Dealing with death and dying: a paramedic s perspective

auk1_05.qxp 15/09/2006 09:38 Page 9 Dealing with death and dying: a paramedic’s perspective Introduction More so than other health professionals,...
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Introduction More so than other health professionals, ambulance crews regularly deal with situations involving sudden and unexpected death. Despite this they receive no formal training in this area. With the exception of being told not to say they are 'sorry', staff receive no training in how to break bad news nor are they prepared for grief reactions that may follow. Recent years have seen the introduction of a confirmation of death protocol within ambulance services. This means instead of waiting for a doctor to attend, ambulance crews can in certain situations, confirm death and leave the incident upon completion of paperwork. Thus, the onus of breaking the news of death now often lies with ambulance staff. Due to lack of training, problems may arise in sudden death situations. Inexperienced and ill-informed management of sudden deaths can have a negative and profound impact upon both relatives and the staff dealing with the incident. The aim of this article is to show how ambulance staff would benefit from formal training in the field of breaking bad news and bereavement management, and to examine what form such a programme could take. Whilst the term paramedic has been used throughout this article it is acknowledged that the subject under discussion is equally applicable to ambulance technicians. Therefore, the term paramedic as used here is also meant to refer to ambulance technicians.

Dealing with bereavement situations There is never going to be an easy way to break the news to relatives that their loved one has died. In cases of illness and expected death, relatives may feel they have AMBULANCE UK

prepared themselves for the event. Even in these situations, however, grief at the news is inevitable. Parkes believes anticipatory grieving can never really be complete [1]. Cases of sudden or unexpected death are fraught with even more complications. In addition to the usual problems and psychological responses death causes, sudden deaths possess their own complications. Watts & Hall found that "the impact of a sudden, unexpected death can impair the bereaved person's ability to cope, leading to long-term psychological disturbance" [2]. Relatives have to deal with the loss with no prior warning or preparation [3], and studies have shown in addition to the way in which a person died, whether it was anticipated or sudden was a major factor influencing long-term outcomes of the bereaved [1].

Sarah Christopher Dip. P.H.C, S. R (Para)

There has been found to be a significantly higher mortality rate among relatives bereaved suddenly compared to those where the bereavement was anticipated [4]. Sudden death can also interfere with normal grieving processes for several reasons. The deceased may have left unfinished business which bereaved relatives now find themselves having to deal with [5]. Relatives bereaved by suicide may be left with feelings of guilt, shame or anger [6]. Sudden death gives no chance to say goodbye and there may be unresolved issues between the deceased and bereaved relatives [7]. Add to this the fact the death must now be dealt with by paramedics in the pre-hospital environment, and even greater complications arise. When dealing with sudden, or for that matter expected death, paramedics by the very nature of their work do not have the same amount of time as other health professionals to establish a rapport with relatives. continued on next page . . . 9

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This can colour the interaction for both paramedic and relatives. From the point of view of the paramedic they have to deal with both clinical and emotional aspects of the situation simultaneously. However, the problems are not insurmountable. By informed and sensitive management of the situation, it can be possible to minimise the effects of bad news simply by the way in which it is given [8]. The way in which bad news is received is often indelibly printed upon the minds of the recipients and can go on to have a profound and lasting effect [9]. This view is supported by Levetown who found interaction between health professionals and relatives at the time of disclosure gave either long-term peace or resulted in psychological trauma which haunted the relatives for the rest of their lives [10]. Additionally, it was also found recipients of bad news often remembered where, when and how it was communicated [11]. One study suggested this may be because during this threatening and distressing time perceptions of events are heightened or more acute [12]. It must be considered then, that when it is so important bad news be broken well, why many health professionals lack expertise in this area. Literature available on this subject is almost exclusively from an in-hospital perspective, although many studies are applicable to the pre-hospital environment. In order to know what form of bereavement management training would be best for paramedics, it is necessary to consider what 'stumbling blocks' exist to prevent bad news being broken well. On considering the literature it is also necessary to compare and contrast the findings applying them to the pre-hospital environment. It then becomes apparent that whilst some of the complications apply to all health professionals, some are the result of the circumstances and environment in which paramedics work and are exclusive to them. 10

