Death is an ever-present reality for nurses. Dealing with and preventing the risks of death, as well as providing end-of-life care when death is inevitable are some of the many responsibilities assumed by nurses in clinical settings. The absence of relevant information about death does not make it easier for nurses to overcome its challenges. On the contrary, it increases the emotional burden imposed on nurses, leading to stress and burnout. The value of proper understanding of death, its theoretical and practical underpinnings can hardly be overstated. Nurses need to be educated about what death is and how they can deal with the physiological, emotional, and psychosocial issues that emerge in response to dying.
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Concept and Purpose of Studying It
As becomes clear from the introductory paragraph, death is at the center of the present discussion. Even though the concept of death is used widely across all clinical settings, its conceptual definition is vague and generates considerable debates. Citing Edwards and Forbes, death can be defined as "a state in which there is irreversible loss of the capacity for consciousness combined with irreversible loss of the capacity to breathe spontaneously" (p. 231). The proposed definition sets an entirely new agenda for the analysis of death as a theoretical concept and a nursing practice reality. It challenges the established beliefs about death as the absence of heartbeat and requires that nurses reconsider their approaches to death and dying in their practice environments. This being said, the purpose of the present concept review is to outline the key facets of death and close the existing gaps in nurses' understanding of the selected concept.
Reasons for Studying the Concept
As follows from the previous paragraph, the main reason for studying death is because the current knowledge of the concept is either poor or particularly confusing. Differences in lay and scientific definitions of death misguide nurses and impede the delivery of high-quality patient care. Another reason the analysis of the death concept is so important is because contemporary nurses face extreme dilemmas working with the relatives and family members of the patients, who have been diagnosed as dead. Quite often, nurses have to suppress their own intuitions and try to prove that the patient is dead, while he or she is still breathing. Finally, it will be useful and relevant to consider what has been written and said about death in the nursing literature. Such literature review will pave the way to the development of robust research frameworks that will help shed some light on the key features and attributes of death from the perspective of nursing.
Due to the vagueness of the concept itself and the dearth of quality research into death from a nursing perspective, delineating the key attributes of death is a matter of extreme difficulty. Few, if any, researchers ever managed to define death and its key features in comprehensive terms. Speece offers a good insight into the nature of death. Even though the subject of Speece's analysis is pediatric death, his findings can readily apply to all population groups, whereas the attributes of death described in his article can be regarded as universal. To begin with, the concept of death should not be treated as a unidimensional construct. Nurses should acknowledge that death can change its color, depending on the circumstances in which it occurs. It can be gradual or sudden. It can be dramatic, unexpected, or peaceful. One may say that no two deaths are the same. However, some attributes are characteristic of all death occurrences. According to Speece, these include universality, nonfunctionality, irreversibility, and causality.
To begin with, universality is one of the principal attributes of death. It means that death is a universal reality. Not a single human has ever managed to escape death. Nurses should understand that every human dies, and the event of death can occur at any moment. Here comes another attribute, which was not mentioned by Speece. Apart from the fact that death is inescapable, it is also unpredictable. Unpredictability in the context of death means that a person never knows when he or she will die. Even at the later stages of terminal illness, patients cannot say with confidence when they will leave this world. Such unpredictability adds to the enigmatic character of death and makes it even more difficult for nurses to cope with its emotional and social consequences.
The concept of death become s even more complicated, when nurses realize its irreversibility. The latter is another defining attribute of the death concept. Irreversibility implies that, a person who has died will never get back to life. Even the most advanced medical techniques lose their relevance in the face of human death. Certainly, not every patient will readily agree that death is irreversible. The existing conceptions of afterlife suggest that humans have more than one opportunity to get back to life. However, the nursing concept of death is typically limited to the physiological aspects of dying. The irreversibility of death means that, once the physical body stops functioning, no resurrection is possible.
This attribute is closely related to another aspect of death – nonfunctionality. The latter entails the disruption of all physical processes that define life. After death, these physical functions immediately cease. Nonfunctionality means that a dead person cannot walk, talk, hear, see, or think. However, the absence of any physical functions following death does not diminish the relevance of causality, as related to dying. Speece writes that causality is essentially about the causes of death. More specifically, every time death takes place, it has a definite cause. Causes of death vary widely, from age to terminal illness. However, like death itself, they are also rooted in science and rest on reason. Most causes of death can be empirically validated.
The current state of nursing literature is rich in discussions of death and dying. In most cases, death is considered as a unit or component of other categories. Only Edwards and Forbes devote their entire article to the analysis of human death. Yet, even their discussion is limited to the concept of brain death as an equivalent of physical death, as it is treated by nurses. Edwards and Forbes recognize that the adoption of brain-centered criteria in diagnosing death is misleading. The researchers mention energy balance and body temperature, which remain unchanged even after the brain is claimed to be dead. Overall, they question the traditional definitions of physiological death used in nursing environments and urge scholars and practitioners in the nursing discipline to adopt a broader view on the concept.
