Emotional distress and insecurity, generated by anticipation of death and the process of dying of oneself or significant others, which negatively effects one's quality of life.

Dysphoria

Expresses concern about caregiver strain

Expresses concern about the impact of one's death on significant other

Expresses deep sadness

Expresses fear of developing terminal illness

Expresses fear of loneliness

Expresses fear of loss of mental abilities when dying

Expresses fear of pain related to dying

Expresses fear of premature death

Expresses fear of prolonged dying process

Expresses fear of separation from loved ones

Expresses fear of suffering related to dying

Expresses fear of the dying process

Expresses fear of the unknown

Expresses powerlessness

Reports negative thoughts related to death and dying

NANDA-I Related Factors*

A diagnosis of a potentially terminal condition or impending death can cause this diagnosis. Additional factors can contribute to death anxiety.

Situational (Personal, Environmental)

Related to anticipation of adverse consequences of anesthesia*

Related to anticipation of impact of death on others*

Related to anticipation of pain*

Related to anticipation of suffering*

Related to awareness of imminent death*

Related to depressive symptoms*

Related to discussions on the topic of death*

Related to impaired religiosity*

Related to loneliness*

Related to low self-esteem*

Related to nonacceptance of own mortality*

Related to spiritual distress*

Related to uncertainty about encountering a higher power*

Related to uncertainty about life after death*

Related to uncertainty about the existence of a higher power*

Related to uncertainty of prognosis*

Related to unpleasant physical symptoms*

Related to personal conflict with palliative versus curative care

Related to conflict with family regarding palliative versus curative care

Related to fear of being a burden

Related to fear of unmanageable pain

Related to fear of abandonment

Related to unresolved conflict (family, friends)

Related to fear that one's life lacked meaning

Related to social disengagement

Individuals experiencing terminal care of significant other

Individuals receiving terminal care tolerance

Individuals with history of adverse experiences with death of significant others

Individuals with history of near death experience

Older adults

Women

Young adults

Depression

Stigmatized illnesses with high fear of death

Terminal illness

AUTHOR'S NOTE

The inclusion of Death Anxiety in the NANDA classification creates a diagnostic category with the etiology in the label. This opens the NANDA list to many diagnostic labels with etiology (e.g., separation anxiety, failure anxiety, and travel anxiety). Many diagnostic labels can take this same path: fear as claustrophobic fear, diarrhea as traveler's diarrhea, decisional conflict as end-of-life decisional conflict.

Specifically, end-of-life situations create multiple responses in individuals and significant others. Some of these are shared and expected of those involved. These responses could be described with a syndrome known as end-of-life syndrome. This author recommends its development by nurses engaged in palliative and hospice care.

The individual will report diminished anxiety or fear, as evidenced by the following indicators:

• Shares his or her decisions regarding end-of-life care.
• Identifies specific requests that will increase psychological comfort.
• Relates that significant others were involved in discussions of end of life.

Level 3 Advanced Focused Assessment (all settings)

Does the individual have a potentially terminal illness?

What is their understanding?

What is his or her understanding of the significant others?

Are their perspectives the same? If not, why?

Is there an understanding of treatment care versus supportive/comfort care?

Has the individual had a discussion with their healthcare professional regarding end-of-life care options?

Determine if the individual has an advance directive or advance care planning. If not, explain or access the designated professional to explain advance care planning.

R:Advanced care planning results in a lower risk of stress, anxiety, and depression in surviving relatives of deceased persons, probably because they were required to make these decisions. Their role was ensuring the decisions were honored. In addition, most individuals and families welcome these discussions and therefore feel better prepared to make decisions for their loved one. Advance care planning spares the individual of unnecessary treatments and also reduces the cost of end-of-life care (Silveira, 2020).

For an Individual with a New or Early Diagnosis of a Potentially Terminal Condition:

• Allow the individual and family separate opportunities to discuss their understanding of the condition. Correct misinformation.
• Ensure access to valid information regarding condition, treatment options, and stage of condition from primary provider (physician, nurse practitioner, physician assistant).
• Ensure a discussion of the prognosis if known.

R:With a diagnosis of a potential terminal illness, individuals and families should be given opportunities to talk about treatments, cures, and goals regarding quality of life (e.g., treatment versus supportive/comfort care).

AUTHOR'S NOTE

After practicing as a nurse practitioner in a primary care practice for 22 years, this author now practices in an assisted living and dementia facility. Residents (if cognitively able) and their families are required to review a document regarding end-of-life decisions. These documents focus on options if the person's heart stops. They do not address hospice care. Hospice care should be discussed at the same time. A competent adult, not their relatives, should choose how and where they want to be when dying. If professionals and the families do not know their loved one's wishes, serious problems can arise.

