Death influence in clinical practice: A course for graduate students

Abstract

A course for graduate instruction was designed to provide for analysis and study of the social, cultural, and psychological conditions that influence death in modem society. The course was open to any graduate student with an interest in the topic, xoith enrollment limited to 16 participants. The formal objectives emphasize the cognitive focus of the course, but there is an overall goal of facilitating an integration of intellectual and emotional learnings in relation to death and dying. Methods of instruction include weekly seminars, experiential out-of-class assignments, specific written assignments, and readings. Seminar topics include social values and death in human society, cultural variations and death expectations, death and the family, institutional death: its fortns and effects, life versus death: an occupational dilemma, recovery care versus comfort care: nurses' problems, dying as a Personal experience, effect of dying on social interaction, and unresolved problems and major issues. Follow-up evaluation by questionnaire for students enrolled betiveen 1971 and 1979 produced a response rate of 55.8 percent with a generally favorable evaluation. The instructor made deliberate efforts to use the seminar as a situation for encouraging the integration of emotional and cognitive learnings. A variety of instructional strategies are described.     

Ethics, technology, and the high cost of dying: a public forum

To increase public awareness of the complexity of the issues surrounding care for the terminally ill, a county medical society and a local hospital council co-sponsored a public forum in October 1985. Panel members discussed the case of a terminally ill cancer patient from the medical, psychologic, economic, legal, and family perspectives. Panel members stressed the importance of helping the dying person to choose the preferred treatment and to achieve an emotionally satisfying death. The audience responded by pointing out the barriers to achieving death with dignity, which include poverty, lack of social support, and difficulty in facing and talking about death. In an evaluation questionnaire, the audience indicated that the emotional aspects and the communication problems involved in care for the terminally ill caused them more concern than the legal and ethical issues.     

Adults’ perspectives on cultural,social and professional support on end-of-life preferences

BackgroundDiverse cultures and social contexts can exhibit different values, religious meaning systems, social norms concerned with social responsibility and interpersonal and family relations. These factors play an essential role in individuals’ decisions and preferences for end-of-life care.AimsTo explore Taiwanese adults’ perspectives on the influences of cultural, social and contextual factors on preferences for end-of-life care.MethodsA semi-structured face-to-face interview approach and content analysis were used. A total of 16 adults were recruited.FindingsMajor themes identified as influencing factors included social, cultural and religious aspects, professional and community resources, perceptions about end-of-life services and attitudes toward death and dying.DiscussionThis suggests that people’s end-of-life preferences can be influenced by social and cultural norms, the adequacy of systems for advance care planning, knowledge about advance directives and palliative care, and emotional reactions toward death and dying.ConclusionsFindings provided insight into adults’ perspectives on how cultural, social norms and religious values and professional support shape individuals’ beliefs and attitudes toward death and dying as well as in end-of-life decision making. These findings contribute to our understanding of adults’ end-of-life preferences and provide guidance for health professionals and communities in assisting Taiwanese people plan for the end of life.     

How to prepare Chinese-born nurses to care for patients at the end-of-life in Western settings: A discussion paper

BackgroundAs a result of globalisation, many Chinese-born nurses choose to work outside China. They are expected to be competent in providing end-of-life care and dealing with dying and death within the new country, where cultural beliefs, attitudes, and values towards dying and death may differ from their own. It is essential to consider the influence of Chinese culture on nurses’ confidence and preparedness for end-of-life care, especially for dealing with dying and death.PurposeTo discuss Chinese perspectives on dying and death, and death education and training in mainland China, from which we propose recommendations for nurse educators, clinical mentors and researchers in Western settings on how to prepare Chinese-born nurses to care for patients at end-of-life.DiscussionChinese-born nurses likely encounter significant cultural challenges when providing end-of-life care to dying patients in Western settings. Chinese-born nurses’ perspectives, attitudes and values toward dying and death are shaped by Chinese cultural and social beliefs, practices and expectations, which contrast with those of Western settings. Nurse educators, clinical mentors and researchers in Western settings are encouraged to support and guide Chinese-born nurses in building their cross-cultural understanding and world view to an international view of nursing; essential foundations to the provision of end-of-life care, and nurse coping with dying and death in Western settings.ConclusionThe development of death education programs and training to support Chinese-born nurses to attain their cultural competence is a priority in Western countries, to better promote these nurses’ competency in providing high-quality end-of-life care.     

