Dying with Dignity

Contact Hours: 2.5

This online independent study activity is credited for 2.5 contact hours at completion.

Course Purpose

To provide healthcare professionals with knowledge on dignity, how it is affected by death anxiety and spirituality, and to review patient-centered care for the terminally ill patient.

Overview

Human dignity is the core of nursing. It manifests when a nurse respects a patient when providing care. The nurse must provide care to the dying patient and their family members that conforms with cultural beliefs and habits. Because death is an unavoidable phenomenon that everyone will experience regardless of health care that is provided, human dignity with respect to end-of-life care must be appreciated. Helping terminally ill patients and their families manage decisions regarding death is a central responsibility of nursing, and it is essential that nurses be given better tools with which to deliver spiritual care. The nurse must provide dignified, spiritually astute (outside of the religious realm), comprehensive care to the dying patient to allow death with dignity to occur.

Objectives

Upon completion of the course, the learner will be able to:

• Define human dignity as it relates to the dying patient
• Describe attributing factors to death anxiety, and ways to assist the patient and supporters in mediating the effects.
• Review the six attributes to spirituality, and how they influence the patient’s and supporter’s perceptions of death.
• Review the American Nurse Association Code of Ethics stance on assisted suicide.

Policy Statement

This activity has been planned and implemented in accordance with the policies of FastCEForLess.com. If you want to review our policy, click here.

Disclosures

Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support.

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Dignity is a human right and it is a core nursing value. Death is inevitable, and it is something that we all will eventually experience. For the terminally ill, the realization of a drastically reduced life span can bring about death anxiety. Death anxiety, which is described as concerns and fears related to the process of death and dying, and lack of spirituality are the main factors that can cause a loss of dignity. ¹ This course seeks to define dignity and death anxiety and recognize attributes of spirituality to better prepare the healthcare professional to care for the terminally ill patient.

Dignity is derived from the Latin word dignities, which means originality and value. ⁴ Familial and cultural aspects are involved with the formation of dignity, which is synonymous with vocation, goal, and value. There are two types of dignity⁷: social dignity and human dignity. Human dignity is an independent concept that cannot be compared or measured, as it is an intrinsic personal value of an individual. Social dignity is a part of human dignity, but is situation dependent, awardable, comparable, and acquirable through social interactions. There are also four aspects of dignity⁷: dignity as merit, dignity as moral stature, dignity of identity and dignity of Menschenwurde.

• Dignity as merit relies on the position and social status of the individual. • Dignity as moral stature relies on the thoughts and actions of the individual and is composed of self-respect and respect for others. • Dignity of identity relies on self-image and the respect for mind and body and is created by present and future social interactions with others. • Dignity of Menschenwurde relies on the need to belong. This aspect of dignity is related to human rights without consideration of social position, race, and gender.

Human dignity is the core of caregiving, and in 1998 the Nurse Association of America identified human dignity as one of the five core nursing values. Human dignity manifests when a nurse respects a patient when providing care, and some scholars believe that maintaining dignity while providing care to the terminally ill can be more important than the patient’s failing health. Death is an unavoidable phenomenon that all humans must experience regardless of health care that is provided, and as such, human dignity with respect to end-of-life care must be appreciated.³ Providing care for the dying patient and their family that conforms to cultural beliefs and habits is one of the professional roles of the nurse. The nurse must provide culturally competent, comprehensive care to the dying patient to allow death with dignity to occur. Maintaining dignity in the final moments of life is important, and the nurse must respect the healthcare choices and decisions of the terminally ill patient. As the end of life nears, the patient and family can be exposed to high levels of stress.

Death anxiety; concerns and fears related to the process of death and dying, is one of the main factors that can cause a loss of dignity and is also a major reason why terminally ill patients request euthanasia and assisted suicide. Death anxiety is a disorder that causes extreme levels of preoccupancy with death or death related situations that can disrupt normal life activities. Although helping terminally ill patients and their family members manage death is a central responsibility of nursing worldwide, and an increasing body of literature suggests that death anxiety contributes to important emotional and behavioral outcomes, theoretical and empirical background of the concept is limited in nursing literature. An extensive online literature search on death anxiety was conducted and found that using the evolutionary method of concept analysis was most beneficial in describing death anxiety. Rogers inductive method of concept analysis involves identifying the concept of interest and related terms, selecting a relevant setting and sample for the data collection, collecting data related to concept attributes and contextual base, analyzing the data and identifying the concept exemplar, and finally developing implications and hypotheses for further concept development. Use of the Rodgers approach is well suited for the concept of death anxiety because it is context dependent and may be interpretable.

