For many nurses in general and community nurses in particular, the advent of caring for dying patients may serve as a constant reminder of how fragile their own lives are, increasing their worries about death and dying. Such death anxiety may be experienced each time they care for someone who is dying. Caring for dying patients brings death to the forefront of their minds and, by extension, ‘builds’ on their existential anxiety. Because its source is patients' death, this experience is termed death anxiety. The point is that community nurses and other palliative care professionals may experience an extra level of death anxiety from being exposed to dying episodes more often than any other health professional.
Great thinkers such as Martin Heidegger and Soren Kierkegaard have argued that we move from our natural day-to-day living without thinking of our existence to being more mindful and aware of life and our need to exist, and hence we make all attempts to preserve life. While thinking of our existence more consciously can be useful, it also means, we inevitably bring death to forefront of our thought processes, which, in itself, may increase death anxiety (Nyatanga and Nyatanga, 2011). This increase may explain the continued presence of death taboos particularly in Western societies, as we attempt to block death from our everyday consciousness (Langford, 2002). The irony, which also makes death anxiety difficult to manage, is that death is the only certainty in life, and yet it remains one of the most potent causes of anxiety. Admittedly, not discussing death does not help us escape its inevitability. Therefore, our minds are perpetually disturbed by this elusive phenomenon in the form of death anxiety, with a potential negative effect on how we care for the dying.
For some time now, evidence has indicated that death anxiety affects resilience and reduces the ability to cope with stress (Langford, 2002; Nyatanga, 2011). If unabated, stress eventually develops into burnout syndrome, which is characterised by the inability to cope, ill-health and absenteeism for health professionals. In a study of 213 nurses, Nyatanga (2011) reported a positive correlation between death anxiety and burnout, illustrating a wider impact on caring and staff wellbeing. Professionals who do not immediately go off sick may lack compassion due to compassion fatigue, which also has a negative impact on the dying patients' experience of care and, possibly, those deemed important to the patient.
What can be done?
Ideally, society at large needs to shift its view of death and accept it as natural part of life, with children becoming involved with dying and the funeral rituals of close relations. This shift would recognise the importance of life while accepting that, at some point, death will interrupt that life and, in most cases, prematurely. Openly discussing death will also mean accepting that the use of euphemisms is a futile attempt to keep death anxiety away. While many people may view euphemisms, such as ‘she slipped away’ and ‘he is resting in peace’, as a kind and caring way of confirming death, the reality is that these are a false representation of what has happened and, therefore, can easily distort the meaning of death among the bereaved while perpetuating the taboo-ness of death.
Palliative care can be a double edged sword: exposure to death anxiety may cause stress and burnout, but equally, it is a privilege to be part of someone's intimate dying experience while providing care for them.
Community nurses and managers need to find ways of supporting staff to avoid the negative episode of death anxiety. This column serves to openly raise awareness about death, dying and death anxiety. There is the realisation that often, death involves uncomfortable experiences and conversations. However, to avoid such conversations is to deny reality and suffocate any efforts to honestly support patients and relatives during this phase of life. Euphemisms have no place in palliative care, as they only serve to deflect from the truth and uncomfortable conversations around sensitive issues of death and dying. By accepting death as a natural part of life, we can make it easier to talk openly about it with patients. From such a position of honesty, it may also be easier to discuss advance care planning with patients, an important aspect of care when they are no longer able to make their own informed decisions.