'Lansley must listen to nurses on the front line' What is the point of the shock felt when someone dies ?
Posted in: Adult nursing | Main nursing areas
24-Jun-2011 9:23 am
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What is the ‘purpose’ of the shock that one feels when someone you care for dies ? Or, when you find someone you know, but are not really close to you, dead ? There is no question that your brain ‘goes very strange’ in that type of situation – why ? Presumably, there is some sort of ‘evolutionary reason’ for those weird feelings, so having them should ‘improve your subsequent life’. Why do we ‘feel shocked’ ?
My instinct, is that to a very large extent, it is because your brain ‘wants to switch off’ as a mechanism to weaken your long-term memories of the ‘death itself’ (when your mum dies, you don’t really want to keep remembering ‘the death itself’, you want to suppress that, and hang on to the earlier memories). Is there a currently accepted theory for this ?
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24-Jun-2011 9:43 am
have you read the detailed and thoroughly researched works of the late Elizabeth Kubler Ross?
She was considered one of the greatest authorities on death and dying and defined the 'Five Stages of Grief' which provides a very helpful explanation of the grieving process. It must be recognized though that these stages are a general rule and not everybody will go through every stage as people are all subject to individual variations. It should also be noted that the works of Ms Kubler Ross were written sometime ago and some of her theories may be giving way to more recent ones. She wrote numerous books among which 'Death and Dying' has become a classic and all details are found by using Google.
Further resources for some of your questions may be the many journals and other resources of geriatrics and gerontology, including the nursing branches, and some of the medical journals. The National Library of America is also a useful resource for all research papers and there are many American resources which can be found on the Internet which might be helpful to you.
24-Jun-2011 11:17 am
No, I have not read them - but are they discussing the question i am interested in ?
I am specifically interested, in 'the shock felt immediately after a death' (the rest of that day) and, the longer term consequences of preventing the bereaved from 'just getting on with things in their own way' during that period.
I am not interested, in 'mental healing' after a bereavement. I am interested, in the question of 'Is it intrinsically mentally damaging, to question bereaved relatives about the circumstances of a death, during the period immediately after the death ?'. Basically, is there any evidence, that by persistently questioning someone about the death of a loved one during the 6 - 8 hrs immediately after it, you will INEVITABLY create worse (more traumatic) long-term memories, for the death ?
24-Jun-2011 12:31 pm
the first of the five stages of grief might partially help with an answer to your question above. it is a while since I have read it but the first stage is numbness caused by the shock of the loss and then comes denial. these are psychological and physiological mechanisms protective mechanisms and the why and wherefore are too long and complicated to discuss here as I do not have the time. Kubler Ross was a doctor of medicine and spent long years carrying out indepth studies of death and dying and interviewed a large number of patients and their relatives on which she based her invaluable findings. it is based on facts and not about 'mental healing' after bereavement as you put it.
This work may provide you with some good background and further excellent insight into the issues you are researching.
Besides if you are looking for answers about shock and grief, some of the webpages of the official organisations for consellors and psychotherapists offer some excellent factual research based knowledge as does the site of the Royal College of Psychiatrists and their professional journal.
I have tried to help by answering your questions in your first post above and given you pointers with information relevant to this but you now bring further issues into the argument in your second post and as you are not interested and reject any help one tries to offer without even considering the information one has taken the time and trouble to provide it makes it difficult.
"No, I have not read them - but are they discussing the question i am interested in ?"
I have put forward the suggestion and it is up to you to find the answer to this question of whether they discuss your interests.
Whilst nurses like to help people, I find your attitude extemely demanding, assuming and dismissive both here and in all the NT comments and although my requests to you not to abuse the comments sections have been firm but polite unfortunately you lay youself open to further attack from others. A little online etiquette and the occasional sign of appreciation such as a please or a thank you may not be amiss!
24-Jun-2011 2:59 pm
24-Jun-2011 12:31 pm
Thank you, but I fear we are at cross purposes (as usual).
