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The effect of witnessing a death 2: Communication and ethics

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VOL: 103, ISSUE: 36, PAGE NO: 26

Dawn Mari Shelvington, RNA, Dip HEd Nurs, is staff nurse, the Priscilla Bacon Centre for Specialist Palliative Care Services, Colman Hospital, Norwich

The first part of this unit explored the effect on patients of witnessing a death in hospital or a palliative care environment. It included a literature review and also examined the implications for nursing practice. Part 2 of this unit discusses communication following the death of a patient and ethical issues that should be taken into consideration.



Good communication is a key skill in enabling nurses to feel confident when dealing with potentially difficult situations. In particular, when nurses inform a patient of another patient’s death, this needs to be done sensitively.



Lawton (2000) has observed that ‘a death commonly prompted other patients in the ward to reflect upon their own deterioration and demise, often in an extremely open and direct manner’.



This may present an opportunity for patients to talk about any worries and anxieties surrounding their own death. However, it is important to be aware that it may be the first time that they have felt able to talk about these issues.



Nurses need to give patients time and listen to them even when these conversations can sometimes be difficult. If it is not possible to spend enough time with a patient when informing them of another’s death, they need to know that they will be able to talk at another time.



Lugton and McIntyre (2005) suggested that ‘nurses can acquire and improve their communication skills by reflecting on their practice, by developing empathy with their patients and learning by role-modelling their peers in the clinical environment’.



An example from practice


An incident in my practice highlighted for me the importance of communication between the healthcare team and the patients they care for.



On one occasion a patient had died on the previous shift in a shared bay, with one other patient in the room. The curtains had been left drawn around the deceased patient’s bed. Later in the evening the other patient in the bay was asked if she would like us to turn the ceiling fans off. She replied that if that was acceptable to the other woman, she would prefer the fans off. She had been unaware that this patient had died some time ago.



She was only then told about the patient’s death and given the opportunity to talk. It could be argued that the fact that she had not been told sooner was a breakdown in communication that could have had upsetting consequences. For example, she may have tried to speak to the deceased patient and looked behind the curtain if she was worried about the lack of response.



The incident also highlights that perhaps nurses could improve this area of their care for patients. This should be a priority and an integral part of nurses’ role - that of supporting patients and ensuring they are informed of a patient’s death and given the opportunity to discuss this if they wish, particularly in relation to their own mortality.



Meeting the challenge in practice


How can nurses meet this challenge in their own practice? Some staff may feel unable to inform a patient about a fellow patient’s death and discuss this with them effectively. Blocking behaviours may be used to avoid such a discussion, for example distancing (deliberately avoiding engaging with patients) or changing the subject (Wilkinson, 1991, in Lugton, 2002). The reasons for this behaviour may include the following:



- Individuals feeling that they do not possess the right skills;



- Wanting to protect the patient;



- Fear of the emotions that may be expressed;



- ‘Not having time’.



The NHS Plan (Department of Heath, 2000) stated that ‘by 2002 it will be a precondition of qualification to deliver patient care in the NHS that an individual has demonstrated competence in communication with patients’. Advanced communication skills training has been identified as a key item in continuing professional development programmes in England and Wales (NICE, 2004).



In addition to formal training sessions in communication there can be opportunities to develop and enhance skills in the practice environment. To enable nurses to feel more confident in their own abilities when communicating in difficult situations, it may be helpful for them to reflect on their own practice. Reflection enables individuals to identify any strengths and weaknesses that they may have, and to formulate an action plan for how they might deal with a similar situation in the future.



Clinical supervision may help nurses to cope with patient communication issues and to learn from colleagues - it can be therapeutic to discuss and reflect on issues in a non-threatening environment. However, clinical supervision may not always be readily available, despite being advocated as good practice (NMC, 2006).



Empathy with patients


It may be helpful to try to see the situation from the patient’s point of view. For example, how would we feel if we were aware that the person in the bed opposite was dying? How would we feel if we had to witness the grief of a family who had just been bereaved? If we had developed a friendship with the dying person, how would we react and cope? All patients are individuals and assumptions should never be made about how they would feel based on our own beliefs and feelings. However, considering the above questions may give nurses some insight and empathy with patients.





There are often ethical considerations within palliative care nursing. The code of professional conduct specifies that nurses ‘must work with other members of the team to promote healthcare environments that are conducive to safe, therapeutic and ethical practice’ (NMC, 2004).



An issue that could be considered is the ethics of keeping dying patients in shared rooms in full view of other patients. The alternative would be to move dying patients into a side room.



This poses the question: whose best interests are being served? It may be perceived that it will be comforting for other patients to see a patient who dies peacefully. However, are the preferences of the dying patient being considered? Don’t they have the same rights to privacy as other patients? (Lawton, 2000).



It could be argued that it is often difficult to ascertain the preferences of a dying patient. However, when a patient’s death is inevitable, there may be opportunities to explore what these might be before the patient’s condition deteriorates to the point where communication is not possible.



One study found that the majority of patients would wish to be cared for in a single room when they are dying (Kirk, 2002). However, often patients cannot be offered such a choice because single rooms are a scarce resource both in general hospital wards and in specialist palliative care units.



The Liverpool Care Pathway (Ellershaw and Wilkinson, 2003) is used within the unit where I work and can enhance end-of-life patient care (Mathews and Finch, 2006). When a patient’s condition is no longer curable and it is recognised that they are dying, the focus of care shifts.



The Liverpool Care Pathway focuses on symptom control, comfort measures and discontinuing non-essential procedures, which is achieved by talking to the patient where possible.



It also involves giving support and information to the patient’s family. However, the pathway makes no mention of patients’ preferences for a single or shared room, or support for fellow patients. Perhaps this is something that could be considered in the future.





It can be seen that patients can be affected by the death of a fellow patient in a number of different ways.



There may be positive effects. For example, patients may find it comforting to see the care and attention given to a dying person and their family, and to see someone die peacefully. This may remove some of the fear of the unknown surrounding death and reassure them that it is not as bad as they had imagined.



However, if a patient’s death is distressing then it may be a negative experience for observing patients and exacerbate their own fear of death.



Other possible negative effects that should be considered include:



- Witnessing several deaths, which could lead to withdrawal and depression;



- Patients may feel that they are intruding on another’s privacy and the grief of friends and family;



- Patients may find it difficult to continue with their daily routine when there is a dead body in the room.



An issue that has been raised is the use of side rooms. It would be good if healthcare staff were able to offer patients a choice of a shared or single room. Unfortunately, most of the time patients are cared for in the bed that is available at the time and so patient choice does not enter into the decision. Nurses have no control over the number of single rooms available. However, the environment in a shared bay can be managed in such a way as to promote the privacy and dignity of patients and those around them.



Furthermore, it should be considered an integral part of nurses’ roles to inform patients if another patient has died and to offer them support and understanding in coping with the emotional effects that may result.



Within nurse training, education training programmes and communication training, this subject could be explored so that this area of care can improve.





1. Understand the importance of good communication skills.



2. Appreciate the importance of privacy and dignity.



- This article has been double-blind peer-reviewed.

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