Factors which confound the breaking of bad news well Lack of Training Probably the single most important reason for breaking bad news badly is lack of training regarding this area of care. This is applicable to all health professionals regardless of environment or role. Most ambulance services now work to the guidelines of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). In their PreHospital Guidelines they state paramedics should offer condolences and leave a leaflet with relatives after confirming life extinct. They also say that whilst some training commitment will be required on the part of ambulance services, they do not believe the knowledge or base skills required are currently beyond the abilities of paramedics [13]. Aside from suggesting the format of an impersonal leaflet this is the only advice given. This is worrying and it would be interesting to know upon what evidence JRCALC have based this assumption. Whilst not based in pre-hospital environments, many studies have been conducted showing lack of training is not uncommon among health professionals, and this evidence is transferable to the field of pre-hospital care. In a survey conducted by Finlay & Dallimore it was found many respondents felt news of death was broken badly [14]. It is interesting to note that in this study the police were seen to be more sympathetic and better at this task than health professionals, which the authors suggested may be due to the fact the police received formal training in this area. In a study conducted by Tye, it was found 58% of nurses involved had never received any formal training [15]. Additionally, over half the sample felt inadequately prepared for managing sudden bereavement. Whilst not impossible for some health professionals to break bad news in a sensitive manner without training, a formal training programme does "bring into focus important aspects and adds to what is learnt from experience" [8].

Fear of Negative Response Again, this is applicable to the prehospital environment. Many people are uncomfortable when confronted by strong emotion and even if bad news is broken in a sensitive manner, the ensuing effect on recipients can never truly be predicted [8]. Additionally, no one likes to be the bearer of bad news. Faulkner pointed out the feeling that bad news is linked to the bearer still exists today, originating from the ancient Greeks who killed the bearers of bad tidings [16]. This is particularly applicable to the pre-hospital environment where sudden death is not unusual. Wilson states as sudden death is more difficult for bereaved relatives to deal with, reactions may prove to be far more unpredictable and therefore far more difficult for health professionals to cope with [17]. It follows then, in cases of sudden death not only is the actual breaking of the news complicated by the totally unexpected nature of the event, but also more difficult if paramedics have no knowledge of grief reactions. This once again highlights a training need. If paramedics are aware of possible grief reactions they would have be better equipped to deal with such situations.

Pressure of Workload This is particularly relevant to the pre-hospital environment. Many health professionals have very busy schedules. With the advent of the eight minute response deadline, an ambulance with prolonged involvement at one incident can cause resource problems. It can be almost impossible to try to support and help bereaved relatives when ambulance control are applying pressure to leave scene as quickly as possible. It was found conflict between resources and the need to devote time to bereaved relatives was a real concern in accident and emergency (A&E) departments [18]. Neither does this go unnoticed by bereaved relatives. In a study by Tye many of them criticised staff spending only brief periods with them and felt they lacked the AMBULANCE UK

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interpersonal skills and sensitivity necessary for this task [15]. It is agreed taking time over breaking bad news is vital to the long-term psychological well being of bereaved relatives and is an important part of all bereavement management guidelines [19-21]. In order to break bad news well, relatives must be given time to receive, process and understand information given at a pace comfortable to them [22]. This is supported by Faulkner who states "Bad news cannot be broken gently, but it can be given in a sensitive manner and at the individual's pace. If bad news has to be broken, it should be at the patient's pace so they can indicate when they wish to stop. If news is given too bluntly it may lead to denial" [16]. This again highlights a need for formal training, not only for operational paramedics but also for control staff in order that they fully understand and appreciate the need for time to be taken at such incidents. Environment Studies have shown that where bad news is broken can be of importance. It is the general belief bereaved relatives should be informed in an environment which is private, quiet and comfortable [9, 21]. In hospital most A&E departments have specially designated relative's rooms for this purpose. Paramedics working in the pre-hospital environment, however, are not afforded this luxury particularly when death has occurred in the home. This is an area of bereavement care over which paramedics have absolutely no control. The best that can be hoped for is a quiet and private area in the home in which to impart the news. This can be very difficult especially when, as is often the case, the house is full of well meaning neighbours and relatives. Breaking bad news is never easy even when it is in the professional's own territory such as in hospital. It is even harder when it has to be done on someone else's territory [23]. Situations involving breaking bad news to bereaved relatives in cases AMBULANCE UK

