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Enfermería Global

versión On-line ISSN 1695-6141

Enferm. glob. vol.15 no.41 Murcia ene. 2016




The look of Nursing on Death and Dying Process of critically ill patients: An Integrative Review

O olhar da Enfermagem diante do Processo de Morte e Morrer de pacientes críticos: Uma Revisão Integrativa

La visión de la Enfermería ante el Proceso de Muerte y Morir de pacientes críticos: una revisión integradora



Freitas, Tiago Luan Labres de*; Banazeski, Ana Claudia*; Eisele, Adriane*; de Souza, Elaine Natália*; Bitencourt, Julia Valéria de Oliveira Vargas** and de Souza, Silvia Silva***

* Academics 10th semester of the course Undergraduate Nursing at University Federal da Fronteira Sul, Campus Chapecó SC. E-mail:
** Nurse Teacher, Assistant professor of the course Undergraduate Nursing at the University Federal da Fronteira Sul, Campus Chapecó SC
*** MS Nurse, PhD in Nursing at UFSC, assistant professor of the course Undergraduate Nursing at the the University Federal da Fronteira Sul,Campus Chapecó SC Brazil.




Facing death at any moment has become essential burden for workers in the health area, in particular to professional nursing, which in turn is who provides the comprehensive care to the patient and the family, and this must deal with suffering , and fears that may exist at different moments involving the care. Therefore, it is necessary to further the nursing professional view on the subject, so that it can see beyond the circumstances, and understand the processes of death and dying, so that their cooperation is quality.
From this, the present study aims: To analyze the national scientific literature on the experience of the nursing team before the death of critically ill patients. We used the integrative review of literature method. We analyzed 14 articles that met the guiding research question and from the approach of these studies, three categories were listed: 1- sensations and feelings that the death of patients awakening in nursing professionals; 2- The Death Process and the conception of the crew; 3-The preparation of nurses in the process of formation on the theme death and dying. The study identified that there is a large unprepared professionals to the process of death and dying, causing suffering of the nursing team, influencing the quality of care provided to patients and their families in this sense become relevant research on this subject for the expansion of knowledge and deconstruction of existing paradigms.

Key words: Death; die; Nursing staff; Attitude to Death.


Encarar la muerte y el miedo a enfrentarse a ella a cada instante se ha convertido en esencial para los trabajadores del área de la salud, en especial para el profesional de enfermería, que a su vez es quien presta los cuidados integrales al paciente y a la familia, ya que este debe luchar con el sufrimiento y con los miedos que pueden existir en los diversos momentos que acompañan el cuidar. Por tanto, es necesario profundizar em la visión del profesional de enfermería sobre el tema, de modo que pueda ver más allá de las circunstancias del contexto, y conocer los procesos de la muerte y del morir, para que su asistencia sea de calidad.
Partiendo de esto, el presente estudio tiene como objetivo: Analizar la producción científica nacional sobre la experiencia del equipo de enfermería ante la muerte de los pacientes críticos. Se empleó el método de revisión integral de la literatura. Se analizaron 14 artículos que cumplían la pregunta principal de la investigación y a partir del enfoque de estos estudios, fueron listadas dos categorías: 1-El proceso de muerte y morir: praxis y significados; 2- La cualificación del enfermero en su proceso de formación ante la temática muerte y el morir. El estudio identificó que existe una deficiencia en el aprendizaje de los profesionales para el proceso de la muerte y el morir, causando sufrimiento del equipo de enfermería, lo que influye en la calidad de la atención prestada a los pacientes y a sus familias. En este sentido, es importante realizar investigaciones acerca de esta temática para la ampliación del conocimiento y (re)deconstrucción de los paradigmas existentes.

Palabras clave: Muerte; Morir; Equipo de Enfermería; Actitud hacia la muerte.


Encarar a morte o medo de lidar com a morte a todo instante tornou-se encargo essencial para os trabalhadores da área da saúde, em especial ao profissional da enfermagem, que por sua vez é quem presta os cuidados integrais ao paciente e a família, sendo que este deve lidar com o sofrimento, e com os receios que podem existir nos diversos momentos que envolvem o cuidar. Portanto, é necessário aprofundar a visão do profissional da enfermagem sobre o assunto, de modo que, o mesmo possa perceber para além das circunstâncias do contexto, e conhecer os processos da morte e do morrer, para que sua assistência seja de qualidade.
A partir disso, o presente estudo tem como objetivo: Analisar a produção científica nacional sobre a experiência da equipe de enfermagem diante da morte de pacientes críticos. Foi empregado o método de revisão integrativa da literatura. Foram analisados 14 artigos que atenderam a questão norteadora da pesquisa e a partir da abordagem destes estudos, foram elencadas duas categorias: 1 -O processo de morte e morrer: práxis e significados; 2-A qualificação do enfermeiro em seu processo de formação diante da temática morte e o morrer. O estudo possibilitou identificar que há uma deficiência no aprendizado dos profissionais perante o processo de morte e morrer, causando sofrimento da equipe de enfermagem, influenciando na qualidade da assistência prestada ao paciente e sua família. Neste sentido tornam-se relevantes pesquisas acerca desta temática para a ampliação do conhecimento e (re)desconstrução de paradigmas existentes.