Contemporary researchers are interested in understanding the multifactorial nature of death and dying, as applied to nursing. They consider the complexity of the experiences, emotional challenges, and quality concerns surrounding death. As an example, Simpson presents the results of her conceptual analysis of near-death experiences. Simpson defines death as termination of life. It is a regular definition borrowed from a common dictionary, which does not reflect the diversity of processes, anxieties, and worries that make up the phenomenon of death.
Here, Henrickson and McCorkle take a different perspective on death and explore the concept of 'good death' in detail. According to Henrickson and McCorkle, good death is synonymous to appropriate or healthy death. It incorporates numerous elements and dimensions, which empower the dying person to preserve his or her dignity, meet his or her cultural needs, and ensure the presence of other family members to facilitate the transition from life to death. Most individuals with terminal illness who approach the moment of death also need time and opportunity to get ready and say goodbye to their beloved ones. Preparedness is another theme identified in nursing literature. McLeod-Sordjan suggests that almost half of elderly people require quality communication and effective decision-making support in the last days of their life. Preparedness as a concept and an activity contrasts the established view of death, based on passivity and silent acceptance. "Death preparedness involves a transition of facilitated communication with a healthcare provider that leads to awareness and/or acceptance of end of life, as evidenced by an implementation of a plan". That is, communication has the potential to minimize the emotional frustration associated with the inevitability of death. Unfortunately, not all nurse practitioners display a perfect understanding of these issues.
Nurses' perceptions of death and dying constitute one of the leading themes in the analysis of the death concept in nursing literature. Spear shares the story of her mother's death and analyzes her experiences from two perspectives – that of a daughter and that of a nurse. Martinez-Alarcon et al. continue the topic proposed by Edwards and Forbes and explore how well nursing students have mastered the concept of brain death. They report that 30 percent of students in their sample have doubts as to what brain death is and how it is operationalized. Likewise, McLachlan uses his clinical experiences to reconsider nurses' attitudes to death and dying. He concludes that not all nurses are comfortable facing death in a clinical setting, but every nurse has an inner capacity to master emotional support and management skills that are so important in the moments of patients' death.
Overall, the current state of literature is insufficient to inform nurses' choices in relation to death and dying. No universal definition of death beyond brain death has been proposed so far. Nurses vary in their perceptions of death and preparedness to deal with dying patients. Simultaneously, they are encouraged to engage in closer interactions with patients to improve their near-death experiences and enhance their death preparedness in the last moments of life.
Theoretical and Operational Definition
Based on the review of literature, the key theoretical definition of death is that, which treats brain death as the key determinant of dying. Referring to Edwards and Forbes, theoretically, death is defined as the irreversible loss of consciousness and independent ability to breathe. Added to this is the irreversible disruption of other major physiological functions such as hearing, seeing, talking, or walking. The operational definition of death is simpler and resembles the ways, in which lay persons perceive the moment of dying. Operationally, death can be defined as the moment, when a person's heart stops beating, launching a series of irreversible physiological processes. Neither theoretical nor operational definition of death includes an emotional component, since the emotional side of death and dying is poorly understood. Simultaneously, nurses should be ready to accept multiple perspectives on death and dying, based on how patients of different ages and cultural backgrounds perceive it.
Applying the concept of death to my practice model will be extremely difficult, at least because the theory of death differs considerably from what happens in practice. For example, when a young male patient is admitted to the intensive care unit after a car crash, the nurse's responsibility is to monitor changes in his vital signs. When the physician diagnoses brain death, the key task is to explain to the patient's relatives why he is considered as dead, even though his heart keeps beating. As a nurse, I will have to use simple words to share the details of the patient's condition with his family members. I will also have to provide valid reasons why the nursing team believes the young patient will not restore his basic bodily functions. The discussed case is unique in the sense that the concepts of near-death experiences and death preparedness apply to the patient's relatives rather than the patient himself. I will have to facilitate effective communication and provide regular emotional support to ensure that the patient's relatives are prepared for acknowledging his physical death.
Value of the Concept to Nurses
The value of the concept to nurses can be considered from two different standpoints. On the one hand, nurses face death on an everyday basis, and they must be aware of what death entails, how it occurs, and they can promote the best conditions for patients' 'good death'. However, nurses can never define the meaning of 'good death' without having a perfect understanding of death as such. On the other hand, the concept of death becomes invaluable, as nurses seek to assist their colleagues and other staff members in overcoming death fears, anxiety, and after-death experiences. Wilson and Kirshbaum state that, with improved knowledge of death, nurses develop a better ability to cope with grief and improve the quality of multidisciplinary collaboration following a patient's death. Thus, by developing nurses' awareness of death and its multidimensionality, health care providers can potentially improve patient and nursing outcomes.
Death is a reality for many nurses. Nevertheless, many nurse practitioners misunderstand its complexity. The concept of death has numerous attributes, irreversibility, causality, nonfunctionality, and universality being the chief ones. The current state of nursing literature offers little guidance in terms of how death should be defined, operationalized, and interpreted in clinical settings. Still, better knowledge of death can inform nurses' actions in overcoming the fears, anxieties, and misconceptions surrounding the concept.