"What's wrong with death sir? What are we so mortally afraid of? Why can't we treat death with a certain amount of humanity and dignity, and decency, and God forbid, maybe even humor. Death is not the enemy gentlemen." (Patch Adams, 1998.) As we all go through life, there is a certainty of death waiting for all of us, and it may strike at anytime. Death in American society is seen as something to be afraid of, something to cover up. People who discuss it are "morbid". Is death anything to fear? Do we really know what lies ahead for us? Death may just be the closing of one's book, each phase in life a chapter, and death is the conclusion. Death may be the loss of the human form, but does the spirit ever die?
In some cultures, we are reincarnated; in another, a celebration of life's good deeds and a transition to an "everlasting" life; and in others, we are buried with our possessions to use in the "after-life". But in our culture, we are washed clean of all our sickness, dressed in our Sunday best, caked with make-up and hairpieces and buried in a box. Where we are headed in our journey is uncertain, but we as a culture have taken every precaution to prevent death and whatever lies ahead with it. But death may in fact be our greatest teacher in life. In this article, I will discuss grief, death and dying from different points of view, as well as the role of the nurse with a dying patient.
"When we have passed the tests we are sent to Earth to learn, we are allowed to graduate. We are allowed to shed the body which imprisons our souls..." (Kubler-Ross, 1969.) One pioneer in on the study of death and dying, Dr. Elisabeth Kubler-Ross, opened doors on the "taboo" topic. She dedicated her life's work to the study of life, death and the transition between the two. Kubler-Ross was successful in teaching not only grieving family members and dying patients, but also doctors, nurses, other health care professionals and the public that death is not a mysterious and frightening experience, but a delicate process and a natural journey of humanity. Perhaps Dr. Kubler-Ross's most well known theory is the five stages of grief. These stages can represent the feelings of a person who is face to face with impending death, or the loved ones who are being left behind.
The stages of denial, anger, bargaining, depression and acceptance are surfacing emotions to the grieving process that may occur at any time, and accepting all of these emotions will be an important milestone in healing and moving forward. In contrast to Dr. Kubler-Ross's theory, Robert Kavanaugh came up with a second theory on grief involving seven stages: shock, disorganization, volatile emotion, guilt, loneliness, relief and reestablishment. His belief was that the "dying mourn their own passage as we intent to mourn theirs". (Brosche, 2003.) In my own personal experience with death, I had found that these two theories are focused more on logic than the emotional process of human nature. Some stages are experienced for a few minutes, some for months or years, some resurfacing with memory, and some repressed into the subconscious.
Death is more confusing than what can be placed in cookie-cutter staging. The components surrounding the death may hinder acceptance; grief may be overwhelming and unable to be dealt with alone. Just as everyone's life is different, everyone's death is also a unique situation. Although the two theories present a good guideline for grief, they are somewhat imaginary. Many patients will be at peace with their death long before their bereaved loved ones, who are left behind with a sense of unfinished business. The stages may allow the thought that one is at peace because they have followed the process as it was laid out in the textbooks, and as the moment of death approaches, become frightened and anxious.
It may provide health care workers with a care plan of grief, but not an identity of the patient. But if Kubler-Ross and Kavanaugh did nothing else, they laid the bricks for Western society to look death in the eyes. They encourage us to take a walk outside our minds, and realize we are all human beings.
"Learn to get in touch with the silence within yourself and know that everything in this life has a purpose..." (Kubler-Ross, 1969). When I entered into college to become an Paramedic, I quickly learned to pocket my own feelings and emotions related to death and dying. I remember my very first cardiac arrest. I remember starting her IV, breathing into her with a purple bag, and pumping her chest, over and over and over again. She didn't make it. I curled up in the back of the ambulance that morning and cried. I didn't know if health care was for me, I didn't think my heart would stand it. As the test of time went on, I found myself getting cold, forgetting the heart beating underneath my hands belonged to a person with a wealth of love and life inside of them.
The true epiphany of my feelings on mortality was on March 11, 2005. Up until this point, I had spent my life like it would never end, doing things I never should have, and thinking that my friends and I had some kind of immortal shield over us. I reported to work that night after having a fight with my boyfriend, not taking the time to tell him I loved him, because I was so sure it would blow over and I would have to deal with his nonsense forever. I had gotten a phone call at 5:37am, saying there had been an accident. At that moment, I knew he was gone. There was a hole in my soul that would never be filled again. I would never see his beautiful blue eyes, hear his laugh or feel his touch again. I felt like I couldn't breathe. Grief had taken me to my knees. I remember the anger that built up within me, towards him for being so stupid and towards myself for being such a self-centered jerk. I remember the denial of feeling that this wasn't him, I couldn't believe the broken body I saw was that of the man I once saw as untouchable.