I am not trying to learn about nursing, and my questions are very specific, because only the answers to very specific questions, allow me to progress the debate I am involved in.
I am interested in the question of 'does stopping someone from grieving as they would themself choose to, inevitably create more traumatic memeories of the death ?' because I wish to consider whether the police questioning a relative after a death, solely because the Police are unsure of factors around a death, will inevitably cause mental damage for the relative. The Police stick to 'we must investigate' but this country has both a presumption of innocence, and also where do the human rights of relatives, against whom nothing has actually been proved, come into this ? If 'hastling relatives' will inevitably cause them significant damage, then the fact that some (or most) are actually innocent, shoudl be a factor in policy and protocol design !
If I fail to show appreciation, that is because I don't usually insert that into discussions, but I am not deliberately showing a lack of appreciation of answers, however it comes across.
24-Jun-2011 3:23 pm
From you first question this morning I understood that you wished to know something about the grieving process which is why I pointed you in the direction of Kubler Ross. her work is about death and dying and bereavement from a medical, personal, patient, family and spiritual point of view and not directly to do with nursing although all these are closely interrelated with death and dying and cannot be separated. I just thought understanding this process, which is what you seem to be questioning above in your first post, might be of some help to you and looking at these sites might not give you the direct answer immediately but may point you in this direction.
your question
"'does stopping someone from grieving as they would themself choose to, inevitably create more traumatic memeories of the death ?'"
is an interesting one but here our psychology and psychiatric cofraternity are the experts and I would suggest looking at the websites of related organisations of which I would suggest that of the Royal College of Psychiatrists would be a good one. they, or other sites, may also have a facility for the general public to post questions or again bring you nearer to the info. that you need.
other questions you raise seem to be more of a legal than a nursing nature.
I think you are on a laborious course and will have accept that you are going to go down quite a few blind alleys in seeking your answers.
I do not wish to criticise you further but unfortunately you have not come across in a very favourable light in your quest for answers because of the tactics you use and I just wonder whether you are sabotaging your own efforts in getting people to respond to you.
24-Jun-2011 3:46 pm
24-Jun-2011 3:23 pm
Thank you ! I will post an expalnation of my objective - and yes, as you observe it is essentially a legal question. The question, is does clinical guidance corrupt the MCA ?
I have asked a pyschologist who e-mailed me, my question - I suspect, there is probably no research. Ethical considerations might prevent clinicians from asking people about deaths 'as they happened' ?
But, I am still interested in nurses' answers to my questions - I wish to be certain of what nurses believe is 'correct', in the area I am debating. 'My' e-mail discussion group does include a nurse, but she is also a Senior Clinical Lecturer, who has a law qualifiaction and specialises in teaching law to nurses. It isn't reelvant, that she and I invariably agree about the legal and ethical questions - the point is, our answers are not the same, as it appears a lot of operational clinicians seem to believe are correct.
And, yes - it is quite difficult to modify the entire clinical belief and behaviour set around EoLC/CPR/VoD, in certain areas ! Especially when organisations such as the BMA, insist on the one hand that they are 'only unions', and yet also issue guidance, which is clearly legal in its nature: any guidance about CPR, is legal in its nature, because of the MCA.
I have no online time left today - I will post an explanation of 'what I am up to', because your previous post implies that you might read it from a rather more neutral perspective.
24-Jun-2011 4:22 pm
I spent a good deal of my time today and did my best to help in attempting to respond to the first questions you asked above this morning, to the best of my ability and in what I consider a reasonable way, within my professional working and personal knowledge.
They were obviously not what you wanted because you keep changing your questions and you are now going round in circles again and I do not wish to be drawn any further into your debate which I know nothing about.
As to questioning your motivations, I unfortunately do not recall at the moment what I said about this and wonder if you are even mixing me up with another anonymous commentator.
My aims in very few posts on this topic have not been to criticize you, but to politely point out the negative effects you have been having for some months now on the comments pages in which I like to participate. you will note that no other nurse or lay person has tried to monopolize or sabotage these pages or try and manipulate nurses in this manner to debate with them and give answers that they may not even have and then criticize them and the profession because, they do not, for fairly obvious reasons wish to respond and are under no obligation to do so.