A review using Roger’s Method⁶ found six attributes of death anxiety which include:

When death anxiety is aroused, it can become harmful to terminally ill patients and family members.⁹ Initially, the terminally ill patient and/or family members may respond positively to a terminal diagnosis by fully embracing life, but over time many will retreat to a more defensive thought process where they try to protect themselves and as a result lose prospective on life quality, instead focusing on insignificant issues in their lives and squandering valuable experiences. Defensive reactions to death are demoralizing and can cause cynicism, hateful attitudes, and depression. Defensive reactions include but are not limited to⁹:

Because death is not preventable, when fears surface the terminally ill patient and family members should take time to face the reality of identity and mortality. They should be allowed to express their emotions on fear, sadness, and anger. As a healthcare provider, the nurse should also assist the patient and family members to communicate their thoughts and feelings while maintaining cultural beliefs and respecting dignity. Nurses must be able to provide end-of-life care for patients from various cultural backgrounds because consideration of culture in caring for dying patients not only provides them with a death with dignity, but also can create spiritual peace and hope for the patient.

Having the ability to define spirituality in a way that is congruent for most people is crucial to end-of-life research. Unfortunately, a common definition of spirituality has not been achieved. A recent literature review attempted to define spirituality through a framework consisting of its most common attributes. By reducing spirituality to common attributes, patients, researchers, and healthcare providers can describe spirituality according to each attribute individually, which taken together can form a more comprehensive view of spirituality.³ Literature review findings revealed that spirituality within the context of attributes was prevalent to the terminally ill and family members.

The following were identified as spiritual attributes:

Spirituality is an important part of one’s day-to-day experiences. The five spiritual attributes can frame the essence of spirituality. Framing spirituality according to common attributes that can be discussed individually offers one creative way of reducing the complexity of spirituality into manageable increments, which can greatly improve the delivery of spiritual care.

Suicide consideration in the general population is often treated as a symptom of mental illness. Assisted suicide as a reasonable choice for the terminally ill however, is a subject of ongoing debate. Although legal and policy descriptions vary by state, nurses continue to care for patients who express the desire to die. Nurses who accept that assisted suicide can be a rational act must take great care that requests do not arise from depression or from another mental disorder that might be alleviated by treatment and alter one’s desire for a hastened death. Careful assessment of mental functioning when a patient expresses a desire to die is essential. Oregon law, which allows a physician to assist a patient in dying, requires a physician to examine a patient if he/she believes a mental disorder is influencing the patient’s decision, and then a referral must be made for patient evaluation. ²

Clinical assessment of the terminally ill patient’s mental state following a request for assistance in dying resembles the assessment of suicide risk in depression, which includes patient demographics and health characteristics, observation of the patient’s behavior, reports from family members and people close to the patient, and an assessment of symptoms. Like the suicide risk assessment, the clinical assessment also relies heavily on the patient’s self-report of feelings and intentions. Death itself is often not the primary goal, but it is perceived as the only way to end psychological or physical suffering. Uncovering whatever mixed feelings, a terminally ill patient might have about wishing for assistance in dying can help the nurse identify and explore other ways of addressing the problem the patient is trying to eliminate.