When someone begins to decline, some families deny that their loved one is on a different journey. This can prevent them from agreeing to hospice. Their loved one will not have access to all the services that enable a "good death." It is a violation of a nurse's professional and moral code to allow a family to deny their loved one a peaceful death because they are in denial or have a conflicted history with their loved one. I call a meeting with the family and review the data to support their loved one is failing and that, without hospice, their loved one will eventually be in the hospital to die. I discuss with them the difference of dying in this facility versus a hospital. No one wants someone they love to die in a hospital, thus hospice begins to appear more desirable.

For the Individual Experiencing a Progression of a Terminal Illness:

• Explore the person's perceptions of the situation.
• Explore their fears, expectations, and their experiences with a dying friend or relative.

R:It is important to determine their understanding of the situation in order to clarify and dispel misinformation if indicated.

• Ensure that the primary physician, nurse practitioner, or physician assistant initiate a discussion regarding the situation and options desired by the individual.
• Provide opportunities for the person to discuss end-of-life decisions. Be direct and empathetic.

R:Clover et al. (*2004) found that a person's readiness to participate in end-of-life decisions depends on the skills of the professional nurse to engage and encourage the individual to divulge his or her wishes.

R:These discussions provide insight into the individual's understanding and direct treatment decisions. Research reports that only 31% of persons with terminal conditions reported end-of-life discussions with a physician (*Wright, 2008).

• Discuss palliative/hospice care with the individual and family separately initially and then jointly. Explain that hospice care is a change of focus from cure to providing comfort on this last journey. This journey may take weeks or months but the focus is the same—comfort.
• Explain care strategies that can be used for dyspnea, pain, and other discomforts (Yarbro, Wujcik, & Gobel, 2018).

R:During the final stage of life, anxiety for the individual and family is highly correlated with the presence or fear of other symptoms, such as dyspnea, pain, and fear of the unknown (Yarbro, Wujcik, & Gobel, 2018).

• Explain to family the changes in their loved one that may occur as death nears (anorexia, slowed respirations, weakness, cool extremities) (Yarbro, Wujcik, & Gobel, 2018).

R:Clear, direct discussions can reduce the family's anxiety when these signs and symptoms occur (Yarbro, Wujcik, & Gobel, 2018).

• Avoid giving a specific time for the expected time of death. "It is helpful to give a range of time, such as ‘hours to days,' ‘days to weeks,' or ‘weeks to months'" (Yarbro, Wujcik, & Gobel, 2018).

R:Family members and friends will be able to better plan their time spent with their loved one with this information (Yarbro, Wujcik, & Gobel, 2018).

• Allow significant others opportunities to share their perceptions and concerns. Advise them that sadness is expected and normal.

R:Clarification is needed to determine if their concerns regarding end-of-life care are consistent with the client. "It is normal and healthy to feel sad at the end of life, to grieve the impending loss of everything a person holds dear" (*Coombs-Lee, 2000, p. 12).

• Discuss the value of truthful conversations (e.g., sorrow, mistakes, disagreements).

R:"Avoiding truthful conversations does not bring hope and comfort: it brings isolation and loneliness" (*Coombs-Lee, 2000, p.12).

• To foster psychospiritual growth, open dialogue specifically (*Yokimo, 2009, p. 700):
  • If your time is indeed shortened, what do you need to get done?
  • Are there people whom you need to contact in order to resolve feelings or unfinished business?
  • What do you want to do with the time you have left?
• If appropriate, offer to help the individual contact others to resolve conflicts (old or new) verbally or in writing. Validate that forgiveness is not a seeking reconciliation, "but a letting go of a hurt" (*Yakimo, 2004, p. 707).

R:"Asking for or providing forgiveness is a powerful healing tool" (*Yakimo, 2004, p. 706).

Level 2 Extended Interventions (pediatrics)

• Educate parents about the need to explain honestly and age appropriately the child's impending death; consult with experts as needed.

R:Chronically ill children with poor prognoses or terminal illnesses often know more about death than adults may think. "Children are harmed by what they do not know, by what they are not told, and by their misconceptions" (*Yakimo, 2004).

When someone else or a pet is dying or has died (*Yakimo, 2004):

• Explain what is happening or what happened.
• Ask the child how he or she feels.
• Have a funeral for the pet.
• Be specific that the child is not responsible for the death.
• Explain the funeral service, and discuss in detail what the child will see.
• Consult the child's health provider regarding if the child should witness an open coffin.
• Explain that adults will be sad and crying. Limit exposure.

Do not:

• Associate death with sleep.
• Force a young child to attend the funeral.
• Tell the child not to cry.
• Give a long, detailed explanation beyond the child's level of understanding.

R:Explanations regarding death need to be age-appropriate and factual to avoid misconceptions and escalation of fears (Hockenberry, Rodgers, & Wilson, 2018). Shielding older children from death and funerals does not prepare them for the reality of death.