Coping with Death: Perceptions of Health Care Professionals Working ...

10.1177/1054137303256534 ILLNESS, Ulla ARTICLE et al. / CRISIS COPING & LOSS WITH (October DEATH2003)

Theory & Research

Coping with Death: Perceptions of Health Care Professionals Working in a Pediatric Intensive Care Unit and in a Geriatric Service Sara Ulla Universidad de Castilla–La Mancha

Cristina Coca Carolina del Rincón José L. Díaz University Hospital La Paz Madrid

Eduardo A. Remor Universidad Autónoma de Madrid

Pilar Arranz University Hospital La Paz Madrid

Ramón Bayés Universidad Autónoma de Barcelona Many health care professionals have to deal regularly with their patients’ deaths and relatives’ bereavement, but frequently they have not been trained in this area, and therefore the psychological cost is very high. The authors’ principal aim in this work is to describe health care professionals’ perceptions about death. A group of health care professionals who worked with children was compared with a group who worked with elderly people. Results showed that emotional aspects were perceived as more important than biomedical aspects in the death process. Between the groups, some differences were detected relating to the perception of the proximity of members’ own deaths, and the authors could also observe that the death of a loved one was perceived as more important than their own death. These results

Address correspondence to [email protected]. Illness, Crisis & Loss, Vol. 11, No. 4, October 2003 318-336 DOI: 10.1177/1054137303256534 © 2003 Sage Publications

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should be taken into account to design training programs for health care professionals to minimize psychological costs and increase the quality of care. Keywords: coping; death-related perceptions; health care professionals; bereavement

During the past century in the developed world, several healthrelated advances have been achieved. Improvements in medical procedures, progresses in technology, and better quality of life conditions have lead to an increase in life expectancy. At the turn of nineteenth century, life expectancy did not surpass 35 years of age, and in the present day, it has reached 77 years (Eurostat 2001). The main function of medicine is not to provide the human immortality but to offer a higher quality of life (Carné 1993), and, therefore, the main objective of health assistance is to maximize patients’ well-being (Bayés 2000; Rodríguez-Marín 1994). Taking this into consideration, and bearing in mind end-of-life, the traditional health care paradigm has changed from “there is nothing else we can do” to “there is so much more that we are able to do.” As David Callahan has pointed out (2000), for the medicine of the twenty-first century, helping a patient to have a peaceful death is as important as averting death. Especially relevant in this direction are the health care professionals’ attitudes toward death (Rainey 1984). In addition to coping with their patients’ death, they also help patients and their families to face it (Haisfield-Wolfe 1996; Kaye, Gracely, and Loscalzo 1994; Robbins 1992). Philosophical and psychological points of view have contributed to merge different proposals that broach the attitudes about death. Most of them have stated the basis of the psychological approaches, but they could not be considered as strict psychological theories. Furthermore, most of the actual psychological models have pointed out the negative attitudes about death, mainly fear and anxiety. Most of them establish a vision of anxiety about death as a relatively stable characteristic that probably remains for a long period of time, but just a few studies have considered the positive attitudes and their practical implications. Several studies have been accomplished within the past few years to establish the real influence of different variables such as age, gender, and occupation on attitudes toward death. Regarding the investigation about anxiety before death, contradictory results were obtained when comparing different age groups. Some studies found differences between age groups (Gesser, Wong, and Reker 1988; Rasmussen and Brems 1996; Stevens, Cooper, and Thomas 1980), others found only slight differences regarding this variable (Gorsuch and Venable 1983;

