s situations.
Note that one of the important developmental tasks of older adulthood involves confronting one’s impending mortality. Many older adults also pass through some of the stages of dying, as they face the realization that they will not live forever. A benefit of normal aging is being gradually able to adjust to the inevitability of death, rather than having to confront it with the immediacy of terminally ill individuals. Table 14-2 reviews the following steps in dealing with death.
TABLE 14-2. Stages of Dealing With Death
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STAGE |
RESPONSE |
SUGGESTIONS FOR HELPING THE PERSON COPE |
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Denial Shock, statements of disbelief, often followed by a feeling of isolation |
"No, not me!” |
Answer questions honestly. Allow person to talk to physician. Do not argue. |
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Anger Rage, acting out physically or verbally against family or health professionals |
"Why me?” |
Listen. Do not take the client’s anger personally. Do not get angry yourself. |
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Bargaining Guilt and developing awareness of diagnosis |
"Yes me, but . . .” "If I could just live until . . .” |
Try to assist in client’s wishes. Encourage family support. Offer spiritual assistance from clergy or support groups. |
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Depression Grief |
"Yes, me.” |
Be there. Listen. Offer counseling or social service assistance. Allow person to rest. |
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Acceptance Self-reliance and a feeling of peace |
"My time is close, and it’s OK.” |
Provide physical care. Be there. Keep room lighted if OK with client. Support family members. |
Denial
Denial, the preliminary stage, occurs when the person does not believe that the diagnosis is correct: This can’t be happening to me. During the stage of denial, he or she may seek advice from several doctors, hoping that one of them will offer a more acceptable prognosis. Because hope is maintained, the client is susceptible to unorthodox, illegal, or harmful ways of coping with a diagnosis.
Anger
In the anger stage, the individual is angry and may have periods of acting-out or rage. He or she may ask: Why did this happen to me? Why now? Who is to blame? Often, the individual envies the person who is young and healthy; he or she may lash out at family members or healthcare personnel. Sometimes, the person facing terminal illness is young, which brings additional stress. The anger that the person is expressing generally is related to the feelings of hopelessness and of helplessness involved with the situation and not the actions of you the nurse or of others who are trying to help. When dealing with an individual who is facing terminal illness and seems angry, upset, or argumentative, it is helpful to understand that the person is probably reacting within the normal stages of death and dying.
Bargaining
Bargaining is a stage of developing awareness of the situation. An individual makes deals or bargains with God or with himself or herself: For example, If I live just 2 more weeks, I can see my son get married. The timeframe for this stage may be relatively short. When the bargained for time has passed, the person may make another such bargain, in the hopes of postponing death indefinitely.
Depression
Depression has been reached when the person realizes that he or she is going to die and that nothing can be done to stop it. The sentiment of this phase would be I am so sad, I have no hope of recovery. Unlike some forms of psychologically diagnosed depression, this stage and form of depression is considered a normal, healthy phase. However, it may be beneficial for the client and, occasionally, family members to receive psychological therapy, including medication.
NCLEX Alert Questions found on nursing examinations often include the definitions and concepts of Kübler-Ross. It is imperative that you learn to identify the stages, apply appropriate nursing interventions, and use effective therapeutic communication.
Nursing considerations related to depression include recognizing that the individual concentrates on past losses. You may assist by listening actively and making sure that pain is relieved. Beware of citing commonplace phrases such as everything will be OK or the universe works in mysterious ways. A touch of the hand is commonly helpful. Some people find comfort in remaining active, writing the story of their lives, or reminiscing on past experiences. False hope or encouragement is generally not meaningful or helpful nursing actions.
