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Nurses in every clinical practice specialty will encounter a patient who is dying and will provide care to that patient as well as give support to the patient’s family. This is not a new phenomenon and the experiences of nurses providing end-of-life care have been extensively documented (Coffey, et al., 2016; Holms, Milligan, and Kidd, 2014; Hussin, et al., 2018; Lusignani, et al., 2017; Puente-Fernandez, et al., 2020; Zheng, Lee and Bloomer, 2018). Over the last several decades, nurses continue to report a lack of education and preparation to manage the complex care associated with dying and decision making at the end of life (Holms, et. al, 2014; McCourt, et. al, 2013; Suryani, et. al, 2018). Nurses’ experiences with death and dying under “normal” circumstances can be challenging and emotional as they advocate for patients’ wishes and promote a comfortable, dignified death (Griffiths, 2019; Peterson, et al., 2010).

Enter COVID-19 – a coronavirus that affected the globe and caused healthcare workers, including nurses, to change their routine practice of caring for patients, particularly dying patients. There is no current literature on the effects of this global pandemic on nurses caring for this special population of dying patients.  Pattison (2020) reviewed some literature on disaster management and end-of-life care with outbreaks such as the H1N1 virus; palliative and end-of-life care planning is not fully developed and still needed. In this current pandemic, COVID-19 has caused a high number of unexpected deaths, there has been greater demand for beds and other resources, and provision of end-of-life care has been hampered due to respiratory transmission of the virus and maintaining safety for nurses at the bedside.

Nursing students, often employed in hospitals as patient care technicians, are witnessing death and dying at an alarming rate. As a professor at a local university, I have spoken with third and fourth-year nursing students who were working in hospital units designated for COVID-19 patients. The students shared that they were performing multiple post-mortem cares on patients that had died from the virus. Students also discussed the difficulty of trying to manage communication between the dying patient and their family, since visitors were restricted. Technology such as smart phones or tablets were used to have video conversations between patients and families as the patient was nearing the end of life.

It is imperative that nurse educators in both academia and healthcare systems provide additional and continuing education and support to nursing students as well as nurses practicing at the bedsides of the dying. The high stress environment of a COVID-19 unit paired with critically ill patients who may die unexpectedly may cause burnout in nurses. Resources such as the End of Life Nursing Education Consortium (ELNEC) are available online for educators to share with students and nurses.  ELNEC has provided educational resources for palliative care and end-of-life care to nurses for the last two decades. Information in the modules includes physical symptom management, pain, spiritual care, ethical/legal issues and communication. ELNEC has created free online resources in response to COVID-19 and may be useful for pre-licensure education as well as continuing education and support for nurses (ELNEC, 2020).

Further support which can be provided to students and nurses includes virtual support groups, arranged by nursing faculty, hospital nurse educators or referral to social media support groups. When nurses are ready to talk about their experiences with dying patients, they need an outlet to express their emotions regarding their participation in end-of-life care during a pandemic. This may assist in validating their feelings and sharing their grief. Additional strategies to enhance positive coping mechanisms include self-care such as exercise, sleep, healthy diet, leisure activities, and spiritual or religious support (Zheng, Lee and Bloomer, 2017).

COVID-19 has changed the way nurses interact with patients and families at the end of life. Technology has been a useful tool; however, we must not forget the human side of care. The need for pre-licensure and continuing education on end-of-life care is essential. Nurses have been reporting high anxiety and lack of preparedness about caring for a dying patient over the last several decades. We must provide education as well as emotional support to our front line during this pandemic as well as prepare for future pandemics and other unusual circumstances surrounding the end of life.

References

Coffey, A., McCarthy, G., Weathers, E., Friedman, M., Gallo, K., Ehrenfeld, M., Chan, S., Li, W., Poletti, P., Anotti, R., Molloy, D., McGlade, C., Fitzpatrick, J. & Itzhaki, M. (2016). Nurses’ knowledge of advance directives and perceived confidence in end-of-life care: A cross-sectional study in five counties. International Journal of Nursing Practice, 22, 247-257. DOI: 10.1111/ijn.12417

ELNEC (2020).  End of life nursing education consortium.  https://www.aacnnursing.org/elnec

Griffiths, I. (2019).  What are the challenges for nurses when providing end-of-life care in  intensive care units?  British Journal of Nursing, 28, (16), 1047-1052.

Holms, N., Milligan, S. &  Kydd, A. (2014). A study of the lived experiences of registered nurses who have provided end-of-life care within an intensive care unit. International Journal of Palliative Nursing, 20, (11), 549-556.

Hussin, E., Wong, L., Chong, M. & Subramanian, P. (2018).  Nurses’ perceptions of barriers and facilitators and their associations with the quality of end-of-life care. Journal of Clinical Nursing, 27, (3-4), e688-e702.

Lusignani, M., Gianni, M., Re, L. & Buffon (2017). Moral distress among nurses in medical, surgical and intensive-care units. Journal of Nursing Management, 25, 477-485. DOI: 10.1111/jonm.12431

McCourt, R., Power, J. & Glackin, M. (2013).  General nurses’ experiences of end-of-life care in the acute hospital setting: A literature review.  International Journal of Palliative Nursing, 19, (10), 510-516.

Pattison, N. (2020). End-of-life decisions and care in the midst of a global coronavirus (COVID19) pandemic.  Intensive & Critical Care Nursing, 58. DOI:10.1016/j.jccn.2020.102862

Peterson, J., Johnson, M., Halvorsen, B., Apmann, L., Chang, P-C, Kershek, S., Scherr, C., Ogi, M. & Pincon, D. (2010).  What is so stressful about caring for a dying patient? A qualitative study of nurses’ experiences.  International Journal of Palliative Nursing, 16, (4), 181-187.

Puente-Fernandez, D., Lozano-Romero, M., Montoya-Juarez, R., Marti-Garcia, C., Campos Calderon, C., & Hueso-Montoro, C. (2020). Nursing professionals’ attitudes, strategies, and care practices towards death:  A systematic review of qualitative studies. Journal of Nursing Scholarship, 52, (3), 301-310.

Suryani, R., Allenidekania, A. &  Rachmawati, I. (2018). Phenomenology on nurses’ experiences in understanding the comfort of children at the end-of-life. Indian Journal of Palliative Care, 24, (2), 162-166.

Zheng, R., Lee, S. & Bloomer, M. (2018).  How nurses cope with patient death: A systematic review and qualitative meta-synthesis. Journal of Clinical Nursing, 27, e39-e49.  DOI:  10.1111/jocn.13975

Stephanie Jeffers, PhD, RN, Widener University
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