The intensive care unit (ICU) offers hope

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1 Thai Buddhist intensive care unit nurses perspective of a peaceful death: an empirical study Waraporn Kongsuwan, Kathryn Keller, Theris Touhy, Savina Schoenhofer Abstract Aim: To describe the concept of a peaceful death from Thai Buddhist intensive care unit (ICU) nurses perspectives. Method: This study was a descriptive qualitative study of data generated from individual indepth interviews of ten intensive care nurses who practiced in adult ICUs in the southern region of Thailand. Content analysis was used to analyse the data. Findings: Four core qualities of a peaceful death emerged as described by Thai Buddhist nurses who practiced in the ICUs. These core qualities are: peaceful mind; no suffering; family s acceptance of patient s death; and being with others and not alone. Conclusion: Thai Buddhist nurses described a peaceful death as a situation in which persons who are dying have peace of mind, and do not show signs and symptoms of suffering. Peaceful death occurs when family/relatives declare acceptance of their loved one s dying and eventual death. Such a death is witnessed by relatives and friends and the dying person is not alone. The findings encourage nurses to be with, and provide palliative care for, dying patients and families. Key words: Thai Buddhist nurses l Intensive care unit l Qualitative l Peaceful death l End of life The intensive care unit (ICU) offers hope to many; however, it is often also a place of death and dying. End-of-life care has become an important issue of care in ICUs all over the world (Carlet et al, 2004). For example, in the United States (US), Canada, and Sweden, the death rate in ICU is 10 20% (Cook et al, 2004; Beckstrand et al, 2006). Provision of palliative and end-of-life care has been introduced as a quality indicator by the Thailand National Hospital Accreditation Authority (Nilmanat and Phungrassami, 2006). The terms peaceful death and good death are often used synonymously; that is, as terms to describe the same experience (Winland-Brown, 2001; Lackie, 2003; Van der Greest, 2004; Vig and Pearlman, 2004). A peaceful death is an individual experience or perception and is based on socioculture and religious belief (Van der Greest, 2004; Vig and Pearlman, 2004; Hattori et al, 2006). In Thailand, Buddhism is the main religion. More than 90% of Thai people are Buddhists (Ministry of Public Health, 2004). Approaching a peaceful death is related to Buddhism religious practice (Barham, 2003; Visalo, 2004; Matetanonto 2005; Kongsuwan and Touhy, 2009). A place to die for Thai people may be at their home, in hospitals, and in temples. Few Thai hospitals have palliative and hospice units for terminally ill patients to die ( P h u n g r a s s a m i ; N i l m a n a t a n d Phungrassami 2006; Matchim and Aud, 2009). Most terminally ill patients may die in ward units or in ICUs. One Thai ICU reported a death rate of 10% of patients admitted (Peirmpikul, 2000). Currently, the death rate in Thai ICUs is 14% of patients admitted to the ICU (Personal Communication, 2008). Thai nurses have a strong presence in the promotion of a peaceful death, particularly in ICUs in Thailand (Kongsuwan and Locsin, 2009; Kongsuwan and Locsin, 2010; Kongsuwan, 2010). Thai ICU nurses, therefore, are a valuable source of knowledge about concepts of a peaceful death, and their understanding could contribute to nursing care that helps assure this important aspect of Thai culture. A peaceful death in ICU: experience of caring The review of literature about a peaceful death, or a good death, in ICUs revealed few studies conducted in the US and Canada that explored the nurses experience of caring for people dying in ICUs (Kirchhoff et al, 2000; Lackie 2003; Beckstrand et al, 2006). Many ICU deaths in the studies conducted in those two countries were not considered a good death because of inherent problems within a culture of care that typically strives to prolong life and prevent death, inadequate communication between physicians and families, treatment decisions based on physicians needs, and constraints on nursing time (Kirchhoff et al, 2000; Beckstrand et al, 2006). The transition point in care between cure and comfort is still unclear and an uncertainty for ICU nurses globally (Kirchhoff et al, 2000; Halcomb et Waraporn Kongsuwan is Assistant Professor, Faculty of Nursing, Prince of Songkla University, Hat Yai, Songkhla, Thailand; Kathryn B Keller is Associate Professor, Christine E Lynn College of Nursing; Theris Touhy, is Professor, Christine E Lynn College of Nursing Florida Atlantic University, Boca Raton, FL United States, and Savina O Schoenhofer is Professor, Department of Graduate Nursing Alcorn State University, Natchez, Mississippi United States Correspondence: Waraporn Kongsuwan waraporn.k@psu.ac.th International Journal of Palliative Nursing 2010, Vol 16, No IJPN_16_5_241_247_Thaiindd.indd /5/10 18:16:07