There are many arguments for and against assisted suicide. The main justification for assisted suicide is that the terminally ill patient is considered rational in concluding that death is the only way to achieve a reasonable goal. ⁶ Respect for patient autonomy and the prevention of unnecessary, unwanted suffering are the two main justifications identified in the literature for allowing assisted suicide to occur. The main argument against assisted suicide is the sacredness of life and the injustice in deliberately ending it. Likewise, saving and improving lives are among the core values of health care, and health care professionals are morally bound to the preservation of life. Many argue that health care providers should not assist in deliberately bringing about a death. Five states (California, Colorado, Oregon, Vermont, and Washington) and Washington, DC currently have laws allowing physician assisted suicide, while 37 states have laws prohibiting assisted suicide. When confronted with a request for assisted suicide from a patient, nurses must formulate a plan of care regardless of whether assisted suicide is legal in their state. The nurse must make an overall assessment which includes the patient’s mental condition and social supports, as well as physical condition and prognosis. Nurses must also be careful to consider the patient’s cultural background and spiritual beliefs since all faith traditions consider the passage from life to death a critically meaningful process.

While nurses continue to create and carry out care plans for patients, from an ethical perspective it remains unclear what role assisted suicide should play in a plan of care. The American Nurses Association (ANA) however, takes the position that participation in assisted suicide is a direct violation of the ANA Code of Ethics. The American Medical Association holds a similar position, while the American Public Health Association supports the terminally ill patient’s right to request and receive support from healthcare providers in pursuit of assisted suicide in states where it is legal.

The ANA position statements on Euthanasia, Assisted Suicide, and Aid in Dying acknowledges that some nurses work in states where assisted suicide is legal, and states that nurses ‘can choose to be involved in providing care to a patient who has made the choice to end his/her life or may decline to participate based on personal moral values and beliefs.’ ⁸For nurses who decline to participate, the ANA position statement refers to the Oregon Nurses Association guidelines, which state that the nurse can ‘conscientiously object to being involved in delivering care , but the nurse is obliged to provide for the patient’s safety, to avoid abandonment and withdraw only when assured that alternative sources of care are available to the patient.’ ANA guidance is clear that even where assisted suicide is legal, individual nurses can opt out of involvement based on personal conscience, so long as the patient’s needs are accommodated through referral.

Care coordination is the organization of events that center around the patient. It involves all healthcare providers involved with a patient’s plan of care to accomplish safe and effective outcomes. A nurse’s coordinated approach to patient care supports patient-centered care as the patient transitions between different settings, such as the transition to hospice where palliative care; the compassionate and comprehensive practice of alleviating suffering from physical, psychosocial, and spiritual symptoms for terminally ill patients and their family members occurs.

Confronting death and the anxiety created by knowledge that it is inevitable is a universal psychological quandary for everyone. For health care providers, death is an ever-present reality despite increases in technologically advanced health systems, longer patient survival rates, and cures from life-threatening diagnoses. Helping terminally ill patients and their families manage death is a central responsibility of nursing worldwide and it is essential that nurses be given better tools with which to deliver spiritual care. Framing spirituality according to common attributes that can be described individually offers one creative way of reducing the complexity of spirituality into manageable increments, which could greatly enhance delivery of spiritual care.

Dying with dignity is an important aspect of clinical practice and nursing care. Caregiving is the basis of the nursing occupation and is a very general concept and encompasses all aspects of patient care, especially maintaining the dignity of the patient at the end of life. Dying with dignity has a positive impact on the reduction of fear and psychological distress in terminally ill patient and their family members, and respecting the dignity of the patient through spirituality, and with the use of pain control, relaxation, and creating a sense of peace results in the reduction of the terminally ill patient’s suffering and prepares them for a comfortable, peaceful death. Based on this positive impact, the clinical aspects of patient dignity at the end of life in conjunction with cultural beliefs should be practiced by all healthcare providers who provide care to the terminally ill patient.

