EXPERIENCE THE DEATH OF VICTIMS OF TRAUMA IN READY-SALVAGE DESCRIPTIVE STUDY

Ana Paula Angélico Ferreira¹, Carlos Eduardo Sabatke², Juliana Helena Montezeli³, Kriscie Kriscianne Venturi⁴

1,2,3 Evangelical Faculty of Paraná – FEPAR; 4 Hospital Regional do Litoral - SESA - Curitiba/Paraná.

ABSTRACT

Objective: To analyze how nurses experience the death of victims of trauma in the emergency room unit.  Method: Descriptive qualitative study using semi-structured interviews with eight nurses from a service breakdown of Curitiba-PR, dealt with the content analysis of Bardin. Results: Three categories emerged: The first describes what the fighting before the death of a trauma victim, the second address to the feelings of nurses in the face of death and the third talks about the difference is the experience of the death of traumatized and chronic patients. Discussion:  feelings about the trauma of death differs from those of a chronic patient, for the first situation represents one break the natural cycle of life and can cause intense frustration to the professional, while the second can be a relief to human suffering . Conclusion:  When facing death, nurses are not devoid of professionalism, feelings and emotions.

KEYWORDS: Emergency nursing; Death, Attitude to death; Hospital emergency.

INTRODUCTION

Although there have been numerous advances in emergency room medicine, the risk of death and death itself are part of daily life of professionals working in this scenario.

The rituals related to death can be observed from the most primitive societies, denoting an attitude at such a solemn event. However, sometimes nursing professionals are adequately prepared for this experience so common in their daily work⁽¹⁾.

Referring these issues to the ambiance of an emergency, specifically for nurses' actions in this context is that this professional routinely experience episodes of death of patients who are there because of the severity of their condition. The role of nurses in emergency services it is a complex issue to address. The dynamic operation of the sector combined with gravity and the constant unpredictability of events make the environment fraught with instability, often being shown the stress of the subjects involved here, besides the exposure of their weaknesses.

Among the weaknesses mentioned above we consider the difficulty in dealing with situations that culminate in the death of the patient, especially when dealing with victims of trauma.

By articulating the theme of death to the issue of trauma, inevitably we are referring to young people who lose their lives abruptly and unexpectedly. Faced with this question, it is not difficult for the professional mechanize their daily activities as a form of self-protection. In nursing, this attitude represents a major negative for the careful acts in the environmental emergency, it is essential to enhance the humanistic posture before death.

Thus, the Thanatology remains restricted to specific groups of students and/or curious, being exploited, not frequently, in a superficial way in the training of nursing professionals. It should therefore, for dealing with finitude, which is intrinsic to the human being, to be broadcast to all categories of health⁽²⁾.

From these considerations and the sharpening of our concerns, emerged the guiding question of this study: How do nurses in an Emergency Room (PS) experience the death of victims of trauma?

To clarify this question, was traced as objective of the study: to describe how nurses in an emergency room (PS) experience the death of victims of trauma.

METHODOLOGY TRAJECTORY

This is a descriptive qualitative research whose scenario was the sector of the Emergency Room (PS) of a teaching hospital-philanthropic school of Curitiba-PR. All nurses in the Emergency Room (PS) were invited to participate in the survey, and the inclusion criteria act exclusively in this sector and accept to participate. Thus, the sample consisted of eight subjects for a total of nine, since one has refused to take part in the study.

The data was collected during the months of August and September 2010, through semi-structured interviews guided by an instrument consisting of three open questions, preceded by a party who expressed the characterization of the subject. It was given after the project approval by a Research Ethics Committee under protocol no.4918/10 and Certificate of Appreciation Presentation to Ethics (CAAE) no. 0069.0.081.000-10.

Each participant underwent an interview just recorded audio, with subsequent transcription of the speeches for analysis. The data were processed by content analysis proposed by Bardin⁽³⁾, according to the stages of pre-analysis, exploitation and processing of results.

From the emergence of categories, developed guided discussions in the literature to support the reflections, which were coded as speech exemplified with EE1, EE2, EE3, EE4, EE5, EE6, and EE7EE8, aiming to maintain the anonymity of participants.

RESULTS

The subjects were characterized by the initial part of the interview instrument and to facilitate visualization of the characteristics of the sample components, presented in Table 1 below.

