This month's column examines the possibility of death and its impact on health professionals as they care for dying patients, who are in their final phase of life. There is evidence that death brings with it a finality to life as we know it. Death equates to our non-existence, and has emotional implications for those close to us.
Eric Erikson's (1902–1994) perspective of contemporary palliative care includes useful discussions on death. Erikson's research proposed the premise that we go through eight developmental phases, with death being the final one. Each developmental phase is unique and brings with it both psychological and physical growth. Here, psychological growth should be considered to include emotional, social, intellectual and spiritual aspects. It results from individuals experiencing life and learning from both good and bad to shape the next phase. However, being the finite phase, death is often viewed differently, with many people feeling indifferent towards how to approach and negotiate this life-ending phase.
One indicator of this final stage is old age, which Erikson argues, raises questions, anxieties and fears about how to face death. Palliative care covers all ages, and those facing death may need the help of health professionals, particularly community nurses when being cared for at home, to negotiate this final stage. There are numerous factors at play within this negotiation that require recognition, for example, reflecting on past experiences, revisiting missed opportunities while not dwelling on them too much, and focusing on accomplishments.
The important point to consider is the need to ensure we can help dying people achieve a balanced perspective on their life already lived and aspirations for the remainder. The factors in question include both good and bad experiences. The general understanding goes back to the 20th century, when Butler (1963) reminded us that at this final stage, it is more about accepting our limitations with humility and embracing our successes. He goes further to say, ‘… life in the eighth stage includes a retrospective accounting of one's life to date; how much one embraces life as having been well lived, as opposed to regretting missed opportunities' (p71).
The emphasis here is for health professionals to help dying patients focus mainly on those positive life experiences for two reasons:
Helping dying patients achieve integrity is fundamental to how they make meaning of their life's journey. Health professionals play a crucial role in supporting patients in creating a comfortable balance between their successes and failures, pleasures and disappointments and, more importantly, those aspects of life that make them feel whole again.
Experienced health professionals should ask dying persons if their past life has not achieved wholeness for them. The next step would be to suggest that perhaps their remaining life could be used to address some of the deficits. Butler (1963) argued that life's development continues as long as one is alive. In other words, health professionals should help the dying person complete their unfinished business or ‘put their psychological house in order’ (Nyatanga, 2008). This can include things like writing their wishes in a will (formally) or informally for their close relations. The alternative is too risky to contemplate, and Butler (1963) claimed that, when dying patients fail to achieve wholeness, they may end up being depressed due to fragmentation of the self and feeling disconnected from life.
Arguably, supporting patients in this manner demands time and energy of health professionals, and it is with this in mind that professionals in the community should welcome any opportunity to refer patients to palliative care services, where the team approach is in force. Referral affords patients access to specialist care and support through this final stage of life. Each individual is unique and, therefore, likely to have different ways of achieving wholeness and dignity. Palliative care services can support patients according to their preferences and wishes, as they are likely to have the necessary expertise, time and staff–patient ratio.