Acceptance
Acceptance, rather than depression, is demonstrated when the client wishes to plan for life after death or for their family after they die. The feeling could be summarized as saying I am at peace with the diagnosis. As an individual resolves emotional conflicts about death, he or she enters the stage of realization and acceptance of the inevitability of death. To reach this point, a person usually must have had time and assistance in working through the earlier stages. As dying persons resign themselves to death, they may seem devoid of all feeling. This time is particularly difficult for the family, who may interpret an individual’s acceptance of death as a rejection of life and of them. The family must come to understand that the person will be unable to die comfortably unless the family helps the individual to give up everything associated with life. Although the dying person may be unable or unwilling to communicate, he or she usually will appreciate short visits or the presence of a family member.
Detachment
Often unnoticed is detachment, when an individual gradually separates from the world so a two-way communication generally no longer exists with people around him or her. Because dying people may be unresponsive during this time, care from others (including nursing care) is primarily directed toward physical needs. It is also important to support the family. It is not uncommon for the family to not want to leave the client alone and to include him or her in bedside conversations. Many people can still hear and understand what is being said, even if they can no longer respond.
Key Concept Examining Kübler-Ross’s stages of grief and loss can help you understand a person’s reactions to illness, stress, and loss. The stages of denial, anger bargaining, depression, and acceptance explain the range of reactions that clients may express. However never assume that a dying person should be in any one stage at a particular time. Dying persons work through their grief in their own ways, moving back and forth from one stage to another and even skipping some stages. Your role is to be understanding and supportive.
DEATH’S IMPACT ON THE FAMILY
Often families with a member who is dying experience stress more keenly than the dying person does. They are coping with deep feelings of anticipated loss, but do not know how to approach their dying loved one. They want to relieve pain, but they do not know what to do to help. Efforts to appear hopeful and cheerful may confuse the dying person because that is not his or her need at that time. Be aware that not all family members may be in the same stage as each other or as the client. Sometimes, the dying person who has achieved a sense of acceptance or detachment actually provides strength for family members who are having difficulties facing the impending loss.
Key Concept The family should realize that crying or sadness in front of dying loved ones is acceptable. Such behavior can be therapeutic, because otherwise the dying individual may feel that nobody cares.
The utilization of advance directives can be of great assistance to the dying client and his or her family. The wishes of the client are more likely to be followed if that individual has considered his or her own desires and ensured that these wishes are given in writing to physicians, family, and significant others. Without an advance directive, family members may be given the responsibility to dictate life or death decisions. Often these decisions can result in feelings of guilt, self-doubt about making the “right” decision, and hostility among family members.
Many aspects of nursing care are related to death, grief, or loss. Everyday problems will confront a family. Financial concerns may become an increasing source of worry. Arrangements for babysitting, transportation, and temporary housing for out-of-town visitors may need to be addressed. Funeral or commemorative services must be prepared. The family must handle all these things at a time often marked by shock, loneliness, and sadness. Occasionally, the stress becomes difficult for families to handle, resulting in increased conflicts and outbursts of emotion or domestic violence. Support from friends, neighbors, and coworkers can also be a tremendous help (Fig. 14-1).
Often, families question how to handle death when children are in the family. Although very young children may be unable to express their thoughts clearly, they do grieve and need to be part of the family’s mourning. Adults should talk honestly and clearly with children about illness and death when it occurs. Children should be allowed to see the body or attend the funeral (or both) if they wish to do so. Children who are dying should be told the truth and be allowed to ask questions.
The process of dying has been compared with the process of labor. They are both parts of the same life journey. They both touch people in deep and lasting ways. Individuals and families who experience this process form bonds beyond those of the everyday world.
FIGURE 14-1 · Support groups can help people work through their feelings of grief.
KEY POINTS
• Death is a normal part of the total life process.
• Culture, ethnicity, and religion influence attitudes toward death and the way people express grief and loss.
• Religious rituals and spirituality are outlets that help individuals to handle death and dying.
• Most people, if they do not die suddenly, pass through definite stages during the dying process (i.e. denial, anger, bargaining, depression, and acceptance).
• Families who face the impending death of a member may endure enormous stress, grief, and loss. They need encouragement to express their emotions.
• Family members and spouses need support following the death of a loved one.