TABLE 1 - Characterization of subjects in the research, 2010, Curitiba.
NURSE	AGE (years)	GENDER	TIME OF PERFORMANCE IN PS	POS-GRADUATION	ACTION IN ANOTHER HOSPITAL PS
1	24	F	2 TO 6 MONTHS	LABOUR NURSING	NO
2	30	F	4 YEARS	URGENCY AND EMERGENCY	NO
3	27	F	2 YEARS	NÃO	NO
4	24	F	1 MONTH	URGENCY AND EMERGENCY	NO
5	40	F	10 YEARS	URGENCY AND EMERGENCY	YES
6	26	F	1 A 6 M	URGENCY AND EMERGENCY	NO
7	29	M	10 MONTHS	NO	NO
8	39	F	3 YEARS	URGENCY AND EMERGENCY	YES

SOURCE: The author, 2010.

From reading the answers given by research subjects, we performed a content analysis, from which emerged the categories: Coping before the death of a victim of trauma, feelings of nurses before the death of a traumatized patient, experiencing the death of difference of a traumatized and  chronic patient.

CATEGORY 1: FACING THE DEATH OF A VICTIM OF TRAUMA

In this category, the subjects emphasized through their speeches some considerations to face daily death due to traumatic events. The first point addressed, relates to the drain of engagement as a self-protection, as shown in the following example:

[...] I try not to get involved with the situation [...] I try not to get involved with a family history of this, because when it happens I get a little shaken, I think here the situation because he had children, he had a wife. Sometimes we get a patient belongs and there is a picture of a baby in the cell (EE1).

[...] When it is a child or when we know the story has a greater involvement when it is a shocking story it is more difficult, we have to call the family’s patient and tell them the bad news, at the moment it is very fast [...] we see the suffering of the family and it's hard not to get involved and there are no feelings, but it much depends on the degree of involvement, when there is no involvement,  no one gets hold of the story, the story is told, but nothing is felt,  but when it is a person that you stay there for two or three hours trying to revive it is more difficult (EE6).

It also expressed the view that the lower involvement can provide more support to the family after death, as shown in the following:

[...] I have to talk to the family and it is difficult to have to talk to them, but we are the whom that receive the family, but for me it is very difficult indeed, it is hard not to cry when we talk to the mother when a young man who  was hit or shot. I suffer a lot, but I try to improve it, it is my role here (EE2).

To cope with the deaths of other injuries, some participants point out that the experience of these routine changes the way you view them, making them closer to a position of greatest coolness:

[...] it is difficult and sad because our job here is to save lives and recover and when it is not possible and the patient goes to death we were very upset, but it is something we experience every day and just getting used to(EE5).

[...] We became colder with the situation and ends up being a protection to our profession because we experience each death we should not suffer so much because there are many patients who come here and it is very difficult but the important thing is to know that everything was done and we could do our best  at that time (EE6).

[...] After a while you end up not much influenced by the situation (EE8).

Respondents point out that coping with the death of polytraumatized children generates an even greater distress, as evidenced in the statements:

[...] Before I felt bad, I lead this situation to home, I was sad. Today I think, I think I did the best I could. Today I face it in a easier way, but when a child does not face well, it is still difficult to go through it, children who died and I will have to report the news to the family. It is difficult to report to them (EE2).

[...] We are more shocked when a child or when you know the story of the person (EE6).

CATEGORY 2: FEELINGS OF NURSES BEFORE THE DEATH OF A TRAUMATIZED PATIENT

Death from traumatic events represents an abnormality in the life cycle, and this arouses sadness and frustration, as evidenced in the following discourses:

[...] When it is a person who is already at the end of his or her life, you know that is closest in death it becomes easier. But there are deaths we already expect, but when you get children, adults and elderly who were not counting on it it is difficult for any team and especially the young patient [...] it is a situation that you feel frustrated and sad, but we know how to work and monitor not to cower and not harm the team and does not trivialize death (EE7).

[...] I get the feeling of pain, sorrow comes to adding the water in my eye, you know. I try not to get involved, but unfortunately [...] it is a person and there is no way you will not get involved. (EE1).

Corroborating this, the question of frustration was clearly emphasized, as these excerpts show:

[...] it depends on the trauma, particularly for young people it is sad because he could not do what I had to do [...]it is a feeling of guilt and frustration, even when the victims arrive at the Emergency Room (ER ) we do everything we want(EE3).