Palavras chave: Morte; Morrer; Equipe de Enfermagem; Atitude Frente à Morte.



Death is one of the events that cause more questions in human history. Philosophers, anthropologists, social scientists and many thinkers made numerous reflections on death and paradigm which is related. However, for a multitude of people, death is still seen as an alien event, far from reality and the modern everyday (1).

For humans, the finitude becomes aware of distressing way, since life is celebrated daily, leaving aside the death, as if it never happened. This anxiety is old, it is reproduced in various cultures of the world, projecting the death as a trivial event, and avoided talking to (2).

In this context, in which death can be trivialized, not drives the interest in debate about its meaning, in order to meet you, as a human phenomenon. It is therefore necessary to develop concepts and define concepts that enable the development of strategies to deal with it. Considering this reality, before a death situation commonly softens the fact, avoiding its confrontation. However, facing death at any moment has become essential burden on the workers of the health sector, especially the professional nursing, which in turn is who pays the full care to the patient and the family (1).

In some European countries such as England, the question of death is being developed and debated since the 90s in a different way from other countries. Practitioners follow the precepts of the Natural Death Centre, educational non-profit organization which aims to disseminate the ideas of "natural death." Therefore these professionals bet on a death of natural and healthy way, ie as a step that permeates the lives of everyone. In this country, it presents an argument in favor of death as "natural as possible," comparing the same with the normal delivery (3).

The nursing staff is the closest in critical situations, who is the patient and family, look for when they need explanations, protection, physical and psychological care. And, the professional must deal with suffering, with grief and fears that may exist in the various stages that involve the care. Such care to be effective not only require nursing techniques and knowledge of the disease itself, but also skills to work with others' feelings and emotions to the patient with or without probability of cure (4,5).

A nurse without knowledge and preparation is far from the situation as a defense mechanism and not facing death. Therefore it is necessary to deepen the nursing professional insight into the subject, so that it can see beyond the circumstances and understand the processes of death and dying, so that their cooperation is quality, striving for completeness and humanized attention to patient care, making it more effective and the link between the patient and the family (4).

During the academic training, professionals will have felt committed to life, is to maintain this preparing, because their training is based on healing, which is his greatest compensation. But during the care given to critical patients generally feel insecure. Thus, the nurse has to deal with death in a balanced way so that there is coldly and not let your emotions influence, at the risk of offering a dehumanized care(2).

From these considerations showing in the Brazilian scenario conflicts of nursing staff in the treatment of death, a situation that can be everyday in a hospital, depending on the complexity and number of beds the same, it becomes relevant to reflect on this theme. Thus, this study aims to: Analisar a produção científica nacional sobre a experiência da equipe de enfermagem diante da morte de pacientes críticos.


Materials and methods

The present study in order to answer the goal, selected as a research method integrative literature review. Thus, data collection followed the methodology used in the five seconds steps Mendes, Silveira and Galvão (2008): a) issue identification and selection of guiding question; b) Establishment of criteria for inclusion and exclusion of studies; c) specification of information to be extracted from the selected studies; d) interpreting the results ee) synthesis of knowledge (6).

Data collection was carried out by consulting in five databases: Latin American Caribbean Health Sciences (LILACS), Database Resource Specializing in the Nursing field in Brazil (BDENF), Medical Literature analysis and Retrieval System Online (MEDLINE), PUBMED and COCHRANE.

The survey of the studies took place in October 2014. To select them, the descriptors were used in Health Sciences (DeCS) "Death", "Nursing Team" and "Thanatology". To perform an advanced search with three descriptors at the same time, the Boolean operators were used "[AND]" and "[OR]," as follows: "Death" AND "nursing team" OR "Thanatology". It was not established prior timeframe, however, be noted that the emergence of studies on the death dated from 2002.

Studies were included which sought to focus the guiding question: What has been published in Brazil on the experience of the nursing team before the death of critically ill patients? Articles: published in Portuguese; available in full in the databases; written by nurses; published in foreign journals, but with studies conducted in Brazil, they are available in Portuguese.

