Supporting nurses through after-death care experiences
An article written by Jessie Rowe, Clinical Nurse Specialist, Royal Children’s Hospital, & Member, End-of-life Advisory Panel Member, Australian College of Critical Care Nurses (ACCCN); and Melissa J Bloomer, Professor in Critical Care Nursing, Griffith University, & Chair, End-of-Life Advisory Panel, ACCCN; on behalf of the entire End-of-Life Advisory Panel.
Critical care is known for its high-intensity, technologically complex and challenging environment focused on saving lives. In neonatal and paediatric intensive care units (NICUs and PICUs) especially, death may be seen as the enemy, disrupting typical assumptions that we die when we are old.
In developed countries, most paediatric deaths occur in NICU and PICU. End-of-life care has been acknowledged as a core component of nursing by researchers and policymakers. The Australian Commission on Safety and Quality in Health Care published guidance on paediatric end-of-life care. [1] Despite their guidance, little time is spent on educating and preparing nurses for end-of-life care and patient death. Like me, most nurses likely learnt about the provision of end-of-life care by being curious, role modelling the actions of others, learning from their mistakes and awkward moments.
End-of-life care is typically understood to include physical, spiritual and psychosocial assessment, and care and treatment delivered by health professionals and ancillary staff. Importantly, end-of-life care also includes support of families and carers, and care of the patient’s body after death. [1] As such, education and training opportunities may often focus on the clinical components of care, with little acknowledgement of the importance of, and practical aspects of caring for family and carers, or the care of self.
The Australian College of Critical Care Nurses (ACCCN) End-of-Life Advisory Panel, which is comprised of adult and paediatric critical care nurses and academic researchers, recently published an integrative review incorporating 32 primary research studies, providing unique insights into nurses’ experiences after death in NICUs and PICUs. [2] Three key themes came out of the review: postmortem care, caring for bereaved families, and nurses’ emotional response to the work. In relation to postmortem care, nurses cared about the child’s appearance and ensuring a peaceful and dignified scene, creating privacy and time for parents and family to say their goodbyes. Preparing the child’s body for the mortuary was one of the most difficult tasks.
Nurses’ connection or bond with bereaved families and sense of shared suffering were helpful to providing immediate grief and bereavement support. Anticipating cultural and religious needs and respecting beliefs, even when different to their own, was important to honouring personhood. The use of diaries and scrapbooks, and collection of mementos were described as ritualised acts intended to personify the child.
Perhaps unsurprisingly, there was evidence of nurses experiencing somatic responses, manifesting as headaches, weariness, exhaustion and high levels of stress. Some reported welcoming their emotional response to the death of a child or neonate as an expression of humility. For others, death of a child was obscure, confusing and incomprehensible, resulting in some nurses questioned the care they provided, feelings of shame, helplessness and guilt. In response, nurses described developing strategies to adapt psychologically, creating self-protective and emotional self-control mechanisms to aid their coping.
Whilst many acknowledged that organisation-led debriefing and counselling services were available via their employers, these were almost unanimously considered unhelpful, attributed to the fact that these experiences are not understood by outsiders. Despite home being considered a safe environment, support was rarely sought at home. Rather, colleagues were considered the most helpful source of support because of shared experiences.
In reflecting on my own practice as a clinical nurse specialist in a large paediatric teaching hospital, I am often reminded of the importance of referring nurses to the range of wellbeing services that are available. Given the findings of this review, perhaps it is time we give greater recognition to the preference and value of peer support, supported in policy, staffing, workforce models and education.
The work of our ACCCN End-of-Life Advisory Panel continues. Currently there are no practical, pragmatic practice recommendations to guide the provision of end-of-life care for children in critical care; a deficit we are working to address so that end-of-life care is optimised.
For further information on the work the ACCCN End-of-Life Advisory Panel, or any other questions please reach out to Melissa Bloomer.
References
- Australian Commission on Safety and Quality in Health Care. National Consensus Statement: Essential elements for safe and high-quality paediatric end-of-life care. Sydney: ACSQHC. 2016.
- Bloomer MJ, Brooks LA, Coventry A, Ranse K, Rowe J, Thomas S. "You need to be supported": An integrative review of nurses' experiences after death in neonatal and paediatric intensive care. Aust Crit Care. 2025;38(3):101149.
Credit for feet photo: Milla, Gavin Blue Heartfelt
Authors
Jessie Rowe (left)
Clinical Nurse Specialist, Royal Children's Hospital
Melissa J Bloomer (right)
Professor in Critical Care Nursing, Griffith University
End-of-life Advisory Panel Members, Australian College of Critical Care Nurses