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Marshall 1982), and in the study developed by Templer, Ruff, and Franks (1971), no relation was found. Other studies have focused on the relationship between gender and attitudes about death. Pollak (1979) carried out a revision, finding that most of the studies pointed out a higher fear in women in coping with death. Subsequent studies found that women reported more anxiety about death than men (Rigdon and Epting 1985; Thorson and Powell 1988), and this was also observed in specific samples such as university women (Davis et al. 1983), high school students (Young and Daniels 1980), and elderly women (Sanders, Poole, and Rivero 1980). These results were also coherent with transcultural studies, and some authors consider it a universal phenomenon (McMordie and Kumar 1984). However, we found studies that did not find differences between genders (Eggerman and Dustin 1985; Marks 1986; Viney 1984) and studies that found the opposite results. Cole (1978) found the opposite results; in his study, men reported more anxiety in coping with death than women, and Krieger, Epting, and Leitner (1974) also suggested that men perceived their own and others’ deaths more threatening than women. Other studies have investigated the relation between the occupation and attitudes about death. Bené and Foxall (1991) and Frommelt (1991) reported that hospice or palliative-care nurses had more positive attitudes than nonpalliative care nurses. Other study found that MD students were more afraid of the death procedure than lawyers (Fang and Howell 1976), and Linn, Moravec, and Zeppa (1982) also found differences related to the occupation. DePaola, Neimeyer, Lupfer, et al. (1992, [1994] 1997) evaluated a group of geriatric nursery staff and another group of professionals who worked in a different environment. They found that the geriatric group showed less fear about people dying and less preoccupation about the death of a loved one. The authors emphasized the importance of taking into account not only the attitudes about the patients’ death but also attitudes about their own death (DePaola, Neimeyer, Lupfer, et al. 1992; DePaola, Neimeyer, and Ross 1994). Other authors have also affirmed that those people involved in critical situations have more death-related fear than those who make no related activities to the death process (Lattanner and Hayslip 1984; Servaty, Krejci, and Hayslip, 1996). But as we can see, other studies do not point out the same conclusion, so there is still controversy related to occupation influence because it can be considered as a fear-prevention factor or as a sensitizing determinant to increase death-related concerns. Today, health care professionals are very keen in the management of sophisticated machines and in the application of complicated techniques, but they frequently feel impotent in coping with a patients’ death (Ulla et al. 2001). The everyday practice shows that health care professionals find it difficult to deal with bereavement because of poor


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training in communication skills, fear of being blamed, a perceived failure in their skill, fear of expressing emotion, and their own fears about death (Williams et al. 2000). Therefore, to diminish these difficulties and to improve quality of care, the health care team should be trained to manage the bereavement. Patients’ relatives also find difficulties in dealing with the death of a loved person, so we have to consider that the relatives’ perception of the health care team and the care provided to the deceased family member can seriously affect the bereavement process and grief response. This issue does not affect only the bereaved but also the health care system because morbidity resulting from loss contributes substantially to health care costs (Kissane 2000). Considering the difficulties and potential handicap of developing personal skills to cope with issues related to the dying process (Gómez and Medrano 1998; Véliz-Pintos and Caballero de Akaki 2000), the first step could be thinking about our own and others’ death (Eakes 1985; Vickio and Cavanaugh 1985). In this way, a pioneer study carried out in our country (Bayés et al. 2000) pointed out aspects that can help to die in peace by asking health professionals about their possible process of dying. This study found that there are neither end-of-life universal worries nor needs, and there is a great variability in the individual perceptions about end of life. No single route leads to a good death; the cultural and economic aspects, the age, gender, and the occupation can shape this perception. If each person feels his or her process of dying in a unique and nonnegotiable way, and there is no one way of dying (Sanz-Ortiz 1985, 1997), it is fundamental that the health care professionals could think about their own attitudes about death because these attitudes could optimize attention and care provided to patients during critical situations (Sábado and Llistuella 2001). One of those critical situations in which health care professionals have to cope with death is in severe disease in childhood. Considering our cultural aspects—shared in a logical way by the health care professionals—we all have the tendency to deny a child’s death. In our opinion, this cultural attitude is reflected in the scarcity of units of childhood palliative care. During the twentieth century, childhood mortality has experienced a great decrease, and nowadays, we can talk about a 4.9 percent of mortality in the first years of life (Eurostat 2001). Just a century ago, a child’s death was frequently assumed. Today, in our culture, it is considered as the most terrible experience. Another serious situation encountered by health care professionals is the mortality rate in geriatric areas. At the beginning of the twentieth century, only 26 percent of the newborns could reach the age of 65. Today, about 85 percent of human beings reach this age. Some studies found that older people reported less anxiety in coping with death