Presenting biological data in a course in death and dying

This article focuses on a current problem in our society: determining when someone has died. This problem is important in an introductory death and dying course. First, because it appears to be a biological or scientific question whose solution depends on empirical methods, it allows us to discuss current technologies and clinical approaches to dying people. In the process of carrying on this discussion, we become aware that what appears to be a factual problem is actually a complex web of empirical and axiological difficulties. This particular problem is valuable in a broader sense because it makes students recognize that problems related to death and dying require decisions based on mixtures of fact and values. Second, extrapolating from the special concerns of those dealing with problems in death and dying, the question of expertise can begin to be seen in a new light. This allows us to emphasize the role of every person in the making of value decisions.

Last, although a variety of problems have this aspect of being at once factual and value laden, this problem is an essential part of a course in death and dying because it is one that many members of our contemporary society may be expected to face themselves. The preliminary reflection on this problem carried out in a course on death and dying thus provides important preparation for people to make an informed decision when and if this distressing question arises in their own lives.     

Educating nurses to care for the dying in Hong Kong: a problem-based learning approach

Caring for dying patients is an essential and major aspect of nursing care. However, previous studies have revealed that nurses felt uncomfortable and inadequate in dealing with the dying patients and their families. This study reports the effectiveness of a problem-based learning approach in death education among a group of registered nurses in Hong Kong. Three problems, with three segmented scenarios related to cancer nursing, were used. Students went through the problem-based learning process and documented their learning throughout the course in journals. A total of 72 sets of journals were collected and analyzed. The strategies of within case and cross-case analysis were employed. The within case analysis explored the learning development of students for each problem. The cross-case analysis compared and contrasted findings of the within case analysis. Three themes have been derived from the findings. They were: nurses acknowledging their emotions in facing death and dying, a need for the nurses to be better equipped in communication and counseling, and a holistic and family-centered approach to care. This study provides evidence showing that problem-based learning is an effective strategy to enhance nurses' self-awareness of death and dying issues, and to stimulate nurses to formulate a plan that addresses the physical, psychological, and social aspects of care. Findings also reveal that nurses need to take into account the particular reactions of death and dying in the Chinese culture when planning care.     

The Return of a Good Book

This study provides an in-depth investigation of the motivations, goals, and impact on 23 university students enrolled in a Psychology of Death and Dying course. Through a grounded theory analysis of precourse perspective and postcourse reflection assignments, several key themes emerged. Participants were motivated to enroll in the course by their self-identified lack of knowledge on the topic and its professional and personal relevance. They identified three main course goals: cognitive comfort, preparation to support others, and personal growth. At the end of the course, participants noted heightened awareness of personal mortality and increased comfort with death-related topics, as well as reduced fear, surprise at the depth of the thanatology field, and enriched context for their experiences with death and dying. The implications of the results for death educators, researchers, and students are discussed.     

Meanings of dying at home for Chinese patients in Taiwan with terminal cancer: a literature review

To maintain dignity, patients with terminal cancer must be able to do things in their own way, to make their own decisions, and to preside over their own dying. Among the tasks considered essential for patients with terminal cancer is deciding where they prefer to die. The actual place of death has been recognized in hospice care as indicating quality of care. Approximately two-thirds of patients with cancer, when asked about the preferred place of death, say they wish to die in their own homes. Patients with terminal cancer dying at home may find physical and emotional comfort there. Home is a place where people may feel safety and a sense of belonging. In dying at home, patients with terminal cancer also may have a greater chance to control their environment, more autonomy and privacy, and a sense of normality. In this article, special cultural meaning of dying at home for the Chinese patient and the family is reviewed. It is essential for health care professionals to understand Chinese cultural beliefs and values related to dying at home in order to provide culturally sensitive care for Chinese dying patients and their families and to enhance their sense of control over the unknown process of dying.     