I remember at his funeral, hoping and praying that he wasn't really in the casket, and that he would pop out of the bushes and tell me "April Fools". There were days I didn't eat, or sleep, or shower. There were so many things I wish I got the chance to say to James. I wish I took the time to tell him I loved him. If I could have taken his pain I would have. I begged God to take me instead. But my whole wall of numbness crumbled because I knew better. The protective shield I had enveloped my thoughts in was broken. After all the patients and families I had seen grieve, it finally clicked. I finally understood the horror they were experiencing. It was so easy for me to run, to clock out and leave them in the morgue. Death was not my enemy, rather, I was my enemy by being unable to cope with loss. James's death made me change my ways and retrace every wrong move I made, and the lessons I have learned from his death are ones I will take with me to my own grave; Things were different after this day.
I've learned to laugh a little more, take the extra time, let the little things go, to enjoy things I would have normally taken for granted, to look for the good left in the world, and to see inside of people instead of seeing them as a "client". It's been two years since his death. My own dreams of becoming a trauma nurse are not only due to my love of Emergency medicine, but due to my remembrance of James and in honor of the medics and nurses who held him as he died. I realize I am not completely at peace with his death, but I am at peace with my own feelings of death and dying. I no longer fear death. Death is inevitable, and will affect all of us at any time, any place, regardless of our age or health. Other people I have worked with have described me as "callous", but I'm not. Many look at the death of a patient and cry. But I don't cry anymore because I know they will no longer be suffering, they won't be trapped in a body full of plastic tubes and will be safer than anywhere in the world: in the arms of God always.
"Nurses arrive at work ready to carry out nursing interventions and aid the patients in healing. With a dying patient, the nurse has to switch gears: the plan of care is not to fix and cure, but to provide the patient a good death." (Brosche, 2003.) As nurses, we are obligated to "do no harm". We take courses on CPR and Advanced Life Support to learn how to save lives. Our charge is to promote well being, health, quality of life and healing. But what is the nurse's role when there is no more hope to prolong life, and letting go is the only choice? Experiencing death is another occupational hazard of nursing.
The nurse needs to be comfortable and at peace with his or her own feelings about death. But nurses seldom talk about their own grief related to a patient's death, and hide behind their professional chameleon mask. The nurse is often the bearer of the sad news, are there to comfort and console the bereaved family, and even help with funeral arrangements. A common thought is that nurses are "sub-human" about the death of a patient; and in all reality, nurses cry and breakdown behind closed doors with little support, because there are other patients to take care of besides the recently departed.
"Distancing themselves from death helps nurses continue to function. It affords some emotional protection and leaves them free to work according to the dictates of their professional knowledge rather than being entirely at the mercy of their own emotions." (Thompson, et al, 2000). What if those tears are inevitable? Are we less competent nurses? Absolutely not. The thought of our own mortality may come into play, a memory of a lost loved one, the hurt from a failure in resuscitation attempts may surface, or simply the thought that this was someone's Mother, Father, Sister, Son, Uncle or Grandpa may bring upon tears. Death has no manual or protocol to follow; there are no straightforward answers to death. There is no formal training in dealing with the anxiety of death because mortality is something that can never be fully understood in a book. Nurses need to be able to accept death, talk about it, and be comfortable with it. Nurses need to experience a certain degree of grief for their patient without letting it overwhelm them. Nurses need to know when to have hope, and when to let go. Whether a student nurse or a seasoned nurse, death of a patient is never easy. We establish trust and friendship with this patient; Nurses treat them as a human being, when the rest of the world just sees an illness with a person trapped inside.
So we hold our patients hands as they breathe their last breath, and slip on the mask of the "professional", and stay strong and in control. We remain focused on our charting and medications, there is no time for a nurse to mourn. We separate the reality of death in the health care setting from the reality of death in everyday life. But most importantly, we can celebrate our positive effects on the dying patient, whether it be heroic efforts or just a comforting touch... because in the end, life and death is the centerpiece of nursing.
"So say it loud and let it ring, we are all a part of everything. The future, present and the past. Fly on proud bird... you're free at last." (Lynyrd Skynard) In retrospect, writing this paper has brought forth a multitude of emotions for me. I have explored two theories of grief, as well as my own thoughts. I think what I have found is that we as a society are more afraid of life than we are of death. We are so busy to make a perfect ending we lose out on the present. The story of life that we each write may have pieces missing in the beginning, middle or end.
Life is about not knowing what's going to happen next; life is about being able to keep loving, keep living, and keep changing so that when the end does come, we can smile at the long, strange trip it's been. A little twinkle turns into a human being in 9 months, and after that we spend our lives growing bigger and brighter until we burn out. We can't fight the past, but more importantly, we can't fight the future.. because in the end, we are all made of stars.
Brosche, T. (Jul/Aug. 2003.)"Death, Dying and the ICU Nurse". Dimensions of Critical Care Nursing. 22 (4):26-173. Accessed August 19, 2007 with EBSCOHost.
Kubler-Ross, Elisabeth. (1969.) "On Death and Dying". New York, MacMillian.
"Professionals and Caregivers". (2000-2006.) Elisabeth Kubler-Ross Foundation. Accessed August 28, 2007.
Thompson, I., Melia, K. & Boyd, K. (2000.) "Nursing Ethics" Philadelphia: ChurchHill Livingstone.