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(Feifel and Branscomb 1973; Wass and Myers 1982). Advanced societies treat the death of elderly people with more naturalness than a child’s death, and even age was considered, until a few years ago, as a discriminatory criteria when older people needed specific benefits from some expensive, limited, or scarce services or procedures such as the admission in the intensive care units, coronary services, or surgery. We know that modern technology leads to therapeutic cruelty, but this is a reproachable decision in every vital moment, and age has no reason to be a part of the criteria to taking decisions without considering other factors. Actually, the inclusion of elderly patients in the intensive care units has been the subject of multiple works and bioethics discussions (Castaño 2000; Gómez-Tello 2001; Palencia 2002). We would like to point out some aspects that have guided our research; first, we know that the attitude toward child and elderly patients’ death has changed and that it has important consequences to health care professionals; we also know that the attitudes about our own death have some influence over the attitudes that health care professional have with their patient’s death and the attention they provide to them. In this article, we have explored attitudes about our own and others’ death in health care professionals. Specifically, our objective was to identify principal concerns—perceived by a group of physicians and nurses dedicated to pediatric intensive care and by a group of geriatrics professionals—and to detect which aspects were considered to facilitate the process of dying.

METHOD PARTICIPANTS A group of seventy health professionals agreed to participate in this research. To assess professionals who worked with elderly people and professionals who worked with children, two different groups were recruited and evaluated, attending to their daily work characteristics. People who constituted group A (52.9 percent) were related to elderly people, and they were all working in different geriatric institutions. Group B (47.1 percent) was formed by a sample of professionals who worked with children. They worked in the intensive pediatric care team from a University General Hospital. Demographic characteristics of the seventy participants in the study include the following: the average age was 38.4 years (SD = 7.66), with a range from 24 to 60; 75.7 percent were women and 24.3 percent were men; 44.3 percent were physicians, 32.9 percent were nurses, 18.6

Ulla et al. / COPING WITH DEATH TABLE 1

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Descriptive Characteristics of the Participants

Characteristic Gender Men Women Mean age (SD) years Profession Physicians Nurses Nurse assistants Social workers

Group A (n = 37)

%

Group B (n = 33)

%

Whole Sample (N = 70) %

37.8 62.2 38

14 23

9.1 90.9 39

3 30

24.3 75.7 38.4

17 53

70.3 10.8 10.8 8.1

26 4 4 3

15.2 57.6 27.3 —

5 19 9 4.3

44.3 32.9 18.6 3

31 23 13

NOTE: Group A = professionals working with the elderly. Group B = professionals working with children.

percent nurse assistants, and 4.3 percent were social workers. These data are presented in detail in Table 1. MEASURES Questionnaire UAB-99c. This is a thirty-seven-item self-report questionnaire designed to assess perceptions and beliefs about death, measuring different aspects related to own death and to the death of a loved one (Bayés et al. 2000). Three parts can be differentiated in the questionnaire. The first part included one principal item about death perception: “At this moment, how far do you perceive your own death?” measured by a visual analogical scale (VAS, 10cm) from something very distant to something very immediate. The second part assessed some aspects that could help a person to die in peace with the following question: “In the case that you were really dying, to what extent do you believe that the following aspects could help you to die in peace?” A list of eleven aspects related to the process of dying was presented; the professionals had to rate them separately in a five-point Likert-type scale, from 1 (not helpful at all) to 5 (very helpful). Later, professionals were requested to choose those two aspects from the presented list that they considered as most important. Internal consistency for these eleven items was .80 (Cronbach’s alpha). The third part assessed concerns about death, related to four different topics: own death, own process of dying, a loved one’s death, and a loved one’s process of dying. Participants had to answer to the following

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question: “To what extent do the following aspects related to the death and the death process worry you?” The professionals had to rate responses, also in a five-point Likert-type scale from 1 (not at all) to 5 (very much). Internal consistency coefficient (Cronbach’s alpha) of this sample in the twelve items from this third part was .82. In the four subscales— worries about death—coefficients were .65, .60, .76, and .69; corresponding to own death, own death process, death of the loved person, and the death process of the loved person, respectively. PROCEDURE The questionnaire UAB-99c was administered to both groups of health care professionals in similar contexts, enclosed in training programs. Participants of the group A (working with elderly) were all attending a counseling training meeting, where they were asked to answer the questionnaire. Participants of the group B (working with children) were all attending a specific counseling training program, and they were asked to fill in the questionnaire at the beginning of the training course. Every participant of both groups agreed to participate voluntarily, and they took approximately 10 minutes to fill out the questionnaire. DATA ANALYSIS Descriptive analysis and nonparametrical tests were computed to obtain samples characteristics and to identify distribution differences. T-scores for death proximity perception were calculated with reference to gender and groups data. To analyze differences in aspects that could help one to die in peace, and in death-related concerns, t tests or z tests (attending to sample and variables characteristics) were computed to identify gender, profession, and groups’ influences.

