Reflections on Death and Dying: The Artistry of Nursing at Life's End

Abstract

Like most nurses, over the decades of my career, I have shared in the last weeks, days, hours and moments of many people. As a nurse, I have witnessed many faces of death—death that comes with sudden, brutal finality, death that slowly stalks, its threat omnipresent, death that is fiercely resisted and death where a person slowly retreats from life, slipping quietly into a realm where sleep dominates and even waking moments are imbued with an ethereal, otherworldly quality.

As a young student nurse aged only 16 years, I can recall being sent to sit with people who were dying, people who had no one else to sit with them at their end of life. There were many shifts as a studentwhen I would sit for hours at the bedside of a person in their last days, just being present, holding their hand, and, where they could speak, listening and responding as they shared memories of their lives.

Later in my career, as a paediatric nurse, some moments particularly stand out. One night shift, I spent the entire night specialling an infant, silently watching as this tiny, fragile life struggled with each breath. The memory of that night, the quiet vigil and the fight for life in those small, laboured breaths remains with me always. Strong in my memory is the young teenager with whom I spent the final days and hours of her life. Even as death approached, her concern remained steadfastly for the welfare of her mother and what would become of her when she had gone. This strong, precious girl waited, holding on until she knew her mother was safe and cared for and not alone, before taking her last breath.

There have been moments over my career that have etched themselves deeply into my heart and mind—being made a godmother at deathbed baptisms, and one unforgettable instance many years ago, when, in the absence of a priest and in the quiet of the night, I found myself blessing a dying infant. All these years later, I can still hear the voice of the priest on the phone, urgently reciting the words I was to say as I made the symbol of the cross. I remember my hands trembling as I performed the sacred rite, knowing this tiny life was slipping away, and that in the final moments of life, this infant was utterly and wholly dependent on nurses and medical staff for human connectedness, spiritual care and comfort.

Each person I have accompanied in their final hours has left an indelible mark on me. Walking alongside them, I have been profoundly touched, emerging from each experience with a deep sense of profundity, privilege and reflection. These encounters have shaped my understanding of life and revealed the strength, fragility and poignancy of our human existence.

Though not everyone has family or loved ones with them at the end of life, witnessing death means not only bearing witness to the passage from this life but also to the intricacies of family dynamics. In these situations, as a nurse, I aimed to be unobtrusive, slipping quietly in and out of the room as needed, yet always letting family members know I was available for support and comfort. My goal was to be present when needed, to offer support and comfort, without being intrusive or disturbing to the family and loved ones in the sacred space of farewell.

As a nurse, I have witnessed a wide range of responses and reactions from family members. I observed their varied responses with a heart that felt deeply, resonating with their pain, their sorrow and their love. There were some shifts when the weight of their grief hung heavy in the air, seeping into my own heart and there were many times I went home from work emotionally drained, filled with sadness and grief and deeply empathetic for the pain and sorrow of the families and loved ones with whom I was sharing space.

So, while not a stranger to death and reasonably well acquainted with the inevitability of mortality and the profound emotional burden it imposes on loved ones, becoming a companion for a loved person with a very limited time left on this earth has provided me with a deeper and transformative understanding of the nuances of the end-of-life journey. In reflecting on this profound and emotive life experience, I acknowledge that I was lucky to have been able to spend this time with the person I loved so deeply. Many people do die suddenly and violently, without the opportunity to be with those they love.

This situation unfolded over a period of many weeks after an acute illness. However, as the weeks turned to months and there was no real improvement, it became clear that this person was moving towards the end of her life. I felt so grateful to have the time with her and treasured the time we shared together, and there was a heightened awareness that this time was now finite. Mercifully, she was comfortable, not experiencing pain and she spent more and more time sleeping. I spent many hours just being present, simply being there. Often sitting in silence, sometimes in more wakeful periods, talking, in short conversations, sharing fragments of memories—memories of the seemingly mundane, of the prosaic, the everyday, little glimpses and snapshots of lives lived and memories shared. One day I asked her what she was thinking of as she dozed and dreamed—she told me she was thinking about her earlier life and the good times we had all been through together. There were moments when one of her memories made her smile, and even laugh, and though she was so weak, I could still see flashes of her life force and spirit as she shared her thoughts and snippets of her memories. I remember feeling overwhelmed with love for her and with gratitude that I could be there with her.