Exclusion criteria were: papers; theses and dissertations; repeated publications cards; editorial; comments; summaries of proceedings; books; letters to the editor; and studies that did not cover the relevant subject to the review objective.

Search of the studies were selected 537 publications being distributed as follows: 33 in PUBMED, 93 in LILACS, 35 in BDENF, MEDLINE and 376 in 0 in COCHRANE. These productions, whether ascertained them articles that were complete as well as those whose thematic directed to the study of the object, leaving 09 in BDENF, 04 in LILACS and 01 production in MEDLINE, for a total of 14 publications.

In data analysis, developed the description thereof, being used tables for the presentation of the summary of the articles included in the review (summary table). As well as to discuss the emerging themes were categorized in order to discuss and scientifically support the meanings of these data, in correspondence to the research focus.



This integrative review, we analyzed 14 articles that met the guiding question of the study, quoted above, which corresponded to the inclusion / exclusion criteria. It is presented in the summary table below (Table 1), the references of selected articles in full with their own code, following the order of the most used in this study.



The selected studies were all conducted in Brazil, five in the South, six in the southeastern region, one in the Midwest and two in the northeast of the country. For the period between publication found a 2013, four in 2012, two in 2011, three in 2009, a 2008, one in 2006 and two in 2005.

To answer the research question, there was the reading of the articles in their entirety in order to identify the experience of the nursing team before the death of critically ill patients.

From the approach of these studies, three categories were listed: sensations and feelings that the death of patients awakening in nursing professionals; The Process of Death and the conceptions of the team; The preparation of nurses in the process of formation on the theme death and dying.



This section discusses the issues that most concerned the articles filtered according to the inclusion and exclusion criteria. Thus, three categories were set, making it easier dynamics, understanding and questioning of the ideas of this study.

1. Sensations and feelings that the death of patients awakening in nursing professionals

The selected items, (A1 to A14), all cite and punctuate discussions regarding the sensations and feelings arising from the death of critically ill patients in nursing professionals. In this logic, below is a compiled discusses the ideas of the authors elucidate in a more explicit in this category.

Professional nurses have many feelings when a patient progresses to death, since more general feelings as the pain of loss, even more specific feelings such as dissatisfaction, disagreement, failure and denial for failing to keep the patient's life, or transform inevitable situation, accompanied by anger, sadness and bargaining. In this sense, the manifestation of suffering happens in many ways, and many are silent, others are isolated, cry and seek justifications for death, realizing that it is the destiny of every human being, as well as frustration, weakness and nurse's inability as dealing with death, dominating the professional and the assistance provided (9,14,17)

Prevailing sensations that express suffering, also notes it is the reflection of these in the work process. The feeling of mourning in such cases is inevitable. It is understandable because they are human beings, because each person has their limitations and every situation expresses a different meaning of emotions. In addition, the fight for the health care professional is acutely It is characterized by psychological and somatic symptoms that cause mental suffering and pain. Those coming from grief symptoms carry affective manifestations, like, guilt, depression and anxiety. Such symptoms impair the working dynamics, leading to the onset of low self-esteem, poor concentration, insomnia, susceptibility to disease, among others. Therefore, so that death does not cause suffering, should avoid feeling (camouflage) mourning as a form of psychological protection. These professionals still believe that they should have a firm stand and be cold or indifferent face of death (11,12,17).

Given this reality it is considering development strategies that can be developed with professionals allowing live these moments healthily. In this sense, the authors mention that for the management of death is essential to know the feelings that nurses experience in their daily work. Self-knowledge is an important issue to be worked in order to improve the way you deal with situations involving a manifest deep emotions, especially those related to death, considered by many a taboo (13).

Members of the nursing staff are human beings unable to separate his feelings from work and his private life, in this sense the feelings arising from their profession are taken to their private lives and can influence family relations significantly. In his work can manifest feelings of self-reproach, low-self-esteem and helplessness, which are also part of mourning, leading to major wear all staff involved with patients at risk condition, demonstrating impotence can not conquer death (9,13).

The logic of self-knowledge, one of the most cited feelings are sadness, and may be varied as the care provided and the time that the team is involved with the patient.

Therefore sadness after the death of his patients is due to the sense of loss and emptiness concerning the death process 15. Since, in this context sadness is characterized as lack of joy, her sorrow, grief and depression. The daily contact with the die can cause professionals to replace the sadness with feelings of coldness and indifference, as a cloaking mechanism to decrease your pain with this process (13,17).