RESULTS Table 1 shows the principal sociodemographic characteristics for the whole sample and also for both groups A and B, separately. No differences were found between groups considering age, but significant differences were detected considering gender (φ = –.355; p = .005). Attending to gender distribution, there were more women than men in both groups, but this imbalance was particularly notable in group B. According to these sample characteristics, and to differentiate gendereffects from group-effects, we computed parallel analysis.


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5 4 3 Group A 2

Group B

1 0 A

B

C

D

E

F

G

H

I

J

K

Groups (A vs. B) differences

FIGURE 1 Aspects That Could Help One to Die in Peace in Both Groups of Professionals. NOTE: Group A = professionals who work with the elderly. Group B = professionals who work with children.

Addressing the perception about the proximity of own death, results for the whole sample showed that the mean (VAS) was 2.87 (SD = 2.3; range 0-10). The mean of this perception in group A was 3.49 (SD = 2.35), and in group B was 2.12 (SD = 2.17), differences were significant (t = 2.430; p = .018). In other words, differences in the perceptions of the proximity of own death are related to the type of patient with the professional work, so those who worked with elderly people perceived their own death nearer than those who worked with children. We could also detect gender differences (t = –2.021; p = .047) in the perception of the proximity of their own death. Men reported to perceive their own death as something nearer (mean = 3.88) than women did (2.54). We tested the possible influence of interaction by means of a regression analysis, but the variable group-gender interaction did not predict perceived proximity of the own death. So we can affirm that gender-mediated differences were independent from group-mediated differences. Regarding those aspects that could help people to die in peace— assessed in the second part of the questionnaire—we could detect some differences between groups A and B, as can be seen in detail in Table 2. Those professionals who worked with children reported the following aspects as more helpful than the group who worked with elderly people: item b, think in a short process of dying; item c, be able to control thoughts and psychological functions; item d, think that their own death will not be an unbearable burden for loved ones; item e, be able to communicate with loved ones; item f, not to have their own life artificially

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TABLE 2

Aspects That Could Help One to Die in Peace

Item A. To think that doctors can control my pain and other uncomfortable symptoms B. To think that my process of dying, if it makes me suffer, will be short C. To think that I will be able to control my thoughts and psychological functions until the end D. To think that my death or my disappearance won’t suppose an unbearable burden (economic, affective, or of another type) for my loved ones E. To feel near, to communicate and to narrow affective bonds with my loved ones F. To think that if I don’t have a real hope of recovery, my life won’t be prolonged artificially G. To think that my life has made some sense H. To believe in another life after death I. Not feeling guilty (or be forgiven) for personal conflicts of the past J. To think that if the situation is unbearable, I will have help to die K. To think that I will be able to die at home

Group A

Group Contrast B (z) n.s.

Contrast Only (z) Womena

Men

Women

3.76

4.1

n.s.

3.8

4.2

3.5

4.5

–3.777***

3.47

4.13

–2.34*

4

4.3

–2.132*

4.17

4.17

n.s.

3.9

4.5

–2.846**

3.88

4.32

4.2

4.7

–2.496*

4.29

4.52

3.8 4.2 2.4

4.6 4.2 2.7

–3.596*** n.s. n.s.

3.82 4 2.82

4.34 4.3 2.52

–2.592** –2.441* n.s. n.s. n.s. n.s.

3.7 3.3 3.3

4.1 4.3 2.7

–2.018* –3.76*** n.s.

3.64 3.11 3.35

4.03 4.03 2.98

n.s. n.s. –2.684** –3.189*** n.s. –2.269*

–1.979* n.s.

n.s. –2.913** n.s.

n.s. n.s.