25-Jun-2011 9:44 am
24-Jun-2011 3:23 pm24-Jun-2011 3:23 pm
Thank you for your post (above). I do think that we have a problem ‘re communication’; because although I am at home, which is offline, and cannot go back to my original questions, I feel pretty sure they did refer to the period immediately after a death, and the purpose of the ‘shock of death’. But whatever I intended to ask, you clearly decided I had asked something different (which is not a problem I usually have, although it does crop up). If I mentioned ‘grieving’ in the longer term, then I screwed up the question.
I am also in an odd situation. As it happens, and despite my ‘amateur’ status, I do ‘know about this EoLC/CPR/VoD stuff’, honestly – but my ‘quest’ is to get relatives properly treated as integral to EoLC situations, not as ‘separate from clinicians’, and for what I can only describe as ‘professional back-covering and bias’ removed from the clinical behaviour and belief set. And you are right – it begins with the question of ‘so what does the law say ?’ and then, for unresolved issues, moves on to morality, logic, ethics and ‘sense’: the question is how to form a balanced synthesis, not a biased and confused conflation.
I said I would explain my motivation. Here is the list, and people who I have been discussing this with properly, and at length, do not disbelieve this:
MOTIVATION I do not want anything similar to my own experience, to happen to anyone else.
OBJECTIVE Essentially, I want clinicians to accept that they are only experts about clinical factors, that the people who are close to patients are the experts on ‘what he would say, if he can’t tell us himself’, and that the default assumption must be that everyone is doing their honest best, but with different knowledge and skill sets. This requires integration between clinicians and relatives, not the erection of unhelpful barriers.
METHOD Actually, it involves presenting the arguments to the Ethics Expert at the BMA who is their person in the current (happening now) revision of the Joint CPR Guidance, pointing out the obvious fallacies in certain publications to their authors, discussing the better guidance with its authors (which is basically Scotland – its CPR/VoD policy is almost acceptable, when viewed by a relative) and trying to embarrass everyone who publishes ‘obvious nonsense’. Which includes the GMC, RCN and RC(UK).
I will illustrate some of my problems, using some of my ‘Musings’ series.
Consider Musings Part 3: Father and Son – what should the son do ? Logically, either the situation is an emergency, and he should call 999, or it isn’t, and he should just let his dad die in peace. As it happens, I did get some answers from an e-mail survey which included that question. The answers to what ‘should’ the son do, included:
Consultant in Palliative medicine (27 years experience) : Wait and call GP later to certify the death
EoLC Facilitator (26 years of nursing (4 years Community Nursing (DN), 11 years Specialist Palliative Care, 5 years GSF/EoLC project work, palliative care degree, DN qualification, Masters module in health and social care): If an Advance Decision to Refuse Treatment (ADRT) has not been made and the father has not verbalized his wishes to a professional involved in his care then the son would have to call 999 as his conversation with his father has not been witnessed and not evidenced as “in his best interests”
End of Life Care Education Facilitator (Medical nursing background, more recently in last 2 years specifically in end of life care education – care homes and community, diploma in palliative care): respect his father’s wishes and not phone 999
Paramedic (15+ years): Preferably make a quick note in care package AND/OR do not call 999
I have two problems, in there. I simply do not agree with the second person’s answer, and it is actually ‘call the GP so the GP can decide whether to certify the death’. But those answers are not identical, are they. And, amazingly, the two EoLC facilitators work for the SAME PCT !
But I also asked ‘what would ‘real’ sons do ?’ What actually happens in the real world, and I tend to agree with the above paramedic who wrote: Most people will call GP/District Nurse/Macmillan Nurse for advice, and invariably be told to call 999.
So, let us assume the son calls 999, and then describes the conversation to the paramedics who turn up. Are the paramedics, supposed to assume the son is describing a genuine conversation, in which case has the paramedic ‘reasonably ascertained’ that the patient has refused attempted CPR (see section 4(6) of the MCA) ?