Negotiating life for the dying: hospice and the strategy of tactical socialization

Hospice is often discussed as a social movement that is attempting to change not only the way particular patients experience dying, but the nature of death and dying for society as a whole. Participant observation research was conducted in the home care components of and a free-standing inpatient facility associated with several northeastern hospice organizations over the course of almost three years. The data are reported using negotiated order theory as a framework for understanding the hospice movement, and tactical socialization is identifide as a majar strategy of hospice workers for accomplishing their goals.     

Symptomatic management of neurodegenerative disease in the elderly

The care of elderly people with progressive neurodegenerative disease is often complex and palliative care may be helpful from soon after diagnosis to enable the quality of life to be maintained as much as possible. Palliative care may be involved in an episodic way, as new problems and issues are faced, throughout the disease progression. There are many issues which require careful assessment, including symptoms, psychological, and social aspects of care. This may include the assessment of cognitive change and ensuring that symptoms and issues are addressed correctly, even if the person cannot communicate or is cognitively compromised. This care will also include carers, spouses and families, professional carers, and carers within residential and nursing homes. Patients and carers may need ongoing support, to cope with the multiple and continual losses faced within neurological disease progression, with the complex interaction with other comorbidities and the effects of ageing. As the progression continues the recognition of end of life, through the assessment of triggers, is important so that all can be prepared for dying and death.     

Can addressing death anxiety reduce health care workers' burnout and improve patient care?

Death anxiety may interfere with health care workers' (HCWs) relationships with patients and patients' families and increase HCWs' levels of burnout. This study shows the impact of a six-day course for HCWs that provided training in communication, in offering emotional and spiritual support to patients, and in personal introspection on death anxiety. The HCWs were given questionnaires to evaluate their level of burnout, personal well-being, and death anxiety as well as the quality of their relationships with patients before the course and four months after it. There were 150 study participants, all HCWs involved in caring for dying patients (85 in palliative care units and 65 in other settings). There was a control group of 26 HCWs who cared for the dying in settings other than palliative care units. The results show that the course appeared to lead to a significant reduction in levels of burnout and death anxiety; they also indicated an increase in personal well-being and professional fulfillment, and participants perceived an improvement in the quality of their relationships with patients and patients' families.     

Attitudes of Asian and American graduate nursing students towards death and dying

This study compared the difference in attitudes towards death and dying between 17 Asian and 11 American graduate nursing students. Asian and American students did not significantly differ in attitudes related to fear of death, of self, or others, but Asian students were significantly more afraid than American students of their own process of dying. Asian students were more averse than American students to interacting and discussing death with dying patients. Talking about death with dying patients was the most difficult aspect of care for both groups. However, Asian students gained more personal satisfaction than American students in caring for dying patients. The findings provoke discussion regarding differences in nursing practice by Asian and American graduate nursing students.     

Emotional involvement with the dying in a coronary care unit

The conflict between professional distance and emotional involvement has been identified as a central problem for nurses in their care of dying patients. While some nurses may attempt to maintain their professional distance, individualised methods of patient care encourage the development of emotional involvement between nurses and their patients. Where such nursing methods are used it is essential that appropriate ways exist of handling the problems which such involvement may cause nurses. In the coronary care unit studied, the organisation of nursing work facilitated close and continuing contact between nurses and their patients, thereby increasing the chance that emotional involvement would develop. The death of a patient was not viewed by the nurses as a 'failure', but there were sometimes difficulties for them arising from their involvement with the patient. This paper describes the handling of death and dying in the unit, and some of the issues surrounding emotional involvement and communication with dying patients.     

Death education for advanced nursing practice

Transition Services is a graduate nursing program in the Department of Community Health Care Systems at the University of Washington's School of Nursing. The program was developed as a specific model of health care for preparing nurses to deliver personalized care to people with advanced cancer and their families. One important aspect of the graduate program is to prepare nurses who are knowledgeable and skillfull at providing terminal care to families in their homes. The article describes the clinical content of the program that helps graduate students to learn about the process of dying during three critical periods: before death, the death event, and bereavement.     

