Elżbieta Goździak writes about how working in Norwegian nursing homes has affected Polish nurses’ attitudes towards death and dying.

By Elżbieta Goździak

Death and dying aren’t popular topics of conversation. Instead of confronting our own mortality, many of us tend to table such talk as ‘morbid’ and try to stave it off as long as we can.

Nurses working in homes for the aged and the infirm confront death more often than the rest of us. Several of the Polish nurses I interviewed in the course of this project mentioned their first encounter with a dying patient when they started practicing nursing in Poland. Some also talked about the cross-cultural differences in caring for terminally ill patients back at home and in Norway. Still others shared how difficult it was to reconcile what they were taught or experienced in Poland with the attitudes in Norway.

Many factors affect attitudes towards death and dying. They include individual fears, a perceived threat to life or experiences with the dying of others, as well as the level of medical knowledge shaping the perception of our chances of delaying death. Cultural and religious factors that help to interpret death and give it a specific meaning also influence attitudes towards death and dying.

Changing attitudes towards death and dying

Attitudes towards death and dying change over time. In Poland, the issue of dying was taken up by doctors and humanists in the 1970s, when the Society for the Promotion of Secular Culture organized a conference entitled Man in the face of death.

Currently, palliative care is provided mainly to cancer patients, who constitute nearly 90 percent of hospice patients. Meanwhile, the WHO estimates that in Europe, cancer patients who need palliative care constitute only 39 percent of those who need palliative care.

Attitudes toward death and dying also change over the course of a lifetime. The nurses I interviewed mentioned how their attitudes towards death and dying, and even aging, changed when their own grandparents died or when their parents got older. Gosia told me: “I had patients in my care die, but I never really thought about death and dying until my granny got very, very old. I helped my mom take care of her, but only after she died, I thought about my own mortality and the way I would like to go.”

Cross-cultural perspective

In Poland, we celebrate the dead on All Saints Day when people visit cemeteries and light candles. Poles also take great care of the graves of their deceased throughout the year, bringing flowers and candles, but discussions about the end of life and associated decisions are rare in Polish households. People focus more on the type of burial they want to have, or what music should be played at the funeral mass.

While palliative medicine and palliative care were part of the nursing school curricula, especially for the younger nurses in our study, most were trained to “fight until the bitter end” and try to cure the patients in their care, said Emilia. When she was still working in Cracow, Polish healthcare law and clinical practice did not allow for formal advance directives. Thus, there were no legally guaranteed ways in which patients could influence their treatment choices in advance. “Medical personnel were obligated to offer life-sustaining therapy,” continued Emilia, “if there was even the slightest chance to increase a patient’s quality of life or prolong survival.”

“In the Polish model of care,” said Gosia, “the patient should not be made aware that she is dying. Everyone is trying not to arouse her suspicions that the disease may have more serious consequences than anticipated. For the patient’s benefit, plans focus on future effective therapies that will bring her relief soon, and any deterioration in health is interpreted as temporary.” “When I first started working in Norway, I was shocked,” said Alina, “that nurses talked about how to prepare their patients to die, when to tell them that they might want to say their goodbyes or take care of outstanding matters.”

Alina was accustomed to the doctor informing the patient’s family of the state of affairs, with the best intention of saving the dying fear and stress. In the medical literature, this approach is called ‘closed awareness,’ a context in which patients are not aware of their own impending death. In Norway, ‘open awareness’ of dying is much more accepted as a feature of palliative care. Emilia told me that in the nursing home she works the patients are fully aware of their diagnosis and prognosis as are the nurses who care for them.

The right to a dignified death

Nurses learn about the methods of coping with the death of a patient throughout their professional lives – they gain experience not only from schools and universities, but also from their own experiences and those of their colleagues. Grażyna told me that to her the most important issue is the awareness that she has done everything she could to help the sick person. “In the past,” she said, “I thought that my duty was to prolong my patients’ lives as long as I could. I still want to do that, but now I also think that a dying patient has the right to die in peace and dignity and if I can help them accomplish that, I am glad.”