And, there is no reasonable way, to decide if the son is being truthful or not, because this is by its nature a stressful situation, so the son is likely to ‘be a bit weird’. Logically, paramedics must have clear guidance about this: either ‘always believe the son’, which leads to leaving the patient to die in peace, or ‘always ignore the son, and attempt CPR’. Now, that second one accuses the son of lying, and directly goes against the father’s wishes (because my scenario, is written: if you want also a second ‘lying’ scenario, you must introduce it AND ALSO a figure, for how likely each of the two scenarios is). So, if the son is aware that paramedics are taught to attempt CPR under those circumstances, we must ask ‘Is the son bound by the MCA ?’. If the son is bound by the MCA, then his decision is still ‘Should I call someone, or just let my dad die as he asked me to ?’ but any decision to call someone ‘for reassurance’ is complicated by sections 4(2) and 4(11): knowing that the paramedics would attempt CPR, if called, is something he must consider. If the son is ‘outside the MCA’, then there seems to be no law, requiring him to call someone to his father’s CPA – there is a law requiring him to report the death, but until CPR becomes impossible, his dad is not dead. But our law, unlike the law in some countries, does not seem to require that you summon medical assistance, unless you yourself caused the injury.
Now, ‘the system’ does not like the above analysis, but it is both logically and, it seems pretty clear, legally correct (because of sections 4(9) and 42 of the MCA) – ‘you’ want clear and simple guidance, which leads to clear and agreed decision-making, and a chain of command: but, the Act itself does not lead to those things, and the Act does not resolve many problems.
The Act is however clear about many things, some of which clinicians attempt to distort, and also awkward or confusing about some others, which are nonetheless ‘logically resolvable’ (again, many clinicians do not reach the logical resolution – there is a particularly tricky one, about whether a verbal refusal of future treatment, is more binding than an Advance Decision: in essence, it depends on whether the Advance Decision has been subsequently discussed face-to-face with a clinician who might attempt CPR. If the discussion has taken place, the discussion, not the Advance Decision, is the reason CPR should not be attempted by THAT PARTICULAR clinician – but, if an Advance Decision is only read after the patient has become mentally incapable, it over-rides any previous discussions: this is an absolute sod to ‘prove’, and it is not something which most clinicians or CPR/VoD design groups have worked out {at least one author has, someone called Bowen – I did not look up the reference, but his ‘ordering’ is referred to in something else I have read, and he has clearly worked it out}) but are not resolved correctly in most clinical literature.
I am going to stop this one here, before I get into the confusion between CPR and VoD. But I will add a couple of closing comments. Ideally, I want nurses to answer my specific questions, without my having explained the answers – I want to know, what nurses believe, and where they get their beliefs from, because it is very clear, that you cannot get to what nurses (or many doctors) believe, if you start from the MCA, and read it ‘as a non-clinician’. Your (I assume it was you) ‘condescending’ point, is tricky – I am claiming that ‘you have got this wrong’, but because you are being badly trained, and are being given flawed guidance to read.
And I don’t like it, when people imply that I am an annoyed, irritating, ill-informed pillock – I object, to being told that I am ill-informed !
And, I am atypical ‘for a relative’. About 10 months ago, the lead on my local CPR/VoD design group, e-mailed me as a result of something I had e-mailed to a Police Officer who was on that group. We exchanged some e-mails, and he asked for my comments on a draft of the Policy, which I supplied. But, his group had for some peculiar reason, decided to use only 2 source documents: one was the Joint CPR Guidance, and the other was the DH End of Life Care Strategy. Within a fortnight of the lead, Paul, e-mailing me, he had been copied in by the BMA’s person on the revision of the Joint Guidance, when she sent an e-mail to me inviting ‘our discussion group’ to provide critical comment and suggestions about the existing guidance, and admitting that I had highlighted a paradox within the current version (involving patient confidentiality – it is fairly easy to see for yourself). So much for one reference. I did not demolish his second reference, but I doubt that Paul expected me to end my e-mail to him with ‘If you have any trouble working out the DH strategy, send me your questions, and I’ll get Tessa to answer them’ – the Tessa in question, is the Head of EoLC at the DH, another member of the e-mail discussion group, I have manoeuvred into existence. I do not agree with Tessa, about everything – in particular, she and I do not see eye-to-eye about the implications of section 42 of the MCA – but I do have some background, here !
