10.1177/1054137303256534ARTICLEILLNESS, CRISIS & LOSS (October 2003)Ulla et al. / COPING WITH DEATHTheory & Research

Coping with Death:Perceptions of Health Care Professionals

Working in a Pediatric Intensive Care Unitand in a Geriatric Service

Sara UllaUniversidad de Castilla–La Mancha

Cristina CocaCarolina del Rincón

José L. DíazUniversity Hospital La Paz Madrid

Eduardo A. RemorUniversidad Autónoma de Madrid

Pilar ArranzUniversity Hospital La Paz Madrid

Ramón BayésUniversidad Autónoma de Barcelona

Many health care professionals have to deal regularly with their patients’ deathsand 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 thiswork is to describe health care professionals’ perceptions about death. A group ofhealth care professionals who worked with children was compared with a groupwho worked with elderly people. Results showed that emotional aspects were per-ceived as more important than biomedical aspects in the death process. Betweenthe groups, some differences were detected relating to the perception of the proxim-ity of members’ own deaths, and the authors could also observe that the death of aloved one was perceived as more important than their own death. These results

318

Address correspondence to sara.ulla@uclm.es.

Illness, Crisis & Loss, Vol. 11, No. 4, October 2003 318-336DOI: 10.1177/1054137303256534© 2003 Sage Publications

should be taken into account to design training programs for health care profes-sionals 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 health-related advances have been achieved. Improvements in medical proce-dures, progresses in technology, and better quality of life conditionshave lead to an increase in life expectancy. At the turn of nineteenth cen-tury, life expectancy did not surpass 35 years of age, and in the presentday, it has reached 77 years (Eurostat 2001). The main function of medi-cine is not to provide the human immortality but to offer a higher qualityof life (Carné 1993), and, therefore, the main objective of health assis-tance is to maximize patients’ well-being (Bayés 2000; Rodríguez-Marín1994).

Taking this into consideration, and bearing in mind end-of-life, thetraditional health care paradigm has changed from “there is nothing elsewe can do” to “there is so much more that we are able to do.” As DavidCallahan has pointed out (2000), for the medicine of the twenty-first cen-tury, helping a patient to have a peaceful death is as important as avert-ing death.

Especially relevant in this direction are the health care professionals’attitudes toward death (Rainey 1984). In addition to coping with theirpatients’ 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 tomerge different proposals that broach the attitudes about death. Most ofthem have stated the basis of the psychological approaches, but theycould not be considered as strict psychological theories. Furthermore,most of the actual psychological models have pointed out the negativeattitudes about death, mainly fear and anxiety. Most of them establish avision of anxiety about death as a relatively stable characteristic thatprobably remains for a long period of time, but just a few studies haveconsidered the positive attitudes and their practical implications.

Several studies have been accomplished within the past few years toestablish the real influence of different variables such as age, gender, andoccupation on attitudes toward death. Regarding the investigationabout anxiety before death, contradictory results were obtained whencomparing different age groups. Some studies found differencesbetween age groups (Gesser, Wong, and Reker 1988; Rasmussen andBrems 1996; Stevens, Cooper, and Thomas 1980), others found onlyslight differences regarding this variable (Gorsuch and Venable 1983;

Ulla et al. / COPING WITH DEATH 319

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 andattitudes about death. Pollak (1979) carried out a revision, finding thatmost of the studies pointed out a higher fear in women in coping withdeath. Subsequent studies found that women reported more anxietyabout death than men (Rigdon and Epting 1985; Thorson and Powell1988), and this was also observed in specific samples such as universitywomen (Davis et al. 1983), high school students (Young and Daniels1980), and elderly women (Sanders, Poole, and Rivero 1980). Theseresults were also coherent with transcultural studies, and some authorsconsider it a universal phenomenon (McMordie and Kumar 1984). How-ever, we found studies that did not find differences between genders(Eggerman and Dustin 1985; Marks 1986; Viney 1984) and studies thatfound the opposite results. Cole (1978) found the opposite results; in hisstudy, men reported more anxiety in coping with death than women,and Krieger, Epting, and Leitner (1974) also suggested that men per-ceived their own and others’ deaths more threatening than women.

Other studies have investigated the relation between the occupationand attitudes about death. Bené and Foxall (1991) and Frommelt (1991)reported that hospice or palliative-care nurses had more positive atti-tudes than nonpalliative care nurses. Other study found that MD stu-dents were more afraid of the death procedure than lawyers (Fang andHowell 1976), and Linn, Moravec, and Zeppa (1982) also found differ-ences related to the occupation. DePaola, Neimeyer, Lupfer, et al. (1992,[1994] 1997) evaluated a group of geriatric nursery staff and anothergroup of professionals who worked in a different environment. Theyfound that the geriatric group showed less fear about people dying andless preoccupation about the death of a loved one. The authors empha-sized the importance of taking into account not only the attitudes aboutthe patients’ death but also attitudes about their own death (DePaola,Neimeyer, Lupfer, et al. 1992; DePaola, Neimeyer, and Ross 1994). Otherauthors have also affirmed that those people involved in critical situa-tions have more death-related fear than those who make no relatedactivities to the death process (Lattanner and Hayslip 1984; Servaty,Krejci, and Hayslip, 1996). But as we can see, other studies do not pointout the same conclusion, so there is still controversy related to occupa-tion influence because it can be considered as a fear-prevention factor oras a sensitizing determinant to increase death-related concerns.