On the other hand, there are professionals that preserve independent of time developing the profession the feeling of sadness. In this regard, Article A5 features professional reports working in the area for a long time, but the pain of losing a patient is present in your daily work, despite the vast experience.

Even professionals who work long in units living with patients in imminent death situations, have trouble finding ways of coping, many end up isolating themselves and not sharing with the rest of the team their anxieties, fears and sufferings. Sadness is a feeling inherent to human beings, all people feel in some part of your life, and how health professionals are coming to experience this daily, and are distinguished candidates vulnerable to it. With living together often this process, they end up becoming defenseless and denying the death, having stigma features in teams(11).

Issues related to impotence professional before the death process are highlighted in studies as far as, attention to family.

Despite all the technological advances for the maintenance of life, professionals feel powerless about the situation and the imminence of death, as seo die depends only on staff efficiency (17).

While providing patient care in the dying process, the nursing professional feels helpless and unhappy facing imminent death, and signals an emotional and psychological unpreparedness, hampering these professionals face the situation as something inherent to all human beings that must be experienced in the best possible way, without interfering in the work of professional, both patient care as the family (15).

Nursing education professional can be cited in this category, in the sense that the authors attribute the despreparação in academia brings to the fore negative feelings towards death. In this sense, the issue of exclusion of death during the process of training at the academy of health professionals, makes them leave unprepared to handle the situation. Most of the academic training that focused on the preservation process of life and curing diseases, identifying a gap in the knowledge of these professionals, and try to get away avoiding a bond with the patient because they are unprepared(11).

However, will always be difficult to experience the moment of death, and what precedes it, to die, because we are dealing with the loss of a human being and even with all the preparation for the hospital experiences each case is unique and each will react staff of a differently. Not knowing how to deal with the feelings arising from the death may compromise, in addition to assistance provided, bring feelings of confrontation surfaced internalized in the minds of professional, damaging her personal and love life.

2. The Process of Death and team concepts

In this category, we highlight the articles that question the theme of Death and Dying Process: A1, A3, A4, A6, A7, A8 and A13, so, following the discussions by setting the ideas of these authors. Subject to setting the A6 articles, A7 and A8, which specifically address an issue within this section.

Death and dying are experiences that include biological events, also taking religious, social, philosophical, anthropological, spiritual and educational, with that every culture has a different concept regarding death and dying, the phenomenon of death is a natural process and not no way to avoid, in this sense death within the area of health, has become isolated and hidden. After the end of World War II from 1937 to 1979, it was not allowed to nursing engage and be moved by the death, and his duty, to offer comfort to the family and the patient, the care focused on the biological question. In this case the nurses had a duty of care of the body and must carry it with patience and love. Still performing all nursing care as buffering and hygiene, giving the body the family with comfort appearance (7,19).

The process of death and dying is an event in which every human being will pass, and a fully connected to life event. Another important event is that man is the only living being who actually is aware of what is death, which is a privileged knowledge to man in this way, death and dying is directly linked to human existence before all the uncertainties that are present in daily life, death and dying become inherent to life of individuals (9,17).

The nursing staff feel helpless as the master's death, thus impairing the patient's care(9). In this sense, we talk about death and dying is not simple, because when you touch on the subject, remembers vivid stories, as if the human being had a limited time. The death happens from when we are born, defining how to stop living, dying, finishing, fall by the wayside, and the way to stay alive is the thought of staying alive. Since death is fraught with difficulties, as there are several definitions, depending on the individual's culture (19).

Therefore it is important for health professionals to understand and learn about the concepts of death and dying, so that during nursing care know how to deal with the situation. It is known that most professionals bring to their religion assistance as a strong tool for the acceptance of death, to become a fact explicable (7).

From the nineteenth century, the man began to worry less about his death and more with the death of the other, as this will leave feelings of nostalgia. From the twentieth century the process of death and dying becomes technicalities, moving to the hospital getting the care of doctors and health staff. Thus, the company created a fantasy of omnipotence over death in the sense that there have been many social and technological changes related to health, providing specialized care. These technologies are increasing life expectations of patients and professionals who are directly linked to their service, to the extent that they can intervene and modify the body postponing the moment of death (20).

In view of technological advances, the A6 articles, A7 and A8 showed so specifies that in the event of these, unleashed the medicalization of death, usually associated with highly complex care for patients who require more advanced technology to maintain the functions physiological. However, it is observed that all this technological support helps maintain bodily functions, not contributing in the dying process of patients making them socially marginalized, because it no longer has its functional role, namely individuality as a human being (12,13).