NOTE: Group A = professionals working with the elderly. Group B = professionals working with children. n.s. = not significant. We have included data related to group-related differences, sex-related differences, and also a specific analysis within women (most numerous sample) to control the effect of interaction. a. Analyzed only women to identify group (A-B) effect. *p < .001. **p < .01. ***p < .05.


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prolonged; item i, not to feel guilty; and item j, have help to die, if unbearable. These differences can also be observed in Figure 1, where we can see similar patterns for both groups, although the professionals who worked with children reported higher scores. Also, some of these differences were detected between men and women (see Table 2). Particularly, significant differences were observed in items b, d, f, and j. Thus, to identify interaction group-sex effects, we again performed these analyses selecting only women from both groups; if every effect was modulated by group variable, differences should disappear. We observed that some differences also remained in this case (items b, f, and j). Also, a new difference appeared, related to item k that addresses the thought about dying at home, in which women who worked with the elderly reported it as more helpful than those who worked with children. The last column of the Table 2 shows these statistical differences that women from groups A and B reported to perceive in aspects that could help to die in peace. Table 3 shows the answer percentages, presenting the priority of the different aspects perceived as helpful to die in peace for the whole group. Apparent differences were found when taking into account percentages of priority between groups and gender, except in item e (to feel near, communicate, and narrow affective bonds with loved ones) that was selected in first place for everyone (see Table 4). To analyze concerns in the perceptions of death and death process for the whole sample—assessed in the third part of the questionnaire—we computed four new variables by adding scores in each topic: own death, own process of dying, death of a loved one, and the process of dying of a loved one; these are presented graphically in the Figure 2. Apparent differences are supported with statistical differences, as presented in Table 5, and the most remarkable ones are those established between their own death and whichever other topic. It is also remarkable that there are no differences between a loved one’s death and a loved one’s death process being both the highest concerns. To verify differences moderated by the people professionals assist daily, we contrasted both groups of professionals: A versus B. As presented in Table 6, considering the questions about the worries related to death and the death process, some significant differences were found between the groups. Gender-modulated differences only were observed in relation to the following items, where women reported a higher concern: “an unbearable continuous pain” (z = –1.997; p = .046), “not being able to communicate with the loved one ever more after his death” (z = –1.981; p = .048), and “feeling lonely without him” (z = –2.970; p = .003).

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TABLE 3

Percentages and Priority Ranking of the Different Aspects Perceived as Helpful to Die in Peace for the Whole Group Percentage Whole Group

To feel near, to communicate, and to narrow affective bonds with my loved ones (item e) To think that my death or my disappearance won’t suppose an unbearable burden (economic, affective, or of another type) for my loved ones (item d) To think that doctors can control my pain and other uncomfortable symptoms (item a) To think that my life has made some sense (item g) To think that I will be able to control my thoughts and psychological functions until the end (item c) To think that my process of dying, if it makes me suffer, it will be short (item b) To think that if I don’t have a real hope of recovery, my life won’t be prolonged artificially (item f) Not feeling guilty (or be forgiven) for personal conflicts of the past (item i) To believe in another life after death (item h) To think that if the situation is unbearable, I will have help to die (item j) To think that I will be able to die at home (item k)

TABLE 4

Item A. B. C. D. E. F. G. H. I. J. K.

Priority

22.0

1

15.2

2

13.6 12.1

3 4

11.4

5

8.3

6

5.3

7

4.5 3

8 9

3 1.5

9 11

Percentages and Priority Ranking of the Different Aspects Perceived as Helpful to Die in Peace for Both Groups and for Each Gender Children

Elderly

Women

Men

% Priority

% Priority

% Priority

% Priority

13.3 10.3 8.6 17.2 20.7 6.9 8.6 3.4 5.2 6.9 1.7

3 4 5 2 1 7 5 10 9 7 11

16.2 6.8 13.5 13.5 23 4.1 14.9 2.7 4.1 — 1.4

2 6 4 4 1 7 3 9 7 — 10

14.3 9.2 9.2 16.3 19.4 6.1 12.2 3.1 5.1 4.1 1

3 5 5 2 1 7 4 10 8 9 11

11.8 5.9 17.6 11.8 29.4 2.9 11.8 2.9 2.9 — 2.9

3 6 2 3 1 7 3 7 7 7


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14,65

Own death

20,12 Own death process

21,25

Death of dearest one

21,07

Death process of the dearest one

0

5

10

15

20

25

FIGURE 2 Scores in the Four Assessed Areas of Death-Related Concerns

TABLE 5

Differences between Concerns in the Death-Related Areas Assessed Own Death

Own death process Loved one’s death Loved one’s death process

z = –6.822*** z = –6.919*** z = –6.996***

Own Death Process z = –2.642** z = –2.439*

Loved One’s Death

n.s.