• An, E., Lo, C., Hales, S., Zimmermann, C., & Rodin, G. (2018). Demoralization and death anxiety in advanced cancer. Psycho-Oncology, 27(11), 2566-2572. doi:10.1002/pon.4843
• Firestone, R. W. (2018, May 18). Death anxiety. Retrieved from https://www.psychologytoday.com/us/blog/the-human-experience/201805/death-anxiety
• Gerber, L. (2018). Understanding the nurse’s role as a patient advocate. Nursing, 48(4), 55-58. doi:10.1097/01.nurse.0000531007.02224.65
• Hamric, A. B., Schwarz, J. K., Cohen, L., & Mahon, M. (2018). Assisted Suicide/Aid in Dying. AJN, American Journal of Nursing, 118(5), 50-59. doi:10.1097/01.naj.0000532831.78142.40
• Hemati, Z., Ashouri, E., AllahBakhshian, M., Pourfarzad, Z., Shirani, F., Safazadeh, S., … Ziyaei, M. (2016). Dignity and Assisted Dying. Journal of Clinical Nursing, 25, 1218-1228. doi:10.1111/jocn.13143
• Lau, B. H., Wong, D. F., Fung, Y. L., Zhou, J., Chan, C. L., & Chow, A. Y. (2018). Facing death alone or together? Investigating the intgerdependence of death anxiety, dysfunctional attitudes, and quality of life in patient-caregiver dyads confronting lung cancer. Psycho-Oncology, 27, 2045-2051. doi:10.1002/pon4773
• Scott, P. A. (2017). Key Concepts and Issues in Nursing Ethics. Basingstoke, England: Springer.
• Snyder Sulmasy, L., & Mueller, P. S. (2017). Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper. Annals of Internal Medicine, 167(8), 576. doi:10.7326/m17-0938
• Solomon, S., Greenberg, J., & Pyszczynski, T. (2015). The Worm at the Core: On the Role of Death in Life. New York, NY: Random House.
• Tong, E., Deckert, A., Gani, N., Nissim, R., Rydall, A., Hales, S., … Lo, C. (2016). The meaning of self-reported death anxiety in advanced cancer. Palliative Medicine, 30(8), 772-779. doi:10.1177/0269216316628780
• Ulrich, C. M., & S., L. (2018). Nurses’ Role in Assisted Suicide/Aid in Dying. AJN, American Journal of Nursing, 118(9), 10. doi:10.1097/01.naj.0000544953.52249.c6
• Vogelstein, E. (2017). Evaluating the American Nurses Association’s arguments against nurse participation in assisted suicide. Nursing Ethics, 26(1), 124-133. doi:10.1177/0969733017694619

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FAQs

What does the Dying with Dignity nursing CEU cover?

This 2.5-contact-hour online nursing CEU covers end-of-life patient dignity, death anxiety, hospice spirituality, and the ANA Code of Ethics on euthanasia. Enroll at Fast CE For Less to earn your palliative care CE credit instantly.

What is death anxiety in terminally ill patients?

Death anxiety is intense fear about the dying process that can trigger loss of dignity and requests for assisted dying. This nursing CEU teaches six clinical death anxiety attributes to improve your end-of-life psychosocial care skills.

What are the two types of human dignity nurses must understand?

Human dignity is an intrinsic personal value, while social dignity is situational and context-dependent. This palliative care nursing course shows how both types guide dignified terminal patient care.

What defensive reactions to death anxiety should nurses recognize?

Dying patients may show denial, substance use, social withdrawal, vanity, or “micro-suicide” — gradual disengagement from life. This Fast CE For Less hospice nursing CEU teaches early intervention strategies for each reaction.

What is the ANA’s stance on nurse participation in assisted suicide?

The ANA Code of Ethics classifies nurse participation in assisted suicide as a professional ethics violation, though conscientious objection is permitted where it is legal. This end-of-life nursing CEU walks through both the ethical framework and the nurse’s legal obligations.

What five spirituality attributes shape end-of-life nursing care?

Beliefs, connections, meaning, values, and self-transcendence each influence how terminally ill patients experience and process dying. This 2.5-hour nursing continuing education course teaches nurses to integrate all five into spiritually aware palliative care.

How does cultural competency apply to dying with dignity?

A patient’s cultural background shapes their death rituals, family roles, and pain management preferences — all essential to dignified dying. This CE course at Fast CE For Less equips nurses to deliver culturally competent terminal care across diverse patient populations.

Who should take this Dying with Dignity nursing CEU?

Hospice, palliative care, oncology, and geriatric nurses benefit most from this end-of-life continuing education course. It awards 2.5 contact hours, is accepted in 40+ states, and issues an instant CE certificate at Fast CE For Less.