2 { The transition point in care between cure and comfort is still unclear and an uncertainty for ICU nurses al, 2004; Elpern et al, 2005; Beckstrand et al, 2006; Kongsuwan and Locsin 2009), and depends on the consensus between patients, families, and staff. Many factors are involved in the decisionmaking process; a process that requires time (Kirchhoff et al, 2000; Badger, 2005). Caring for critically ill dying patients can cause tension, conflict, moral distress, grief, and suffering for critical care nurses that affect job satisfaction and lead nurses to feel burned out (Halcomb et al, 2004; Elpern et al, 2005). Canadian critical care nurses shared their experiences of providing care for a good death, stating that open and honest communication with patient, family, and physician was important (Lackie, 2003). Several studies (Kirchhoff et al, 2000; Beckstrand et al, 2006) explored the experiences of ICU nurses in the US about a good death in ICU. These nurses understood that in order to have a good death in the ICU, physicians, families, and nurses must accept the inevitability of death, have a decision to cease treatment, focus on comfort care, and promote death with dignity. In addition, the nurses suggested that following patients wishes for end-oflife care, being with the dying patients, and communicating effectively contributed to having a good death in the ICU. Three recent nursing studies relating to a peaceful death in Thai ICUs have been published (Kongsuwan and Locsin, 2009; Kongsuwan and Locsin, 2010; Kongsuwan, 2010). Kongsuwan and Locsin (2009) conducted a preliminary study, using grounded theory, to determine the process of promoting a peaceful death among Thai nurses in ICUs in a hospital in the south of Thailand. Three Thai ICU nurse participants met the criterion of believing they had been involved in peaceful deaths in the ICU. The participating nurses shared the view that a peaceful death was difficult to achieve in ICU; similar to what nurses in the US have disclosed (Beckstrand et al, 2006). Three thematic statements emerged to illustrate promoting a peaceful death in ICUs. These include starting care through raising awareness of dying, creating a caring environment within which the patients could be allowed to die without aggressive treatment; and promoting end-oflife care congruent with patients beliefs. The results were also revealed that these participants dealt with the difficulty of promoting a peaceful death in ICUs alone, as interdisciplinary teamwork did not function well. Furthermore, the participants dealt with physicians who lacked knowledge of palliative care concepts (Kongsuwan and Locsin, 2009). In the next year, Kongsuwan developed a research project to explore nurses experience of caring for people who had a peaceful death in Thai ICUs. Hermeneutic phenomenology was used as a method of the study. Sixteen thematic categories were analyzed from the interviews. The description of this experience provided by Thai ICU nurses was understanding the other through valuing experience and enhancing relationships with others by recognizing time is short and is a priority (Kongsuwan, 2010). In addition, some thematic categories in this study (Kongsuwan, 2010) were selected to further illuminate the meanings by using aesthetic expressions (Kongsuwan and Locsin, 2010). Yet, these studies did not examine and describe the concept of a peaceful death in ICU. The Study Aim The aim of the study was to describe the concept of a peaceful death from Thai Buddhist ICU nurses experiences. Understanding a peaceful death from the experiences of Thai Buddhist ICU nurses is a needed perspective for guiding quality end-of-life care that promotes a peaceful death in congruence with Thai societal norms. Design A descriptive qualitative design was used to obtain the descriptions of Thai Buddhist nurses about their conception of the occasion of having a peaceful death in ICU. ICU nurses who were known to have experience of caring for a person whom they perceived had a peaceful death were contacted initially and invited by the researcher to participate in an individual interview. The participants were recruited through personal networking and word of mouth. Snowball purposeful sampling provided the opportunity to select participants who had rich and in-depth information about people experiencing peaceful deaths. Participants Ten ICU nurses who met the criteria of the study participated in the interviews. Inclusion criteria of participants were: Thai registered nurses currently working in ICU in the hospitals in the southern region of Thailand; have cared for adult dying people and believe that one or more persons they cared for had a peaceful death; have at least 6 months of ICU experience; and be willing to participate in the study. The age of participants ranged from years old, with a mean of 40 years old. All participants were women and described themselves as Buddhists. Six participants had graduated with a baccalaureate degree as their highest level 242 International Journal of Palliative Nursing 2010, Vol 16, No 5 IJPN_16_5_241_247_Thaiindd.indd /5/10 18:16:07

3 of education, and four participants reported that they graduated with a master s degree. Years of experience of working in ICU ranged from 5 28 years, with a mean of 12 years. Ethical considerations The research study was approved by the Florida Atlantic University s Institutional Review Board as part of a larger research project. A detailed description of the study, the risks and benefits, confidentiality, and the informed consent procedures were given during the initial phone contact with prospective participants before their participation. Each interview was audiotaped after receiving written consent to participate in this study, and permission had been granted to audiotape the interview. Data collection After contacting the participants, the researcher and the participant mutually agreed upon the setting for the interview. All interviews were conducted