Improving Care for the End of Life, Online Edition The Palliative Care Policy Center

Sourcebook : Improving Care for the End of Life : 11.7 Offer Employee Counseling and Education about Death and Dying

People who work in end-of-life care face experiences most other workers do not: Answering services receive late-night calls from families in crisis; nursing home receptionists answer calls from people who may not yet know that a loved one has died; data entry clerks key information about a patient's death. In each instance, the staff person faces, however briefly, a sense of loss.

Organizations whose staff work with seriously ill and dying patients must attend to the bereavement needs of staff, from direct care workers to medical records clerks. Teams can help staff by providing opportunities for them to reflect on their own beliefs and feelings about death and dying. Shared memorial services and sharing family expressions of gratitude also help.

As part of its new employee orientation program, the Palliative Care Center of the North Shore offers a session titled ``Personal Death Awareness.'' After completing a written exercise (an adapted version of which appears below), staff members meet in small groups to exchange thoughts and ideas. The program is designed to help employees understand and clarify their own ideas about the meaning of death and dying. Such awareness can promote empathy for patients and families and enable employees to be more effective in their work with dying patients.

Some programs hold occasional memorial services during which staff members can remember and acknowledge the lives of patients who have been in their care. In some communities, staff use this time to remember and honor their own loved ones who have died.

Other organizations offer grief and bereavement counseling to staff members; larger organizations may have half- or full-time staff dedicated to this position. In some cases, staff are referred to counselors and mental health professionals to work through personal issues.

Administrators need to be tuned in to how staff are doing and how they are coping with patient deaths or family needs. In some cases, administrators may notice a ``red flag'' that a problem is developing. One administrator explained that if a troubled family repeatedly calls on only one clinician to respond to its questions, or if a staff member becomes extremely attached to a patient, administrators will ask that the staff social worker speak to the employee. Professional boundaries offer some protection from exhaustion and burnout. Boundaries are often hard to maintain, and they still offer only partial protection. People working with very sick patients and families usually need some counseling from time to time.

Professionals and staff working in end of life need time and opportunity to recognize their own humanity, to consider their own mortality, and to integrate - and separate - their personal and professional lives.

Personal Death Awareness Exercises

The following exercises are intended to help you learn more about yourself and your feelings and beliefs about death and dying. The notes you make on these pages are for you alone, and you need not share them with others.

Set aside a quiet time and place to reflect on these exercises. Allow yourself to be reflective. You may need two or three hours to complete these exercises.

Exercise 1: Draw a straight line of any length with a beginning and an end. Consider this line to be your total life span. Place a slash mark at any point along the line where you think you are today in your life’s chronology.

Complete the following fill-in-the blanks statements:

I expect to live until age ____.
I am now ____.

When you compare your present age to the age at which you expect to die, how much of your life do you find you have already lived? Half? Two-thirds? One-quarter? Now look at the line you drew. How does your estimate of the time you have left to live on the lifespan line compare to your numerical estimate?

How did it feel to commit yourself to a definite lifespan? Some people worry that they may “jinx” themselves by doing this. Old superstitions rise up and haunt them. Does this concern you? Were you uncomfortable? If not, why do you think you felt comfortable doing this? Take a minute and answer these two questions.

Exercise 2: Complete the following statements.

The first death that I experienced was the death of __________.
I was __ years old.
At that time, I felt:
I was most curious about:
The things that frightened me most were:
The feelings that I have now as I remember that death are:
The most intriguing thing about the funeral was:
I was most scared at the funeral by:
The first personal acquaintance of my own age who died was:
I remember thinking:
The death of ____________ has been the most significant for me. It was significant because:
The most recent death I experienced was when _____________________________died ____ years ago.
The most traumatic death I ever experienced was:
At age __________, I personally came close to death when:
Exercise 3: Do you view death as a beginning or an end? Do you mourn or celebrate death or do both? Do you have tradition and ritual to serve you in the dying process? Are feelings about death universal or are they unique to individuals and cultures?

Adapted with permission of the Palliative Care Center of the North Shore, Evanston, IL.

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].

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