Holistic Nursing at End of Life

According to the Center for Disease Control and Prevention, in 2006, approximately 2,426,264 U.S. residents died.1 Among them, it is estimated 903,953 (about 37 percent) were pronounced dead at an inpatient hospital or within another medical setting.2

 

But if it is estimated that nearly half of the number these deaths occur within a hospital milieu and not in the comfort of the patient’s home, why do we, as healthcare providers, feel so challenged and even plagued when assigned to a patient who is nearing death? Is it not our obligation to ensure that the patient’s last moments of life are ones of comfort?

 

 

In a world where death resounds every second, it is essential nurses assume their roles as educators, surrogates and patient advocates.

Toward that end, we have devised a model entitled C.A.R.E., which provides guidelines for nurses when catering to the physical, psychological, emotional and spiritual needs of the patients and their loved ones:

C – (cultural sensitivity);

A – (active listening);

R- (respect for the wishes of the patient and family); and

E – (emotional support).

Cultural Sensitivity

When providing care to bereaving family and other loved ones, we must continually consider that a patient’s dead body is still a being and should be treated as such. This especially includes maintaining cultural sensitivity.

As we all know, we come from different backgrounds and have specific preferences in life and death. Therefore, when a patient dies, it is imperative that we maintain provision of culturally sensitive care identified by the patient’s cultural practices as appropriate.

Cultural considerations may include religion, specific rituals after death, hygiene care, etc. Many patients may request the presence of a representative and recital from sacred text, according to their preferred religious practice. Listed below are brief guidelines for major religions in the U.S.3

Christians – May request presence of pastor or other church leaders based on denomination. Reciting of prayers and Bible passages.

Catholics
 – May request to receive the sacrament of anointing the sick and religious icons placed beside the patient, e.g., rosaries, crucifixes, holy water, etc. Likely to request and receive Holy Communion and last rites from a priest.

Mormons
 – A sacred undergarment may continue to be worn after death.
Jews – “Ideally, a non-denominational room should be provided for the time before burial and the patient’s feet should be positioned pointing towards the door.”3 Also, hygiene care will take place by the holy society prior to burial.

Buddhists
 – If possible, allow privacy and time for quietness, meditation and/or chanting. Those surrounding the patient must remain calm for this will influence the character after rebirth.

Muslims 
– Ensure the patient is facing head first and pointing towards Mecca. The patient should be removed from the hospital and buried as soon as possible. Routine last offices are usually performed by family at this time.
Hindus – Family may administer Ganges water-tulsi plant and request to burn incense. “Religious objects, for example, wrist and/or neck threads should not be removed.”3 Ideally, the patient does not receive hygiene care from nursing personnel.
Atheists – Respect patient’s own beliefs. May request presence of family and loved ones, including pets.4

If a patient is not religious or has cultural practices or religious denominations not listed above, the nurse should ask relatives to outline the patient’s previously expressed wishes, if any exist, or that of the family.3 All cultural considerations must take place.

A – Active Listening

A person’s reaction after death of a loved one can vary from shock and disbelief, sadness and grief, to anger and distress.

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Because of the delicate nature of such an event, it is essential for nurses to be available as much as possible throughout this process in order to establish a therapeutic relationship and aid in the grieving process. At this time, it is important to consider the nurses’ own beliefs about death but remain sensitive to those surrounding the patient (Wasserman, 2008).5

Actively listen to the family and friends of the patient. This not only includes hearing but also remaining empathetic to what is said. Anticipate questions or concerns and assess the need for additional assistance, such as grief counseling, funeral preparations, and refreshments, e.g., water or juice.

R- Respect Final Wishes

Allowing for patients to die a respectable death, according to Farber and Farber (2006), requires “healthcare professionals to listen to the dying and their family members to help relieve their suffering.”5

All healthcare professionals must diligently work to care for the needs of the patient and family, ensuring to not only address the physical components but also the psychological, emotional, and spiritual aspects of their suffering.

We must respect patients’ wishes regarding life-sustaining measures, cleansing procedures, their families’ wish for privacy during this process and the relationship that has been formatted between oneself, the patient and the family.

Providing the patient and family with a respectable death is not only necessary to maintain dignity of the patient, but also is essential in maintaining credibility within the medical field.

E– Emotional Support

After the death of a patient has occurred, family members may experience a large variety of emotions and distress cultivated by loss, confusion and uncertainty.

As nurses we should explore these feelings and provide reassurance to an open path of communication and assistance. We should render ourselves their blanket of support and exhibit an ample sense of sensitivity during this process.

“Maintaining a high degree of sensitivity after a patient has died can help families not to misread information” and help reduce the sense of ambiguity that may occur.3 It is also essential that family members of the patient are encouraged to share their feelings with one another about the loss, ensuring the death is not concealed or suppressed. If death is not talked about or is done so in hushed tones, persons pick up a strong signal that they are not permitted to discuss its occurrence.6

Caring for those in bereavement is a holistic process that is universal and encountered by all. Healthcare professionals should familiarize themselves with this process and utilize the C.A.R.E. model to enhance their provision.

In providing holistic care, nurses should be cognizant and actively listen to the families’ concerns, emotions and cultural wishes. This, along with the administration of respect, will assist the family of the patient to heal and begin their grieving process with a sense of healthcare support.

For more information on the responsibilities a nurse is mandated to follow in providing care after death, refer to your hospital’s nursing policy and procedure manual.

Meanwhile, remember that although the act of displaying care and love is not a mandate in one’s hospital policy, as nurses, the art of compassion and humility should be ingrained in all procedures we perform.

References for this article can be accessed here.

Ngozi Eboka and Genevee Fallesgon are students at California State University San Bernardino School of Nursing.

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