in quiet, private, comfortable, and convenient settings outside the ICUs. These settings were either in a private home, a private area in the hospital, or another area mutually agreed upon. Individual one-to-one interviews were conducted in Thai language. The tape-recorded interviews took between 30 and 60 minutes. The question asked in the interviews was: Can you describe to me your understanding or perception of peaceful death? The other questions used during the interview to encourage the participants to continue reflections their perceptions were: Please tell me more, Can you give an example, How did you understand/perceive that, and You said that.... The researcher used silence as a way of prompting the participants to recall and share their understandings. Each interview was concluded when the participant indicated there was nothing further to share. Data analysis Audiotapes were transcribed in the Thai language for further data analysis. All translations were done by the researcher and the translations were validated by two bi-lingual nursing professors who are proficient in both Thai and English. Both translators are qualitative researchers and one is experienced in end-of-life care. The translated data were analyzed using the process of qualitative content analysis. The objective of this method of analysis is to provide a clear understanding of a concept. Without the influence of preconceived categories or theoretical conceptions, the analysis proceeds by defining codes that were derived from the data. Subsequently the codes are organized into the categories that ultimately make clear the concepts derived from the analysis (Hsieh and Shannon, 2005). All transcriptions of the interview records were read and analyzed carefully by the researcher. Participants words, phrases, and statements that appeared to describe their understanding of a peaceful death in an ICU were highlighted. Similar phrases and statements were coded based on the generated data and coded data were grouped together, forming the core qualities of a peaceful death, and organized. This provided rich categorical descriptions used to formulate a description of the concept of a peaceful death. Rigor of the study The study and its findings were subjected to the rigor of Lincoln and Guba s (1985) criteria of credibility, transferability, dependability and confirmability. The credibility was accomplished by recruiting the participants who were able to describe the concept of a peaceful death in ICU. The transferability was sought by providing the audience with rich in-depth descriptions. Dependability was achieved when findings were auditable as when another researcher can follow w i t h o u t c o n t r a d i c t i n g t h e f i n d i n g s. Confirmability was accomplished by using the audit trails demonstrating the thought processes that followed. Findings Participants indicated that their understanding of the concept of a peaceful death was derived from Buddhism, Thai culture, personal experience of family members deaths and the clinical experience of patients deaths. Core qualities and a clear description of the concept of a peaceful death in ICU were revealed by the qualitative content analysis of interview data (Hsieh and Shannon, 2005). Core qualities of a peaceful death in ICU The four core qualities of a peaceful death in ICU that emerged from the process of data analysis are: n Peaceful mind n No suffering n Family accept patient s death n Being with others and not alone. Peaceful mind Peaceful mind, the first core quality of a peaceful death was described by ten participants. The { Core qualities and a clear description of the concept of a peaceful death in ICU were revealed by the qualitative content analysis International Journal of Palliative Nursing 2010, Vol 16, No IJPN_16_5_241_247_Thaiindd.indd /5/10 18:16:08

4 { Being free from worry and thinking good things brought the dying person into mindful readiness to die participants perceived that a peaceful death would happen when the dying person has peace of mind and was not worried. His or her needs and wishes were addressed by immediate family members and other relatives, and by nurses. A peaceful mind came when there was no unfinished business. A participant explained: It is like his needs and wishes were addressed, then he will die peacefully... like the patient is ready to go and no worrying. The participants understood that the dying person s mind needed to be prepared to approach death. The participants perceived that when the dying person focused his or her mind on positive or pleasurable things, merits, or faith, his or her mind would be at peace. A participant stated that: His mind is at peace... thinking about good things, things that gave him pride. Being free from worry and thinking good things brought the dying person into mindful readiness to die. As a participant expressed: There is not any worrying thing in mind. This is a peaceful death... dies without worrying and with readiness to die. It s like his mind adheres to monk/buddha. There is a calm mind... concentration... mind focusing at one point. Another participant affirmed the idea that focusing the mind on good things during the time of passing was important to a peaceful death in the ICU environment, which is rarely serene. Peaceful death is his mind... catching on good things. Perhaps the environment surrounding him is not quiet but if his mind attaches with good things, he can pass this period of time. No