Given this, the authors reflect how much this new context implies the process of death, that principle is conceived as natural. Thus, the illusion created through technological equipment creates an expectation both in the family and in the team that this patient will be able to survive this period of hospitalization because both are attached in the hope that the end of life of patients is far, however this hope in some ways is a continuation of suffering, for death is imminent (14).

At cross purposes, so referring to a meticulous and humane analysis of the situation, is the fact that although there is a team of professionals trained to handle the equipment, we can see the unpreparedness of the team as dealing with death and so can not help empathetically patients and their families, this process is performed mechanically (12,17).

Thus, we see the importance of understanding the professionals about the process of dying for assistance, both in graduation, with themes that can support quality care for the patient and family in these difficult times to face, as in education permanent and continuing, seeking comfort and a humanized care, thereby improving the care of the human being at every stage of life.

3. The preparation of nurses in the process of formation on the theme death and dying

Evidenced in this study, that 7 of the articles (A4, A5, A7, A9, A11, A13, A14) included in this review cite and problematize the unpreparedness of the professionals in nurses issuer death of critically ill patients in their care, yet without issue a plausible solution for changing this context.

With respect to academic education, it is inferred that death, as one of the most intriguing phenomena to human beings, to awaken generally, apprehension and fear, since it demarcates the human terminal illness, you need the professional prior and specific preparation for working with this event in their daily work (21).

Consequently, a challenge to teachers to work content to report on this subject in nursing, due to the fact that they have not received training / qualifications needed to talk about death in the classroom or feel apprehensive. Thus, this may limit its activities, hinder the teaching process and disqualify the formation of new professionals. Thus, in the absence of the thematic discussion, always had different interpretations and even wrong (22).

Thus, in questioning the teacher's unpreparedness as the subject of teaching methods in focus, it was identified in the speeches that permeated some articles, that the issue of development "death and dying" in turn was not worked at any time during training academic participants of the studies. Some report that the matter was only passed quickly and objectively, printing a devaluation of the subject.

What sustains most of the time the argument stop working death is the fact that most of the courses have in the menus of the disciplines the focus of work just in life, healing and well being of the patient. Thus, one can see a huge gap within the curricular matrices of undergraduate courses. The reflection of that is the training of professionals without full preparation to deal with death during his professional practice (16).

It notes that of the most current and inserted curricula within an anthropological and psychological perspective value disciplines and times when the scholar, with his personal issues, may have space to express their principles in order to mature vision of reality. However although, this configuration expressed in the documents that guide the educational praxis, currently, still, it is clear that professionals working in practice and did not have that look and this foundation, leaving a disproportionate gap in the daily work (13).

It is noteworthy that, in the gym, with respect to theoretical and practical classes, create opportunities situations that help nursing professionals to use satisfactory coping mechanisms in the face of death is extremely important for the preparation of a fit and ready professional to handle any type of situation, making it a remarkable strategy for this type of experience that awaits them.

From this logic, building a quality service, say by the way, quality for both the patient and the nurse who provides it, providing opportunities for an environment that glimpse the open dialogue to express their anxieties, fears, fears, among other feelings that exacerbate in their lives, not only as professional people in order to help them develop the art of living with death and dying that permeate constantly in your professional life(13).

From these considerations, it is clear that death is a crucial point in the professional life of nurses, and so should be discussed in undergraduate nursing courses. This is a gap considered for debate in the formulation of teaching plans, the logic of forming nurses critical, reflective and generalist, able to act in various scenarios of health scenarios in which both permeate life and death. Death is always present in the daily work of nurses, this academic preparation mode for understanding this theme as something natural and inherent in every human being.



The study identified that there is a huge lack of preparation professionals to the process of death and dying, causing suffering of the nursing team, influencing the quality of care provided to patients and their families. Thus professionals end up bringing sensations of pain for the loss, or feelings of denial, dissatisfaction, sadness and even anger, for failing to maintain the life of this patient, causing a low self-esteem wearing professionals and staff.

It is felt that this issue was considered of little relevance to be worked out at the gym, because the focus was biologicist, a fact that has been quietly changed over time with the reformulation of the Pedagogical Political Project (PPP) of the undergraduate courses, assuming a profile formation of a professional facing bio-psycho-social care.

In this context, it was evidenced that emerged in recent years, studies about death and its influence on the team, care and quality of care, an issue that until then was seen as a taboo and rarely discussed. In addition, the vast majority of professionals consider death as inevitable and natural having difficulty understanding the process of death and dying and their representation in this regard because they feel unsuccessful and powerless when a patient dies.

As a result, become relevant research on this subject for the expansion of knowledge and deconstructing existing paradigms. Thus creating subsidies for permanent and continuing education of professionals.



Received: December 10, 2014
Accepted: 18 January 2015



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