*p < .001. **p < .01. ***p < .05.

DISCUSSION The main objectives of this work were to describe death-related perceptions in health care professionals and to analyze personal and situational factors that could modulate these perceptions. An early and broad analysis led us to affirm that professionals who work with patients in critical situations and with the terminally ill appraise emotional aspects in a higher degree and priority than biomedical aspects in the process of dying. These results coincided with previous studies (Bayés 2000). However, as we could see in items priority, each person—according to his or her different worries or necessities—perceives the process of dying in different ways. We have detected differences related to the work that people develop, as, for instance, the perceptions of the proximity of own death, which is

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TABLE 6

Differences between Group of Health Professionals in Death-Process-Related Concerns Means Whole Group

About one’s own death To lose everything you have in this life Not being able to feel or think any more The total impossibility of communication That nobody remembers you after your death To die young Own process of dying An unbearable, continuous pain To lose control of my physiologic functions The deterioration of my mental capacities The possibility to die alone, without the presence of loved ones Uncertainty involved in the process of dying The loved one’s death His/her definitive loss The fact that I won’t be able to see, to feel, or to hear him/her any more Not being able to communicate with him/her any more To regret not to have taken more advantage of his/her company when they were alive To feel lonely without him/her The process of dying of the loved one To watch his/her pain and suffering To watch him/her losing control of physiological capacities To watch his/her mental deterioration To think that he/she could die alone without the presence of loved ones To feel powerless to help him/her

Group A

Group B

Contrast (z Test)

2.39

2.0

2.8

–2.375*

2.81

2.9

2.6

n.s.

3.04

3.1

2.9

n.s.

2.95 3.61

2.7 3.9

3.1 3.9

n.s. n.s.

4.47

4.3

4.6

4.0

3.9

4.0

4.25

4.0

4.4

–2.486*

4.26

4.1

4.4

–2.197*

3.6

3.4

3.7

n.s.

4.53

4.5

4.4

n.s.

4.48

4.4

4.5

n.s.

4.31

4.2

4.4

n.s.

4.44 3.91

4.3 3.5

4.5 4.3

4.63

3.5

4.7

3.52 4.08

3.3 3.7

3.7 4.4

n.s. –3.047**

4.47 4.75

4.1 4.6

4.8 4.8

–3.337*** n.s.

–2.264* n.s.

n.s. –3.405*** n.s.

NOTE: Group A = professionals working with the elderly. Group B = professionals working with children. *p < .001. **p < .01. ***p < .05.


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influenced by the type of patient the professional works with. Thus, those who worked with elderly people perceived their own death nearer than those who worked with children. We could also see that men reported to perceive their own death as something nearer than women did. This seems to be incoherent with those studies that have reported a generalized higher death related anxiety in women (Rigdon and Epting 1985; Thorson and Powell 1988), therefore more research is needed because some intervenient variables may be modulating both deathrelated dimensions. We could identify which were the most and the least helpful issues to die in peace. We could see that the first- and second-ranked circumstances perceived as helpful to die in peace were related to the relationships with the loved persons: to feel near, to communicate and to narrow affective bonds with loved ones, and to think that their own death will not suppose an unbearable burden for the loved ones. On the other side, least valuable aspects were related to have help to die if the situation becomes unbearable and to have the possibility to die at home. We want to remark also that we could detect important differences related to work context and related to gender so that professionals who work with elderly people have different perceptions than professionals who work with children. We could also observe that men and women have some different perceptions about death and the death process. For women, some aspects are worthier than for men, and we can affirm that women would rather have a short process of dying, which is not prolonged artificially, they would like to have help to die if it is unbearable, and are specially concerned about relatives’ pain. On the topic of the results about death-related worries, it is important to remark that the highest concern associated with own life was to die young, and the least valued was to lose everything one has in this life. About the own death process, the highest concern was suffering unbearable pain, and the lowest was the uncertainty associated with death. In relation to the death of the person that professionals felt closest to, the most important issue was his or her definite loss, and the least important was to feel lonely without him or her. Also linked to a loved one, but now to the process of death, the highest concern was to feel without resources to help him or her, and the least important was to watch him or her losing control of physiological functions. We could also detect that aspects related to a loved one’s death and his or her death processes were perceived as the most important worries, higher than those related to own death. This is a relevant finding for the consideration of the relatives in the death process in different situations, such as emergency departments, geriatric institutions, palliative services, and those places where people find death. According to the perception found in this study, we can affirm that a loved one’s death is