suffering The second core quality of a peaceful death is no suffering. No suffering was described by nine participants. The participants perceived that the dying person would have a peaceful death when the dying person was not suffering. Activities of saving and extending life were understood by the participants as generating suffering for the dying person. It was made clear that to have a peaceful death, there must be no holding onto life with aggressive treatments. The dying person must not receive cardiac massage and other treatment procedures to prolong life. As a participant explained: There is not any suffering from treatment procedures in his last moments of life... no CPR... no aggressive treatments such as renal dialysis and haemodialysis. There is agreement to stop performing all things that bring the patient pain. This is a peaceful death. Similarly, another participant affirmed: There is no CPR, no insertion of tubes. Even though the patient s situation is acute I see that this can be a peaceful death. In addition, the participants understood that the dying person, who can die without suffering has a peaceful death. As a participant declared: Peaceful death... we must not make him suffer; let him die on his own. Family accept the patient s death The third core quality of a peaceful death is a family s acceptance of the patient s death. Eight participants described this core quality. The participants perceived that the dying person s family were important to a peaceful death of their loved one. The participants discerned that relatives reactions could affect the dying person s calmness. One participant observed: I see that the dying patient whose relatives are calm can be calm too. Another participant elucidated: Having a peaceful death depends on relatives reactions and perceptions. If the patient is dying and relatives still suffer and have something left on their mind... I think that truly, the patient was not at peace, did not pass away peacefully. The dying person would die peacefully when relatives were feeling calmness. The calm reaction of the family was perceived as the consequence of accepting death of their loved one. As a participant articulated: Family accept death and are ready to let patient go. The family don t want to see the dying patient s suffering. They can provide care or do things for the dying patient. This is a peaceful death. Relatives who accepted the patient s impending death will be calm and have chosen to let go of the dying person. The family will be more attuned to what they can do or how they can 244 International Journal of Palliative Nursing 2010, Vol 16, No 5 IJPN_16_5_241_247_Thaiindd.indd /5/10 18:16:08

5 care for the dying person. The family will have time to be with the dying person and provide holistic care such as cleansing the body according to cultural and religious traditions, and following the dying person s needs and wishes. The family will have time to arrange or perform religious rituals at the end of life for the dying persons. These activities will assist dying people to approach death with a peaceful mind. Being with others and not alone The fourth core quality of a peaceful death is being with others and not alone. Being with others and not alone was described by eight participants. The participants understood that a peaceful death happened when the dying person had loved-ones, family, friends, and other significant persons surrounding him or her at the time of passing. As a participant described a peaceful death: The dying patient doesn t die alone. Relatives and people whom the patient needed were surrounding him. Being with others and not alone was perceived as an attribute of a peaceful death in accordance with culture and belief. Thai Buddhists believe that it is necessary to visit and be with the dying person at the last moment in order to assist the dying person s mind to be at peace and prevent any worrying. It is believed that people who are with the dying person at the last moment of life will also gain happiness by having the opportunity to see the dying person during the time of passing. As a participant expressed: In our culture as Buddhists, if you come to visit the dying patient [ ma-du- jai, in Thai language], you will feel good, happy, and the patient will also go peacefully, without any worry. Dying patients want to have their children and grand-children around them. Description of the concept of a peaceful death in ICU The four core qualities of a peaceful death were synthesized to express a concept of a peaceful death in ICU. The description of the concept of a peaceful death was gleaned from the experiences of Thai Buddhist nurses as: a situation in which persons who are dying have peace of mind, and do not show signs and symptoms of suffering. Peaceful death occurs when family declare acceptance of their loved one s dying and eventual death. Such a death is witnessed by relatives and friends and the dying person is not alone. Discussion Although the review of existing literature clarifies that there is no universal definition of a peaceful death and it is based on religious and socioculture factors (Van der Greest, 2004; Vig and Pearlman, 2004; Hattori et al, 2006), the four core qualities described by this current study have some similarities to the summarized core qualities of a peaceful death, or a good death, across several cultures in American society (Weisman, 1979; Winland-Brown, 2001; Vig and Pearlman, 2004), European society (Ruland