Guiding the Process of Dying: The Personal Impact on Nurses

Dianne White, MS, RN; Mary Ann Meeker, DNS, RN, CHPN


Journal of Hospice and Palliative Nursing. 2019;21(5):390-396. 

In This Article

Abstract and Introduction


Some of the most ethically challenging and emotionally demanding aspects of nursing occur in caring for patients and their family at the end of life. The aims of this study were to examine the views of acute care nurses caring for patients during transition to comfort care, to describe the personal impact on nurses, and to identify nurses' strategies for self-support and development of competence. Using a qualitative descriptive approach, we analyzed data from 26 semistructured interviews. Nurses experienced moral distress in situations of continuing treatment when a cure was unlikely. In managing symptoms for patients, they struggled to foster an often-tenuous balance of patient comfort and calm without oversedation. They struggled to manage the competing demands of a workload including patients receiving curative care juxtaposed with those focused on comfort care. Nurses reflected on their fears as new nurses caring for end-of-life patients, the inadequacy of their preparation for this role, and their distress when the care provided felt inadequate to them. Nurses navigated challenges through support from nurse colleagues and effective leaders. They appealed to administrators to attend to care concerns arising from time-intensive nature of care. Mentoring and education facilitated assimilation to comfort-care nursing for novice nurses.


Some of the most ethically challenging and emotionally demanding aspects of nursing occur in caring for patients and their family members at the end of life. As they respond to patient and family suffering, nurses themselves are at risk of experiencing multiple forms of distress.[1] At the same time, nurses are central to the provision of excellent end-of-life (EOL) care.

As individuals and their families struggle with the challenge of making EOL decisions, nurses regularly find themselves embedded in a morally distressing process.[2] Moral distress is defined by Jameton[3] as a phenomenon in which one knows the right action to take but is constrained from taking it. Johnson-Coyle et al[4] reported that main sources of moral distress among intensive care unit health care professionals are related to controversies in EOL care and poor communication between health care providers and patients. Participating in EOL decision making and caring for dying patients are risk factors that lead to burnout syndrome in nurses.[5]

Nurses caring for patients at end of life have significant demands on their time as they provide physical and emotional care for the dying patient as well as emotional care for the family.[6] Strong nurse communication practices that establish trusting relationships with patients and loved ones facilitate conversation that informs EOL decision making.[2,7,8] Studies emphasize that it is important for nurses to provide families with support and validation when they have made difficult decisions.[2,7–9] Yet, the standard of care may not include the time required to provide increased attention to psychosocial and emotional issues seen with EOL decision making.[10]

Professional nurses often lack education and experience in the specialized knowledge and skills needed to provide quality palliative and EOL care, adding to their risk of distress.[8,11–13] Nurses have identified increasing EOL education as a suggestion to improve quality care to dying patients.[14]

Because the competence and well-being of nurses are crucial for good EOL care, we sought to understand their needs and perspectives. The purpose of this qualitative descriptive study of acute care nurses was to describe the personal impact on nurses of caring for dying patients as well as how they responded to and managed that impact.