Coping with the death of a patient is one of the hardest challenges facing health professionals. This is especially true for young doctors, nurses and therapists who may be unfamiliar with death. We must deal with our personal feelings of loss, when the patient is perhaps someone whom we have known well and liked. Additionally, there are complex professional issues.

The relief of suffering and the prevention of death are fundamental objectives of most forms of health care. It is, therefore, hard to avoid a sense of professional failure when one of our patients dies. On the other hand, sometimes death seems like a merciful release for a patient who is suffering and has little hope of recovery. In other words, death, which we try to prevent, may provide the relief of suffering which we want for the patient. This apparent contradiction can be very troubling for health care workers and is a great source of stress.

These personal feelings may present difficulties even for experienced health professionals. Therefore, while we try to behave in a controlled and professional manner when a patient dies, the fact that we have personal feelings or are uncomfortable in dealing with death does not mean that we are less professional. Rather, this demonstrates human qualities which are important in care givers.

Notwithstanding our own thoughts and emotions, in a professional situation the highest consideration must be given to the welfare of the patient and their family.

It is often said that culture has much to do with how we face death. Certainly, culture and religion determine much about one's attitudes towards life and death in general. In practice, however, much depends upon the individual and the immediate circumstances. Therefore, in helping patients and their families face death, there are few useful rules for the young professional.

Situation 1: A nurse is talking to a family member about the condition of a patient who is expected to die within the next few hours. The patient's condition has been deteriorating for about a week, and the family understands that there is little hope of recovery.

Nurse: Mrs. Wilson, you look tired. Have you been in to see your father?

Mrs. Wilson: I'm just going in now. My brother has been with him all morning. Has there been any change?

Nurse: Not really. Your father's heart is getting weaker. I think you know it's only a matter of time now. I'm sorry.

Mrs. Wilson: That's okay. We've been expecting this for some time.

Nurse: You look exhausted. Have you been able to get any sleep?

Mrs. Wilson: Hardly any. I want to be with my father as much as possible.

Nurse: I understand, but please look after your own health as well.

Mrs. Wilson: How much longer do you think he has?

Nurse: I'm sure you understand that it's hard to say, but certainly not much longer. Perhaps a few hours, perhaps tomorrow. Mrs. Wilson, I think you understand that, if necessary, there are things that we could do to try to resuscitate your father.

Mrs. Wilson: No, we don't want that.

Nurse: Have you had a chance to discuss this with your brother?

Mrs. Wilson: Yes, we have discussed this with the doctor as well. We don't want him to suffer any more.

Nurse: Of course, I understand. I just wanted to know that you had all discussed this and agreed. In the meantime, we want to do everything that we can to keep your father comfortable.

Mrs. Wilson: Thanks. I know that this has been hard on all of you as well.

Patterns:

* Have you
... been in to see your father
... able to get any sleep
... had a chance to discuss this with your brother

* I think you know,
... it's only a matter of time now
* I'm sure you understand
... that it's hard to say
* I think you understand
... that, if necessary, there are things that we could do to resuscitate your father

* I want to be with my father
* I just wanted to know that you had all discussed this
* We want to do everything that we can

Discussion:

1. In the first situation, the nurse and Mrs. Wilson avoid using the words "death" and "dying". Why do you think that this is so?

2. In the first situation, the nurse expresses concern for the health of Mrs. Wilson, rather than for her dying father. Do you think that this is natural and proper?

3. In the first situation, Mrs. Wilson seems relatively calm and resigned to the death of her father. How do you think she would act or feel if her father's death was unexpected?

4. Why do you think that it is or isn't proper to try to resuscitate an elderly patient who is dying from an incurable disease?

5. When should the decision to resuscitate or not resuscitate a patient be discussed with the patient themselves?