and Moore, 1998), African society (Van der Greest, 2004), and Japanese society (Hattori et al, 2006). Core qualities across several cultures, as perceived by terminally ill patients and nurses in the relevant society were related to accepting death (Winland-Brown, 2001; Van der Greest, 2004; Hattori et al, 2006); being at peace (Ruland and Moore, 1998, Winland-Brown 2001; Van der Greest, 2004; Vig and Pearlman, 2004); being comfortable (Ruland and Moore 1998; Vig and Pearlman, 2004; Hattori et al, 2006); being with loved ones (Weisman 1979; Ruland and Moore 1998; Van der Greest 2004; Hattori et al, 2006); following an individual s wishes and religious tradition (Weisman 1979; Hattori et al, 2006); taking place at an appropriate time (Hattori et al, 2006; Van der Greest, 2004); and being natural and dignified (Weisman, 1979; Ruland and Moore, 1998; Winland-Brown 2001; Van der Greest 2004; Hattori et al, 2006). Hence, this moves us closer to defining and describing the concept of peaceful death across various cultures and has relevance for a better understanding of the concept. The four core qualities from Thai ICU nurses in this current study are a peaceful mind; no suffering; family/relatives accept patient s death; and being with others and not alone. The first, peaceful mind could be contributed to the core quality of being at peace (Ruland and Moore, 1998, Winland-Brown 2001; Van der Greest, 2004; Vig and Pearlman, 2004). The second, no suffering could be added to the core quality of being comfortable (Ruland and Moore 1998; Vig and Pearlman, 2004; Hattori et al, 2006). The third, family/relatives accept patient s death could be congruent with the core quality of accepting death (Winland-Brown, 2001; Van der Greest, 2004; Hattori et al, 2006). The fourth, being with others and not alone could be similar to the core quality of being with loved ones (Weisman 1979; Ruland and Moore 1998; Van der Greest 2004; Hattori et al, 2006). This study is the first in Thai society to iden- { Being with others and not alone was perceived as an attribute of a peaceful death in accordance with culture and belief International Journal of Palliative Nursing 2010, Vol 16, No IJPN_16_5_241_247_Thaiindd.indd /5/10 18:16:08

6 { Buddhists value approaching death in a quiet environment surrounded by loved ones and family members tify and describe the concept of a peaceful death based on experiences of Thai Buddhist ICU nurses who felt they participated in the promotion of a peaceful death for people dying in ICUs. Two previous studies in Thai society dealt with a peaceful death in ICU (Kongsuwan and Locsin, 2009; Kongsuwan, 2010). The first study (Kongsuwan and Locsin, 2009) explored how ICU nurses promoted a peaceful death in Thai ICUs, using grounded theory. The nurses, both Thai Buddhists and Muslims, were invited to describe their processes of promoting a peaceful death. The second study (Kongsuwan, 2010) explored the lived experience of nurses caring for people who had a peaceful death in ICU. The ICU nurses narratives were analyzed using Van Manen s (1990) hermeneutic phenomenological approach. These two studies did not provide explanations of qualities of a peaceful death in ICU, while this current study attempted to describe these fully. The descriptions of a peaceful death in ICU in the current study are consistent with the concept of a peaceful death in Buddhism. Buddhism offers the perspective that a peaceful death will occur when a person accepts death as a natural law of life and has peace of mind, with no clinging to the body or things, and no worrying (Barham, 2003; Visalo, 2004; Matetanonto 2005; Kongsuwan and Touhy, 2009). Buddhists value approaching death in a quiet environment or at their home, and surrounded by loved ones and family members. These circumstances assist in creating a sense of peace, having a peaceful death and being reborn in a good place (Barham, 2003; Visalo, 2004; Kongsuwan and Touhy, 2009). Since all participants in the current study were Buddhists, their understandings or perceptions of a peaceful death were no doubt shaped at least in part by their belief in Buddhism. Conclusions and implications Even though a peaceful death is an individual perception and experience, the four core qualities of a peaceful death and a rich description of the concept of a peaceful death provide knowledge and understanding of the value Thai Buddhist ICU nurses give to end-of-life care in ICU. The findings of this study can be used to suggest implications for practice and/or policy as in the following: n The four core qualities of a peaceful death could be used to enhance nurses understanding of the concept of a peaceful death n The four core qualities of a peaceful death could be used as a conceptual framework to create nursing practice interventions for quality endof-life care n Health-care organizations could consider the environments that support peaceful death which may include appropriate staffing to respond to the quality of end-of-life care standards in intensive care units. Limitations This current study presents knowledge of the concept of a peaceful death from the perspective and experience of participants who were Thai Buddhists. Their perceptions of a peaceful death may be influenced by Thai culture and Buddhism. While no doubt useful to Thai nurses, the knowledge developed from this study may not be fully applicable in other cultures and religious beliefs. 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