of sudden death in the home cause further complications. In many cases the body of the deceased is not transported by the ambulance crew or coroner and is left 'in situ'. This can take away the relative's choice of whether or not to see the body of their loved one. In a study conducted by Ashdown it was found, however, no bereaved relatives interviewed regretted viewing the body and some, in fact, found it helpful [9]. Other studies have supported this. Haas states it is now generally accepted relatives allowed to see the body of their loved one have a better long-term outcome, as it helps them to come to terms with the death [24]. This is supported by Wright who found time with the deceased can be a meaningful experience which will stay with the bereaved for years [12]. In his study, Tye found none of the bereaved regretted viewing the body of their loved one [15]. It is a very different matter, however, seeing a deceased relative at peace in a chapel of rest to seeing them before these preparations have been made. One study, however, found seeing the body at this stage can be helpful rather than causing greater distress. "Some relatives have expressed real gratitude they were able to see the loved person at that time, immediately following the death rather than later in the chapel of rest in a 'postundertaker' state" [9]. This has proven to be helpful even in cases where the deceased may be disfigured. Studies into the Granville rail disaster in Australia in 1977 found those who adapted best in the longterm to their loss were those who had been allowed to view the body of their loved one [25]. It was found that of the widows interviewed, the general consensus among them was that the thought of how their husbands may look was far worse than the disfigurement itself [25]. Some studies argue something as distressing as seeing a deceased loved one disfigured or mutilated could be dangerous to the mental

health of the bereaved and may lead to post traumatic stress, [2627], although neither study gives any evidence to support this. It should be remembered, however, some relatives will not want to see the body of their loved one under any circumstances. This does not pose a problem in a hospital environment but may be impossible when death occurs at home. Another complication of sudden death in the home is the possibility of relatives witnessing a full resuscitation. Resuscitation can be an undignified process and although efforts are usually made by paramedics to remove relatives from the room, it is not always possible. Many studies have been conducted into the effects witnessed resuscitation has on bereaved relatives. Arguments exist both for and against. Schilling states a small degree of humour in upsetting situations can often help health care professionals to cope under stress, and argued this may be inhibited in the presence of a relative, thereby affecting the performance of the team [28]. Redley & Hood argue in cases of witnessed resuscitation, panic by relatives may disrupt medical efforts [29]. They also argue that in the presence of a relative, staff may feel unable to voice honest opinions regarding the patient's condition [29] Arguments also exist in favour of allowing relatives to witness resuscitation. It can allow relatives to see everything possible is being done for their loved one [30]. A study conducted by Robinson & Mackenzie found little evidence to support the exclusion of relatives who wished to be present during resuscitation. It was found all relatives who had been present felt it had benefited them, and there were no comments on technical procedures, including a difficult intubation [31]. Additionally, it was found there was a lower risk of post traumatic stress and grief related symptoms [31]. Studies in the United States support 11

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this. Hanson & Strawser concluded in their study there were no instances of interference by relatives and witnessed trauma resuscitation is now practised [32].

Body Language and Lack of Awareness As has been discussed, paramedics and other health professionals have great demands on their time. This may lead to feeling that breaking bad news is the next task in a long line which needs to be completed as quickly as possible in order to move on to the next [8]. This attitude can very easily lead to a complete lack of awareness of the needs of the bereaved. The health professional suffers tunnel vision seeing only the goal of getting their task out of the way [8]. This can lead to a total disregard of the body language of both the person imparting the news and the bereaved. The health professional may be unaware of how they appear to the relative. Ashdown (1985) found many bereaved relatives commented on the body language of those breaking the news to them. "One person, somewhat graphically and angrily, described the doctor as 'performing like a bus conductor, swaying on both legs with one hand on the door post and looking into the distance'" [9]. Other bereaved relatives had positive experiences. "Comments such as 'I'll never forget the nurse's face; such kind eyes and words' have real meaning" [9]. The same study found these experiences varied greatly from one nurse to another which again suggests benefit could be gained from training. Additionally, studies show breaking bad news in a sitting down position can be valuable. They show the ability to sit down and assume the same postural level as the bereaved relative was extremely helpful [9, 33]. Again, these issues could be addressed by providing staff with a structured training programme. Emotions and Difficult Personal Issues Another factor affecting the way in which bad news is broken are the inner feelings and emotions of 12

