If death is the ultimate healing, is it also the threshold for terminating patient care? It might seem an obvious conclusion, until the topic of attending a deceased patient's wake, shivah, funeral or memorial service is raised. Then the edges to continuum of care are blurred.
A review of literature about the pros and cons of attending post-mortem services for patients reveals that little has been written on the topic. A 2013 research project conducted at a children's hospital in Brisbane, Australia, sought to develop guidelines for staff attendance at patient funerals. (A pictorial presentation is available at www.anzchog2013.org/files/pdf/Cherie-Lowe-Staff-Attendance-at-Patient-Funerals_31-may.pdf.)
The research noted that patients' families appreciate such acts of kindness, believing they alleviate feelings of isolation and validate their deceased loved ones. Providers who participated in the research said attending a wake or funeral allowed them to process their own emotional response to the loss of a patient and helped them manage "the emotional sequelae of nursing practice."
Yet the practice is not globally accepted. When a question was posted on a 2012 online nursing forum asking if going to patients' funerals might be deemed "unprofessional," one British respondent said: "In the UK it is considered absolutely inappropriate to attend a patient's funeral. We are supposed to remain professional at all times and once the patient has left the building, that's it; no further contact with the family is allowed ."
Some Do, Some Don't
In the United States, there is no stigma of unprofessionalism attached to attending services for deceased patients. When Nurse Practitioner Perspective canvassed a cross-section of nurse practitioners, most said they approve of the practice although not all participate.
Vanessa Pomarico-Denino, MSN, FNP-BC, is interim director of the family nurse practitioner track at Southern Connecticut State University in New Haven and practices at Medical Associates of North Haven. She often attends wakes/funerals and noted that ". there is no prevailing thought on the topic that I know of. However, I do integrate discussion of this issue into my chronic care classes at the university. I also share my feelings with students I precept so they understand that the death of a patient is difficult on providers as well."
Pomarico-Denino added that attending a wake or funeral may be influenced by a provider's own cultural belief system. "As Roman Catholic Italians, my parents ingrained in me that while these events are never easy, they are necessary to show respect."
Barbara Resnick, PhD, CRNP, is a professor at the University of Maryland whose clinical practice is in a continuing care community. She said, ". in our world of geriatrics, I could go to a funeral every day. It would be hard to draw the line between which patients' funerals you attend and which you do not." She prefers, instead, to send a personal note to a grieving family. And while she respects the right of other NPs to follow their own dictates, she reminded, "We are advanced practice nurses; helping the family after the death is not really our role - that's not necessarily our expertise, nor do I think we should step in.
"In geriatrics, death is a celebration; it's not a negative word in our world. The gift we give the patient and family is to help them through the process of dying. By the time you've gone through that, going to the funeral is a moot point," Resnick said.
Similarly, KC Arnold, ANP, MSN, owner of The Diabetes Center in Ocean Springs, Miss., said she typically does not attend patient funerals, except on a rare occasion when she has a personal connection to the patient. That is not to say she does not extend condolences. "If a patient from our clinic has died, we call the family and send a card," Arnold said. "We designate the chart 'deceased' immediately so that we do not accidentally call the patient's family in error."
Arnold said she sees no harm in NPs attending funerals, but noted there could be a an emotional toll when having to report right back to work.
Kristene Diggins, DNP, DCC, of Charlotte, N.C., is a gerontologic NP who is an adjunct faculty member for Kaplan University and the MSN program at Liberty University. She has only attended two funerals in the last 8 years, and said the decision about whether or not to attend should be based on ". if it will help the healing process - for both the NP and the patient's family. Sometimes the NP needs that closure having followed a patient for a long time, but it might not be a healing process for the family to see you there. Be sure you are invited."
Beyond acknowledging respect for individual patients, attending funerals could lead to a broader acknowledgement, Diggins said. "As nurses we are nurturers by nature, and somewhere along the way we may lose touch with our humanity in order to survive all the suffering we have to see. Attending funerals may help us to close the loop and get back in touch with our humanity."
She recalled one patient who had been diagnosed with breast cancer at an early age. Diggins cared her for through 3 years of chemotherapy and surgery, followed by 6 months of palliative care. "When she died, the family invited me to the funeral and I knew I had to go for my own healing. My peers advised against it, believing it would leave my wounds open and make me unable to get back into the swing of proactive care. But I needed to be self-aware of my grief to evolve in what I do. Instead of feeling defeated, I felt this person's life journey had been completed. There is an honor in funerals; you have been with this person in battle, and there is a certain victory in helping them successfully reach that threshold of death."
Wendy Wright, APRN, FAANP, owns primary care clinics in Amherst and Concord, N.H., where she and her colleagues attend many funerals. In fact, she believes it is exactly this kind of caring that sets NPs apart from other providers. "As a primary care practitioner, I have been with many of these families when babies were born," Wright said, "and I think it is just as important that I be there when they lose a loved one."
Wright contends that this after-death extension of care is part of the holistic ideal of nursing. "Is it difficult sometimes?" she asked rhetorically. "Sure it is. But that's our work - it is often difficult; that's the nature of the beast. But patients choose NPs for a reason - they want a certain level and style of care. And ultimately, everyone wants to know that their family member was loved."
Marcia Kesner, APRN, FNPC, owner of Spring Valley Care in Springfield, W. Va., agreed, saying attending funerals is one more way to personalize care for members of the small community that has embraced her practice.
"Many patients are searching for care providers who aren't afraid to be on a personal level with them while professionally taking care of them. Going to funerals allows us to appropriately show our feelings," Kesner said, adding that such integration into a community ultimately improves the level of care. "These patients aren't just patients . they aren't just numbers. I take an interest in their lives, their heath, their well-being and their families. When they lose someone, I am in mourning too. I wouldn't be in healthcare if I didn't care this much."
Continuum of Life
Joseph Mazza, an NP at MJHS Hospice and Palliative, one of the largest hospice and palliative care programs in New York State, has had experience with inpatient, outpatient, wound and nursing care. He also created an inpatient hospice center inside a nursing home.
"As a hospice NP, I've attended a lot of funerals," Mazza said. "It's not part of the job, but still it is part of what I do." When training NPs for hospice work, Mazza teaches that within hospice care, "It's a lot more about the family than it is the patient. Often patients come to hospice late in the disease process and they don't have much time. We can just make them comfortable. But the family, they really need you there. And that carries through right after a death. We must be careful not to cross a border into psychiatric care or therapy, but offering support is important."
Mazza noted that in advanced practice nursing, relationships with patients can extend over decades; patients can become extended family. "When those individuals die, the loss can hit a provider hard. We're human beings, and deaths affect us," Mazza said. "Going to a funeral does help to give closure."
Margaret Fitzgerald, DNP, FNP-BBC, NP-C, FAANP, CSP, FAAN, DCC, president of Fitzgerald Health Education Associates, believes this after-death extension of care is more than a nice gesture. "To me, this is part of our social contract with patients," she said.
Fitzgerald recalled a funeral that followed the death of a long-term yet young patient who had cancer. Fitzgerald was the last person the patient had acknowledged and reacted to before dying.
"To be able to tell her family how comfortable, peaceful and well-cared for she was gave them a tremendous sense of peace," Fitzgerald said. "It also helped me to be able to close this page in our relationship.
"Often healthcare providers get into the mindset that death is always the enemy. But there's one truth: If you were born, there is a 100% chance you will die. It's that continuum of life we need to acknowledge; we have to honor the beginning, the ending, and everything in between."
Valerie Neff Newitt is a staff writer. Contact: firstname.lastname@example.org