25-Jun-2011 9:53 am
24-Jun-2011 4:22 pm
If you did not question my motivation - and I did wonder lasy night, if I had mixed that up: how can one work out, whether two 'anonymouses' are the same person ? - then I apologise for saying (or positing - I have no time to go back to check) you did.
I am not trying to sabotague anything, I am trying to discover, why nurses hold their current belief set, around CPR decision-making. I do not keep changing my objective, but it is very complex issue and debate. When you wrote:
'I do not wish to be drawn any further into your debate which I know nothing about.' the 'which I know nothing about', is rather the point.
I repeat, I have never been trying to upset nurses, but I am very annoyed about th eissues which bother me (and the 'still seething' part of my brain, sometimes tries to get the upper hand). Sorry I keep upsetting you !
25-Jun-2011 9:57 am
24-Jun-2011 4:59 pm
I am an old guy, and I have no idea how I would start a blog, even if I wanted to.
But what I want, is quite complex feedback, which I can harvest, and use to further my ongoing discussions with the DH, BMA etc. I am not interested, in publishing my opinions - I am interested, in people either agreeing with, or disputing with their reasons, my comments about EolC/CPR/VoD behaviour: isn't that what a 'forum' is for ?
25-Jun-2011 11:17 am
you are clearly not interested in answers to the questions you posted at the top of the page and I cannot help you further with any of your other questions which are a different issue.
Please note the only anonnymous comment on this page so far that I did not post was the one suggesting you start a blog. It suggests that you put you opinions in a blog instead of here but I have the impression that you are asking questions and seeking answers rather than expressing your opinions and I would suggest that the forum is the most suitable place for this rather than the comments following articles on various other unrelated topics.
25-Jun-2011 11:52 am
"...the purpose of the ‘shock of death...’"
this is what the information I gave you was intended to answer in your initial question and not a whole host of other questions you posted in your comments later on after I had sent my comment!
"I repeat, I have never been trying to upset nurses, but I am very annoyed about th eissues which bother me (and the 'still seething' part of my brain, sometimes tries to get the upper hand). Sorry I keep upsetting you !"
Irritating and exasperating might be more accurate. Nurses are trained professional adult men and women and very busy ones at that who do not like their time on or off duty wasted. We are used to working under highly stressful and complex conditions and are not little children who get upset easily.
Unlike the comments page you can direct your own forum in the way you wish but i would suggest if you do not wish to continue to debate with yourself, which seems to be the case so far on the other pages, you try to calm the 'seething part of your brain' and then sit down and clearly formulate your questions you wish to put forward and state plainly to whom they are addressed instead of pages of repetitive ramblings which few of us have time or inclination to read.
I acknowledge your frustrations and do not wish to sound harsh or critical but I still believe that you maybe sabotaging your own efforts which have already received some negative and unhelpful responses and will fail to get the reponses you are so desperatly seeking.
.
25-Jun-2011 1:39 pm
25-Jun-2011 11:52 am
I am not really desperately seeking usable responses, they would however be helpful, and it is truly annoying that the answers to the relevant specific questions are so difficult to elicit !
My questions on NT are addressed to nurses, and they are specific.
If you want one, and this is 'out there', what wording on an Advance Decision, would you personally accept as indicating that the person wished to refuse future CPR attempts, irrespective of the cause of any CPA or of his clinical condition prior to the CPA, and without his explaining why he was refusing CPR ? To be clear, he is saying 'the cause of the CPA is irrelevant - he is not trying to somehow negate section 25(4) (c) of the MCA, which cannot be ignored). Is that clear enough for you ?
