How are Healthcare students taught about the physiology of dying?

Promotional abstract: We aim to promote discussion about teaching of physiology of death and dying to Healthcare students. Knowledge of body systems is expected as part of training of healthcare professionals, so we examine content from textbooks related to mechanisms that are common to terminal illness and sudden death. We suggest that Healthcare students who are caring for patients and their families benefit from clear, honest explanations of what is happening at the end of life. We make suggestions about ways to introduce physiology of death and dying in workshops with the aim of alleviating anxiety and distress.

Key concepts to be addressed, including, where possible, the international relevance: There are an almost infinite number of different possible causes of death, but the fundamental mechanisms underlying the dying process and death itself are universal. There is an expectation that Healthcare students develop understanding of anatomy and physiology as part of their training, so that they develop competence to plan, organise and implement care across the lifespan (Biosciences in Nurse education, 2016; College of Paramedics, 2019; General Medical Council, 2018; Nursing and Midwifery Council, 2018). However, our experience of teaching physiology across the range of professions suggests that we, as educators, are rarely called upon to explain or discuss the physiological processes leading to death and dying, even during teaching about palliative care and end of life.

Aim(s)/focus: The aim of the investigation was to determine the extent to which physiology of death and dying was included in 150 physiology, nursing, medicine, paramedic science and pathophysiology textbooks and 30 curriculum documents for Healthcare programmes were also examined. Keywords and index terms used to examine the texts for terminology and content included death, dying, end of life. The majority of textbooks included explanations of mechanisms for cell death, while some examined palliative care, brain death and mortality. The most infrequently used term was dying, which suggests that this was not considered to be a key physiological process by many authors.

Evidence base and literature informing the arguments: Observable alterations towards the end of life include increased somnolence, mottling of the skin and reduced ability to maintain consciousness (Minett & Ginesi, 2020). Students and family members may come across expressions like Cheyne-Stokes respiration and “death rattle” (Hui et al., 2014) but these terms alone, without further description, do very little to explain the physiological changes which are happening in the dying person. The process, and the basis for clinical observations, can be attributed to a much more finite range of physiological mechanisms. For example, muscle atrophy related to cancer is predominantly attributed to an increased rate of protein degradation, as a consequence of impaired nutrient availability, that is aggravated by the metabolic disturbances induced by the multiplex of factors released by the tumour (Aversa, Costelli & Muscaritoli, 2017). When death is imminent, cyclic alterations in cardiovascular and neurological activity, exemplified by fluctuations in heart rate, blood pressure and muscle sympathetic nerve activity (MSNA) (Cherniack, Longobardo & Evangelista, 2005) progressively lead to poor perfusion of tissues, failure of respiratory drive, hypoxia and irreversible metabolic disturbance and progression to organ failure.

Issues for debate: We appreciate that the multitude of mechanisms and causes of death cannot always be attributed to underlying physiological changes in isolation. Unique to every individual, death may occur suddenly and unexpectedly (Hillman, 2003) or may be a more gradual process and there is an undeniable distinction between the trajectory of a death attributed to a terminal illness and sudden death.

Three key points to indicate how your work contributes to knowledge development within the selected theme: Just as knowledge of systems anatomy and physiology is expected as part of the education of healthcare professionals, we make suggestions about introducing discussion about the physiology of death and dying in student sessions. We propose that there is an opportunity to improve students’ understanding of physiological processes that lead to terminal changes including apnoeic breathing, dysphagia and agitation that occur towards the end of life. Healthcare students who are caring for patients will benefit from clear, calm and honest explanations of what is happening and of what might be expected when death is imminent can alleviate anxiety & distress (Mannix, 2018)

References:
Aversa, Z., Costelli, P. & Muscaritoli, M. (2017) ‘Cancer-induced muscle wasting: latest findings in prevention and treatment’. Therapeutic Advances in Medical Oncology, 9(5), 369-82.
Biosciences in Nurse Education (2016) Quality Assurance Framework for Biosciences
Education in Nursing [Online] Available from: https://www.advance-he.ac.uk/knowledgehub/biosciences-nursing-education-developing-quality-assurance-framework-b-qaf-net2017 (Accessed 25/02/22).
Cherniack, N.S., Longobardo, G. & Evangelista, C.J. (2005) ‘Causes of Cheyne-Stokes respiration’. Neurocritical Care, 3(3), 271-79.
General Medical Council (2018) Standards and Outcomes [Online] Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-andoutcomes/outcomes-for-graduates (Accessed 25/02/22).
Hillman, H. (2003) ‘The physiology of sudden violent death’. Resuscitation, 56(2), 129-133.
Hui, D., Santos, R., Chisholm, G. et al., (2014) ‘Clinical signs of impending death in cancer patients’. Oncologist,19(6), 681-87.
Mannix, K. (2018) With the End in Mind: How to Live & Die Well. 1st Ed. London: HarperCollins Publishers.
Minett, P. & Ginesi, L. (2020) Anatomy and Physiology. An introduction for nursing and healthcare. Banbury, Oxon; Lantern. Chapter 17 [Online] Available from: https://www.lanternpublishing.com/titles/470-9781908625731-anatomy-physiology (Accessed 25/02/22).
Nursing and Midwifery Council (2018) Standards Framework for Nursing and Midwifery [Online] Available from: https://www.nmc.org.uk/standards-for-education andtraining/standards-framework-for-nursing-and-midwifery-education/ (Accessed 25/02/22).

Keywords: Healthcare Education. Physiology. Death. Dying.