The feelings aroused by the death of other injuries, in the view of nurses studied, generate a series of reflections. These episodes may be evidenced reflective speech exemplified subsequently:

[...] You have a sense of sadness even as you lost someone you know looking and had a life ahead, it's thoughtfully [...] we go back  home and we will do something, for example, light a barbecue, sometimes burned patient is serious, then we keep thinking it looks like it did then I'm very thoughtful, with a feeling of sadness (EE1).

CATEGORY 3: DIFFERENCES BETWEEN THE EXPERIENCE OF THE DEATH OF THE TRAUMATISED AND CHRONIC PATIENT

When asked about the existence of difference between the feelings experienced before the death of a traumatized patient during the emergency care and those in the terminal, the subjects expressed different opinions. Some said they felt the same way as the death of a patient it is always an irreparable loss, it is a unique feeling, as it can be seen in the following lines:

[...] There is no difference between the feelings of death from a chronic patient to a trauma (EE1).

[...] No. The death should be regarded in a natural way, it is our only certainty, and sooner or later it will happen (EE8).

Nurses in other settings, it is evident that there is a reference to the patient's death as a relief for chronic pain that he had the same:

[...] The death of a chronic patient is perceived as a relief for him and his family (EE2).

With respect to the differentiation of feelings between the death of a patient and a victim of chronic trauma, there were those who mentioned that this exists:

[...] There is a difference in feelings between the experience of the death of a patient and a chronically traumatized by life expectancy (EE5).

[...] There are different feelings when a trauma patient who is young. It is difficult because it is something unexpected. We tried to move to the first team to see the neurological part and there is a positive influence, the feelings are different. In the case of trauma it is more difficult. Everything is very fast and the feeling of sadness and frustration are larger (EE7).

DISCUSSION

It is observed that the subjects shy away from involvement with the victim's story and that, on occasions when this is developed, generates anxiety and feelings that make it difficult to cope with that situation. Thus, advocates of the need to not be involved in order to support the victim's family.

Avoid creating link to alleviate the suffering before death is not the privilege of study subjects. However, please note that this posture, when exacerbated, can culminate in carefully guided exclusively on mechanical acts.

There is great concern with the technical bases of polytrauma care; however, this may encourage the tendency to take care of the human being mechanized, since the procedures are performed in a short time. As a result, the vision of the whole human being can be harmed by the nurse, so that it will adopt an approach focused exclusively on aspects of techno science⁽⁴⁾.

Thus, the condition of dynamism and complexity of activities in the emergency room nurses require different skills, since time is a factor in the effectiveness of care delivery and maintenance of life. In this world of instability, although the activities performed by nurses in the sector in question resemble those performed in other settings, the emergency context requires a more incisive in the face of adversity every day, between them, face to face episodes of death due to events traumatic.

The tendency to coldness and self-protection mechanism in the face of death is not the privilege of the findings. In research done in an intensive care unit (ICU), the participants also forwarded to the theme, noting that the experience provided by these episodes allows a better coping with this, however, allied to this, entails certain indifference as a way to endure suffering triggered by the loss of a patient⁽¹⁾.

Despite the suffering, the practice of nursing requires that we continue to care for others who also suffer. Thus, with constant approximations, employers look to neutralization as a strategy to minimize their own suffering, gradually developing their feelings⁽¹⁾.

Another important aspect when discussing the trivialization of death is that in our culture, health professionals, among them those of nursing are unprepared to deal with issues related to death and dying process. This tends to be considered a less important issue in health care, the hospital because the image is linked to a place of healing, and all who seek hope to get out ripened⁽⁵⁾.

Reiterating a more intense discomfort in dealing with the death of politraumatized children, it is clear that such evidence was also reported in a study with nurses in an ICU, in which study participants explained that it considered more painful encounter with the child in the dying process, resulting in feelings of anger and pain⁽⁵⁾.

The continuing education about death and dying can be considered a strategy to promote a professional attitude in order to be effective at such harmonious situation, allowing the professional to create mechanisms that do not interfere with their quality of life and quality of care provided to patient at risk of death⁽⁶⁾.

Many feelings are manifested in nurses facing death, and with regard to its occurrence in trauma, grief and frustration at the abnormal termination in the life cycle were mentioned by the subjects.

Unlike die as a phase of life as well as born, grow, and others, death is seen as a fact depersonalized and annoying. It disturbs and challenges the alleged omnipotence of man and can have different meanings, depending on the bases of personal and professional development of each individual⁽⁷⁾. Given the above, it is natural that feelings manifest themselves in the subject.