health professionals. This is applicable to all health professionals in all environments. Problems can arise for a variety of reasons. One is the implicit feeling health professionals should not become emotionally involved with patients and relatives. Studies have shown, however, nursing staff who accepted this were less able to manage their own distress as there was no opportunity to acknowledge their need to express their sadness [34]. "The notion of clinical detachment being helpful seems to be related to a concern the opposite, over-involvement, is detrimental" [8]. Obviously it would be unhealthy to become overinvolved with patients and relatives, however, an excess of clinical detachment can lead to the importance of acknowledging feelings being denied or ignored [35]. By its very nature, work involving care of the dying or bereaved is distressing. Burnard & Chapman believe in order to deliver a high standard of care health professionals must have some level of involvement [36]. If this is not the case then all patients and relatives are treated with the impersonal approach that they are all the same and quality of care suffers [36], however, it must be stressed that it is important to obtain the right balance. Emotions can also affect health professionals when they find themselves strongly identifying with patients or relatives. Spall & Callis recount a situation where a nurse found a patient strongly reminded her of her husband [8]. This was an unresolved loss for the nurse involved and resulted in her experiencing a very strong reaction to the patient's death. Studies have also been conducted into what is termed 'bereavement overload' [37]. This is where several deaths occur in close succession not allowing care-givers time to deal with the first bereavement before another follows. Rando states if this accumulated loss is not dealt with, health professionals are just as vulnerable to the results of unresolved grief as any

other person who has failed to deal with the issue [38]. Emotions can also be affected because of feared loss. This can be the fear of one's own death or the fear of losing loved ones. Feared loss has been defined as "any potential loss causing us to feel uneasy, anxious or low in mood when we think about it" [8]. Saunders & Valente state people usually survive on a day-to-day basis by ignoring the possibility of either their own death or that of a loved one [39]. Health professionals who deal with death on a regular basis do not have this luxury. They are regularly reminded of mortality on a regular basis and cannot stick their heads in the sand. Saunders & Valente also state death can shake a person's sense of security by showing life is tenuous [39]. It can be seen then, emotions of health professionals play a large part in bereavement care and the breaking of bad news. Yet again, this could be addressed by training. Paramedics would benefit from some knowledge of reflective practice systems in order that emotional issues could be dealt with if necessary, especially if these issues are unresolved. This would result in their being better equipped to deal with such situations should they arise.

Who Should Break the News? In a hospital environment there is a choice of who should break bad news to relatives. Staff members with the most experience and training can be appointed the task and doctors are available to answer fully the relative's questions. Yates, Ellison & McGuinness state this is an important consideration when breaking news of bereavement, and found in their study the most senior members of staff were usually chosen for this task [18]. Tye found in his study age, education and length of specialist experience were all significant factors affecting how well nurses perceived the needs of bereaved relatives [15]. It would make sense, therefore, to AMBULANCE UK

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choose who should break bad news by taking this into account. Additionally, studies have found it important for bereaved relatives to have access to doctors in order they may be informed of any clinical issues surrounding the death of their loved one [40-41]. It is perfectly natural for relatives to want to know cause of death and a doctor is the person who will most likely possess this knowledge. Considering these points then, it is immediately obvious that for paramedics working with only one colleague in the prehospital environment, there is virtually no choice in who should break the bad news. Bereavement management training is virtually non-existent within the ambulance service and very rarely is a doctor on hand to assist. Although this situation cannot be altered, it could be improved by introducing a structured training programme. If paramedics have no choice but to break bad news, at least they should be trained how to do so.

Implications for practice It can be seen then, from considering the available literature and applying it to the pre-hospital environment, paramedics would benefit from formal training in the management of bereavement and breaking of bad news. Most factors affecting bad news being broken well could then be remedied. Many training programmes exist but none are specifically designed for paramedics or take into account the pre-hospital environment in which they work. However, many still have value and with certain modifications could form a framework for a paramedic training programme in bereavement management. It is necessary then, to consider what should be included in such a programme. "Notifying survivors about an unexpected death is very stressful. Therefore, individuals who are, or will be, involved in the process would like to learn it in a nonAMBULANCE UK

threatening environment before they have to 'fly solo'" [20]. This statement is very true and ideally ambulance staff would receive bereavement education as part of their basic training. This, however, would not address the needs of staff that are already operational. Farrell came up with the idea of a two part training programme, the first part of which would be ideal for ambulance staff. This encouraged participants to reflect upon their own personal and professional experience of bereavement management and breaking bad news [42]. This would be a very valuable exercise and excellent starting point for ambulance staff, and an opportunity for them to consider what they had learnt from their experiences. It would also be a good opportunity to introduce them to structured models of reflection which, although having limited value in some situations, would be of use here. Paramedics would be given the opportunity to address any unresolved issues they may have themselves regarding bereavement issues. As has been discussed previously, such issues can affect a person's ability to deal with certain aspects of bereavement. If these issues were addressed this could be avoided [43]. On considering the possible content of a training programme it appears to fall naturally into four sections. The first, as mentioned, would have its basis in reflection. The second part would give instruction on issues such as the complications particular to sudden death situations, awareness of grief reactions, seeing the body and witnessed resuscitation. All the areas, in fact, where the literature has shown problems may arise. Instruction could also be included regarding bereavement customs of other cultures. This would be extremely relevant to paramedics who are in and out of peoples homes on a regular basis. In the multi-cultural society we live