And each day as she grew weaker and literally faded before my eyes, her life force diminished. Looking at her, I could see her vulnerability and her utter dependence on those around her to care for her. It was hard to see her so small and so faded, so much weight lost, no longer interested in eating—only taking small sips of fluid. The emotions were overwhelming and exhausting. Yet there is nowhere I would rather have been, and I had an awareness that these moments we shared would live with me forever.

As the days passed, the periods of wakefulness were shorter and less frequent. There was less interaction and less response. So, I focussed on forging human connectedness through touch—gentle, loving touch, holding hands, brushing her hair, rubbing moisturiser into her skin as she dozed. Hoping she could feel the love, hoping she felt connected and not alone. I would feel her hand going limp in mine as she dozed and dreamed. Then, as she woke, her hand gripping mine again. I asked her how she felt and her telling me she felt so very tired—like she had run a marathon. And in many ways, she had.

As she lay there, nearing the end, I held her hand and thanked her for everything she had given me, for shaping my life and my values. I told her how grateful I was to have her in my life, how deeply I loved her and how much her love had built the foundation of my happiness. Her voice was weak but filled with love, and she said she was glad I had a good life—and that she loved me too. I tried to hold back my tears, but they came anyway, streaming silently as I struggled to stay strong for her. Sensing my sadness, she asked, in her gentle way, if I was alright and my heart broke all over again.

All the while throughout these moments, there was awareness of the nurses coming into the room, attending to her, interacting with us, displaying kindness and attentiveness, working with skill and being present with us through this long goodbye. Through their actions and their very presence, they let us know they were there for her and they were there for us too. Little things—a hand on the shoulder, the offer of a cup of tea, in so many ways letting us know they were there if needed. Having been ‘the nurse’ so many times, and now being ‘the family’, I was so grateful for the nurses, for their expertise and for the care and the empathy they showed. I watched them working efficiently, with skill and compassion. They had a lot to do, and did it in an unhurried way, spending the time that was needed to do things well, taking the time to be gentle and avoid causing pain or distress. And taking the time to make sure we were OK too.

There is real artistry in nursing work. I saw this in the ways that the nurses did what needed to be done and did it in ways that fostered and nurtured human connectedness and genuine human caring. It could be seen in the ways that nurses synthesised the multiple and complex needs of our whole family, sometimes seeing and recognising needs we did not even know we had and then set about trying to anticipate and address those needs.

As nurses, we inevitably confront death in our work. Despite advancements in technology, the human touch and caring presence that nurses offer at the end of life remain irreplaceable. It is perhaps the most poignant aspect of our work. While it can be emotionally challenging and taxing, these moments we share with those who are dying and their loved ones are also so precious.

It is in these moments of life and death that nurses go beyond the performance of clinical skills and respond wholistically to the uniqueness of every person's situation, to tailor nursing actions and interventions to best meet the needs of the particular person and family they are supporting and to convey caring and compassion to those who are suffering. Sharing these experiences help to shape us as people and as nurses, and I know, from experience, that the caring actions shown by nurses become cherished memories and sources of comfort for those having to say farewell to those they love.

The experience of witnessing death, whether as a nurse or a family member, leaves an indelible imprint on our hearts and minds. Because in addition to what we encounter as nurses, we also confront death in the many other roles we have in our lives—in our roles as mothers, fathers, sisters, brothers, sons, daughters, aunts, uncles, partners and friends. Perhaps it is when we encounter death in our personal lives that we truly come to see and appreciate the absolute importance of skilled nursing presence at the end of life. Nursing at the end of life goes far beyond the performance of clinical tasks and technical competence—it encompasses the profound acts of being present—of offering comfort, working with empathy and nurturing human connectedness in the face of imminent mortality. This skilled and wholistic form of presence reflects the core of what it means to care deeply for others and underscores the irreplaceable artistry of nursing.