Thus, the experience of death manifests clashes between different individuals. Corroborating this, it is mentioned that some retrench and experience fear, but others begin to appreciate the time and still have come to see life more fully what favors an adaptation⁽⁵⁾.

Feeling guilt and frustration at the death of patients is reported in the literature as coming from the feeling of not reaching the goal by the professional, representing an action failed^{(1, 2)}. However, nursing has a philosophy to assist individuals in their entirety in order to cover the physical, emotional, social and spiritual, including the guarantee of a dignified death⁽⁷⁾.

The professionals who perform their duties in emergency rooms with patients living in unstable conditions of health and death it is part of everyday life. In the death scene of emergencies becomes permeated with many surprises and questions, causing fear and insecurity. Reviewing one's own feelings and the concept of death is the strategy that the professional can use right now⁽⁷⁾.

The testimony of nurses emphasizes a number of specific situations in the polytraumatized experience of death. The evidence of death is a constant in the lives of professionals and this notion has a transformative impact on association with the living.

Trauma is an event that victimizes, in most cases, young people, in their productive of his life⁽⁸⁾. Inevitably, this issue refers professionals to different reflections, since death is seen differently by individuals in different stages of life⁽⁵⁾.

The reactions in the face of human finitude are dynamic and diverse and will be modified to the extent that patients and their families experience different stages of the health-illness and death⁽⁵⁾.

So even though this issue to trigger various feelings, usually of dismay, depending on the suffering that humans are exposed, it is possible that the professional does not want the death to the patient, but accepted the situation of death as relief for what seems be cruel and painful⁽¹⁾.

However, in sudden death, such as trauma, this dynamism is replaced by the sudden loss, which awakens in different ways professionals to experience it, especially since the emerging thinking about the time of life that was lost by that person.

It ends up using the following thought: whereas in our society work tends to be fragmented by specialization, bureaucratization, tending to mechanism, impregnated with rules and routines, focusing on requirements, sometimes obsolete or exaggerated that often prevent the man to transform and recreate your work, it is important to grasp and understand the values underlying the different representations of the process of dying and death, in order to rescue them and integrate them into the mode of being, thinking, feeling and acting that give meaning to the professional activities ⁽⁵⁾.

FINAL CONSIDERATIONS

The trajectory showed that the subjects experience the dilemmas punctuated by the literature on the experience of death in trauma victims in the emergency room.

Study on the experience of death creates a huge number of context and controversy because even this at some point in life of every human being is still a difficult issue to be experienced and mainly accepted. The confrontation with this situation is a challenge for health professionals that, while prepared to reclaim lives, facing death daily.

This topic provides considerations beyond those where death is seen only as the cessation of bodily function or failure of a vital organ. It also demonstrated that when faced with death, nurses are not or are devoid of professionalism, feelings and emotions, as they are daily faced with this situation.

It is observed by subjects' speech as a form of protection that they try not to get involved with the patient and their history to facilitate the experience of death before. But the study population reported to be greater difficulty in experiencing the death of children in the emergency department, a fact that causes pain, distress and stress in nursing staff.

Thus, this study demonstrates the need to review issues related to death and dying process for continuing vocational training as they develop their activities surrounded by a lot of excitement and questions, since they were not prepared to work with death, and yes to life.

In order to prepare future professionals to deal with human beings in the process of life and death, this event is seen as part of the work process in health, develop nursing care in this context becomes essential.

For that you need to break down paradigms and change the look of the nursing staff on the subject, thus facilitating the experience of the team before the death of victims of trauma in the emergency room. Concomitantly, needs to be taken into consideration that victims of trauma, the vast majority are young people who are in full activity, healthy, and suddenly they are led to deaths due to traumatic circumstances, a fact that only makes it difficult to accept and experience this event.

You could say that this matter is not handled the way it should easily accepted by the professionals to talk about death. However, any professional in the area is subject to deal with this situation at some point in their work and should be prepared to direct his team during the emergency care and, especially, after confirmation of death of the victim.

REFERENCES

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Authors’ contribution:

Pesquisa bibliográfica: Ferreira, Sabatke, Montezeli, Venturi

Coleta dos dados: Ferreira, Sabatke

Concepção e desenho: Montezeli

Fundamentação dos resultados: Ferreira, Sabatke

Análise dos dados: Montezeli, Venturi

Revisão crítica do artigo: Venturi

Aprovação final do artigo: Montezeli, Venturi.

Received: 09/07/2011

Approved: 04/03/2012