in today it is all too easy to cause offence by ignorance of another's beliefs and customs. The third part of the training programme would centre on the actual breaking of bad news. Many structured protocols for the breaking of bad news exist [44, 21, 8, 19, 20]. It would be of value to examine these in detail to see which would be the most applicable to the prehospital environment. One could then either be adopted wholesale or those parts of value taken from each, resulting in a 'hybrid' protocol specifically designed with prehospital care in mind. It would be valuable in the fourth and final part of the training programme to allow participants to put into practice what they have learnt. This could be achieved by role play exercises which have been found to be successful in other bereavement training programmes [20, 42, 21]. This would be of value to control staff as well as those working operationally, as it may result in a greater appreciation of the factors involved.

Conclusion There is currently no formal training within the ambulance service in the field of bereavement management and the breaking of bad news. By analysis of the literature it can be seen both ambulance staff and bereaved relatives would greatly benefit from such training. By the introduction of a formal training programme, staff would be given the resources to deal with such situations in a sensitive, informed and professional manner. This would minimise the risk of increasing the suffering of bereaved relatives and would hopefully leave them remembering the ambulance service and paramedics involved in a positive way. References 1. Parkes, C. Bereavement. Studies of Grief in Adult life. Third Edition. 1998. London. Penguin Books Ltd. continued on next page . . . 13

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Dealing with death and dying: a paramedic’s perspective 2. Watts C, Hall B. Loss Adjusters. Nursing Times. 1997 January 8, Vol. 93: No. 2. 3. Mian, P. Sudden Bereavement: Nursing Interventions in the Emergency Department. Critical Care Nurse, 1990; 10(1): 30-40. 4. Lundin, T. Long Term Outcome of Bereavement. British Journal of Psychiatry, 1984; 145, 424-28. 5. Anderson, M. Death in the Family: Newcastle Centre for Family Studies. 2003 Available from: ww.ncl.ac.uk/ncfs/ncfs/ document55.html [Accessed on 18.09.04]. 6. Gutstein, SE. Adolescent Suicide: The loss of Reconciliation. In: Living Beyond Loss: Death in the Family. Eds. F. Walsh & M. McGoldrick.1995.New York.Norton. 7. Rando, T. On Treating those Bereaved by Sudden Unanticipated Death. In: Session Psychotherapy in Practice. 1996. Vol. 2 (4): 59-71. 8. Spall, B, Callis, S. Loss. Bereavement and Grief. A Guide to Effective Caring. Cheltenham.1997. Stanley Thornes (Publishers) Ltd. 9. Ashdown, M. Sudden Death. Nursing Mirror.1985 October 30, 161: No.18. 10. Levetown, M. Breaking Bad News in the Emergency Department: When Seconds Count. Topics in Emergency Medicine. Jannuary/ March 2004; 26 No. 1: 35-43. 11. Wooley H, Stein A, Forest GC, Baum, JD. Imparting the Diagnosis of Life Threatening Illness in Children. British Medical Journal, 1989; 298: 1623-1626. 12. Wright, B. Sudden Death: Intervention Skills for the Caring Professions. Edinburgh. 1991. Churchill Livingstone. 13. Joint Royal Colleges Ambulance Liaison Committee. Pre-Hospital Guidelines. 2003. Warwick. University of Warwick. 14. Finlay I, Dallimore D. Your Child is Dead. British Medical Journal. 1991; 302: 1524-25. 15. Tye (1992) Qualified Nurses' Perceptions of the Needs of Suddenly Bereaved Family Members in the Accident and Emergency Department. Journal of Advanced Nursing. 1992; 18: 948956. 16. Faulkner A. Communication with Patients, Families and Other Professionals. In: Fallon, M and O'Neill, B (Eds). ABC of Palliative Care. London. 1998. BMJ Publishing Group. 17. Wilson, R. The Whirlpool of Grief. In: Good Grief: Exploring Feelings, Loss and Death with Over Elevens and Adults. Ed. B. Ward. 1993. London. Jessica Kingsley. 14