Learner-centered learning in an undergraduate interdisciplinary course about death

Recurring themes in thanatology include the interdisciplinary nature of the field, the cognitive and affective nature of the content, and the need to develop programs for specific audiences. This paper demonstrates how one assignment in an undergraduate course in death and dying was designed to reflect these concerns, and be sensitive to the diverse learning needs of the students. It will show how course design and structure can correlate with the information about death which is presented in the classroom.     

The role of neonatal nursing in palliative care of the newborn

Nursing dying newborns is an inherent part of working in a neonatal intensive care (NICU). Holistic care involves recognizing the physical, emotional and spiritual needs of the dying infant and the family. The present article aims to explore how nurses can provide the best practices in neonatal palliative care. Palliative care is composed of three components: assistance with end-of-life decision making; pain and comfort management, and bereavement support with cultural competence. These issues have implications for improving nursing practice.     

Concept Analysis of Good Death in the Japanese Community

PURPOSE: To describe the meaning of a good death in the Japanese community. ORGANIZING FRAMEWORK: Rogers's (2000) concept analysis strategy. METHODS: A review of the literature was done in March 2004, with a focus on older adults' experiences of good death in the Japanese community; "good death" was the subject heading or key words; and literature was published in English or Japanese. FINDINGS: Attributes of a good death include sociocultural norms, personal experiences, and continuous process. The person's experience of dying, the social context, the patient's autonomy and control over the dying process, and quality of end-of-life health care are the consequences of the concept. When good death occurs, it leads to family satisfaction, positive bereavement process, and work satisfaction for healthcare professionals. CONCLUSIONS: Integration of findings from the concept analysis and field research results in more accurate understanding of good death. Knowing the individual concept of good death enables nurses to provide culturally competent care to achieve an optimum death experience for both patients and families.     

Nursing older dying patients: findings from an ethnographic study of death and dying in elderly care wards

Nursing older dying patients: findings from an ethnographic study of death and dying in elderly care wards Background and aim. The aim of the study was to explore the experiences of dying patients and nurses working in three elderly care wards focusing on the management of care for dying patients. The majority of patients who die in hospital are over the age of 65 and evidence suggests that three fifths are over the age of 75. Older patients pose tremendous problems and challenges to nurses and doctors regarding the provision of good terminal care, particularly in relation to developing effective communication. METHOD: An ethnographic research design was chosen. The research sample consisted of 74 patients, 29 nurses and 8 physicians. The principle data collection methods were participant observation and semi-structured interviews. All respondents were interviewed following a period of observation on each of the ward areas. The data obtained from participant observation were then used to structure the interview questions. The purpose of asking questions about meanings associated with observational material was to evaluate the extent to which convergence or divergence of the data was taking place. FINDINGS: The findings demonstrate that the care of older dying patients was defined by a lack of 'emotional engagement' with the patient and the institutionalized nondisclosure of information about death and dying. The study raises issues concerning the lack of effective communication about terminal diagnosis and the strategies used by nurses and doctors for disclosing information about death and dying. The findings suggest that although nurses provide individual care to dying patients, much of this was aimed at meeting patients' physical needs. Nurses reported psychosocial aspects including spiritual and emotional care to be important, although there was little evidence of them being orientated towards this in practice. CONCLUSION: The indicative conclusions from this study suggest that terminal care for some elderly patients remains hampered by a reluctance of nurses and doctors to be more open in their communication about death. It would appear that hospital culture and the mores, beliefs and ideologies that emanate from the biomedical model, significantly shape the experiences of older dying patients.     

Death of a child at home or in hospital: experiences of Greek mothers

The purpose of this study was to investigate the experiences of Greek mothers who cared for a child dying of cancer at home or in the hospital, and to highlight some of their major needs during the terminal period. Fifteen mothers were interviewed and both quantitative and qualitative procedures were used to analyze the findings. Ten families (67%) chose to care for the child at home without having access to home care services, while the remaining five sought hospital care. Their decision was primarily based upon the child's expressed wish and parental preference. The family network played a significant role in supporting the mother-child unit, especially when death occurred at home. Mothers assessed positively the services provided by nurses and social workers, and had expectations that physicians would support them on a psychological level during the terminal period. The care of the dying child is influenced by cultural factors predominant in Greek society and some of the findings are discussed in this light.