332


perceived as much more important than their own death. Undoubtedly, this must be a central point of attention to guide intervention with patients’ relatives before, during, and after the bereavement. We want to emphasize the necessity of continuous research on the conditions that help people in the process of dying, bearing in mind each individual’s values, to help them to find a peaceful death. In this work, we studied the perception of health professionals who work directly with terminally ill patients because we believe that it is a good way to motivate these professionals to think and work out a comprehensive care program to help people die in peace. Nevertheless, we have to mention some methodological limitations of this study that should be addressed and explored in future studies. As we have explained, we have compared two groups, but these presented some differences that could affect some of the results. One of them was already mentioned, and it concerns the imbalance within groups regarding sex and profession; women mostly composed both groups, but one of them had a predominant group of physicians and in the other most participants were nurses. We have taken it into account and we have computed analyses to control it, but we are conscious that an experimental control is better than a statistical one. The second issue is related to the work environment; we have compared geriatric and pediatric professionals, but the first group develops its work principally with chronic patients, while the second does it with children in acute situations. The better comparison would be between four groups, with children and elderly care professionals, and in chronic and acute situations. But the problem in finding those comparable groups has to do with the normal lifecycle and also with health care guidelines. Most children who are chronically ill are not attended to continuously in a hospital or medical institution. The medical policy tends to attend to them at a hospital only in critical situations and develop the daily care at children’s home. On the other hand, the elderly are more frequently attended to in institutions, also when they are not in a critical situation; and even when they are ill and they have any kind of crisis, they are less frequently attended to in an intensive care unit than younger people because this would be an artificial prolongation of their life, with a high suffering component. These circumstances led us to select the groups analyzed. Finally, we have to remark that death perceptions are not independent from other cognitive, behavioral, and affective structures and processes of each person; otherwise, these perceptions are perfectly inserted in a pretty complex frame of attitudes, behaviors, expectancies, attributions, and emotions—which are undoubtedly modulated by the environment and the different contexts in which each person develops, works, and lives. So, every intervention, training design, program


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Sara Ulla, Ph.D., is a professor in the Department of Psychology at the Universidad de Castilla–La Mancha (Spain). Her main lines of work and research are related to healthrelated behaviors, psychoneuroimmunology, and psychooncology. Cristina Coca is a researcher at the Section of Psychology of the Hematology Department at the University Hospital La Paz (Madrid, Spain). She is a specialist in psychological assessment and treatment in palliative care. Carolina del Rincón is a health psychologist at the Section of Psychology of the Hematology Department at the University Hospital La Paz (Madrid, Spain). She has a master’s degree in palliative care and is a predoctoral student. José L. Díaz is a health psychologist at the University Hospital La Paz. He works with chronically ill patients with hemophilia. Eduardo A. Remor, Ph.D., is a health psychologist teaching at the Universidad Autónoma de Madrid (Spain) and working as a researcher at the University Hospital La Paz (Madrid). Pilar Arranz, Ph.D., is a clinical psychologist at the Section of Psychology of the Hematology Department, University Hospital La Paz (Madrid, Spain). She is an associate professor at the Public Health National School, Madrid, Spain. Ramón Bayés, Ph.D., is a renowned researcher of the Spanish psychology. He is today an emeritus professor at the Universidad Autónoma de Barcelona and has a wide career in the study and research of health psychology.