18. Yates D W, Ellison G, McGuinness, S. Care of the Suddenly Bereaved. British Medical Journal.1990: 301: 29-31. 19. Walsh N. Use Mnemonic 'FEARED' When Breaking Bad News – A Structure for Difficult Conversations. 2002. Available from: http://articles.findarticles. com/p/articles/mi-MOCYD/ is_16_37/ai_90792549 [Accessed on18.09.04]. 20. Iserson, K. Grave Words: Educational Models for Notifying Survivors after Sudden, Unexpected Deaths. Arizona. 1999. Galen Press Ltd. 21. Buckman R. How to Break Bad News: A Guide for Health Care Professionals. 1992. Toronto. University of Toronto Press. 22. McIntyre R. Breaking Bad News. 2003. Available from: www.show.scot.nhs.uk/crag/ TOPI.../BREAKING_ BAD_NEWS_WORKSHOP.HT [Accessed on18.09.04]. 23. Manvey C. Death in Residence. In: Last Things: Social Work with the Dying and Bereaved. Ed. T. Philpot. 1989. Wallington. Reed Business Publishing. 24. Haas, F (2003) Bereavement Care: Seeing the Body. Nursing Standard.2003; March 26, Vol. 17: No. 28. 25. Singh B, Raphael B. Post Disaster Morbidity of the Bereaved: A Possible Role for Preventative Psychiatry. The Journal of Nervous and Mental Disease. 1981; 169, 4: 203-212. 26. Cathcart, F (1998) Seeing the Body after Death. British Medical Journal. 1998; 297, 6655, 997-98. 27. Vanezis M, McGee A. Mediating Factors in the Grieving Process of the Suddenly Bereaved. British Journal of Nursing. 1999; 8, 14: 932-37. 28. Schilling R. No Room for Spectators. British Medical Journal. 1994; 309: 406. 29. Redley B, Hood K. Staff Attitudes towards Family Presence during Resuscitation. Accident & Emergency Nursing. 1996; 4, 145-51. 30. Martin J. Rethinking Traditional Thoughts. Journal of Emergency Nursing.1991; 17: 67-68. 31. Robinson SM, Mackenzie S. Psychological Effect of Witnessed Resuscitation and Bereavement Services. The Lancet. 1998; 352: 614-617. 32. Hanson C, Strawser D. Family Presence during CardioPulmonary Resuscitation: Foote Hospital ED Nine Year Perspective. Journal of Emergency Nursing. 1992; 18: 104-106.

33. Chinese University of Hong Kong. Communication in ICUBreaking Bad News. 2003. Available from: www.cuhk.edu.hk/ med/ans/Trainee%20Manual/ General%Management/ Communication% 20in%20ICU.pdf [Accessed on18.09.04]. 34. Davies B, Cook K, O'Loane M. Caring for Dying Children: Nurses' Experiences.Paediatric Nursing. 1996; 22: 500-7. 35. McMahon R, Pearson A. Nursing as Therapy. London. 1991. Chapman and Hall. 36. Burnard P, Chapman C. Professional and Ethical Issues in Nursing: The Code of Professional Conduct. 2nd Edition. 1993. Chichester. John Wiley. 37. Cook AS, Oltjenbruns KA. Dying and Grieving: Lifespan and Family Perspectives. New York. 1989. Holt, Rinehart and Winston. 38. Rando T. Grief, Dying and Death. Clinical Interventions for Caregivers. Illinois.1984. ResearchPress. 39. Saunders JM, Valente SM. Nurse's Grief. Cancer Nursing. 1994; 17: 318-325. 40. Cooke MW, Cooke HM, Glucksman EE. Management of Sudden Bereavement in the Accident and Emergency Department. BMJ. 1992; 304: 1207-9. 41. McGuinness S. Death Rites. Nursing Times. 1986; 82 (12): 2931. 42. Farrell M. Breaking Bad News. In: Shaw T & Sanders K (Eds). Foundation of Nursing Studies Dissemination Series. 2002, Vol. 1, No. 2. 43. Benner P. From Novice to Expert. Excellence and Power in Clinical Nursing Practice. Commemorative Edition. 2001. New Jersey. Prentice Hall. 44. Mueller P. Breaking Bad News to Patients. The SPIKES Approach can make this Difficult Task Easier. Post-graduate Medicine Online. 2002. Available from: www.postgradmed.com/issues/ 2002/09_02/editorial_sep.htm [Accessed on 18.09.04].







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