Today, health care professionals are very keen in the management ofsophisticated machines and in the application of complicated tech-niques, but they frequently feel impotent in coping with a patients’death (Ulla et al. 2001). The everyday practice shows that health careprofessionals find it difficult to deal with bereavement because of poor

320 ILLNESS, CRISIS & LOSS (October 2003)

training in communication skills, fear of being blamed, a perceived fail-ure in their skill, fear of expressing emotion, and their own fears aboutdeath (Williams et al. 2000). Therefore, to diminish these difficulties andto improve quality of care, the health care team should be trained tomanage the bereavement. Patients’ relatives also find difficulties in deal-ing with the death of a loved person, so we have to consider that the rela-tives’ perception of the health care team and the care provided to thedeceased family member can seriously affect the bereavement processand grief response. This issue does not affect only the bereaved but alsothe health care system because morbidity resulting from loss contributessubstantially to health care costs (Kissane 2000).

Considering the difficulties and potential handicap of developingpersonal skills to cope with issues related to the dying process (Gómezand Medrano 1998; Véliz-Pintos and Caballero de Akaki 2000), the firststep could be thinking about our own and others’ death (Eakes 1985;Vickio and Cavanaugh 1985). In this way, a pioneer study carried out inour country (Bayés et al. 2000) pointed out aspects that can help to die inpeace by asking health professionals about their possible process ofdying. This study found that there are neither end-of-life universal wor-ries nor needs, and there is a great variability in the individual percep-tions about end of life. No single route leads to a good death; the culturaland economic aspects, the age, gender, and the occupation can shape thisperception.

If each person feels his or her process of dying in a unique and nonne-gotiable way, and there is no one way of dying (Sanz-Ortiz 1985, 1997), itis fundamental that the health care professionals could think about theirown attitudes about death because these attitudes could optimize atten-tion and care provided to patients during critical situations (Sábado andLlistuella 2001).

One of those critical situations in which health care professionalshave to cope with death is in severe disease in childhood. Consideringour cultural aspects—shared in a logical way by the health care profes-sionals—we all have the tendency to deny a child’s death. In our opin-ion, this cultural attitude is reflected in the scarcity of units of childhoodpalliative care. During the twentieth century, childhood mortality hasexperienced a great decrease, and nowadays, we can talk about a 4.9 per-cent of mortality in the first years of life (Eurostat 2001). Just a centuryago, a child’s death was frequently assumed. Today, in our culture, it isconsidered as the most terrible experience.

Another serious situation encountered by health care professionals isthe mortality rate in geriatric areas. At the beginning of the twentiethcentury, only 26 percent of the newborns could reach the age of 65.Today, about 85 percent of human beings reach this age. Some studiesfound that older people reported less anxiety in coping with death

Ulla et al. / COPING WITH DEATH 321

(Feifel and Branscomb 1973; Wass and Myers 1982). Advanced societiestreat the death of elderly people with more naturalness than a child’sdeath, and even age was considered, until a few years ago, as a discrimi-natory criteria when older people needed specific benefits from someexpensive, limited, or scarce services or procedures such as the admis-sion in the intensive care units, coronary services, or surgery. We knowthat modern technology leads to therapeutic cruelty, but this is areproachable decision in every vital moment, and age has no reason to bea part of the criteria to taking decisions without considering other fac-tors. Actually, the inclusion of elderly patients in the intensive care unitshas 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 re-search; first, we know that the attitude toward child and elderly patients’death has changed and that it has important consequences to health careprofessionals; we also know that the attitudes about our own death havesome influence over the attitudes that health care professional have withtheir 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 iden-tify principal concerns—perceived by a group of physicians and nursesdedicated to pediatric intensive care and by a group of geriatrics profes-sionals—and to detect which aspects were considered to facilitate theprocess of dying.

METHOD

PARTICIPANTS

A group of seventy health professionals agreed to participate in thisresearch. To assess professionals who worked with elderly people andprofessionals who worked with children, two different groups wererecruited and evaluated, attending to their daily work characteristics.People who constituted group A (52.9 percent) were related to elderlypeople, and they were all working in different geriatric institutions.Group B (47.1 percent) was formed by a sample of professionals whoworked with children. They worked in the intensive pediatric care teamfrom a University General Hospital.

Demographic characteristics of the seventy participants in the studyinclude the following: the average age was 38.4 years (SD = 7.66), with arange from 24 to 60; 75.7 percent were women and 24.3 percent weremen; 44.3 percent were physicians, 32.9 percent were nurses, 18.6

322 ILLNESS, CRISIS & LOSS (October 2003)

percent nurse assistants, and 4.3 percent were social workers. These dataare presented in detail in Table 1.

MEASURES

Questionnaire UAB-99c. This is a thirty-seven-item self-report ques-tionnaire designed to assess perceptions and beliefs about death, mea-suring different aspects related to own death and to the death of a lovedone (Bayés et al. 2000).

Three parts can be differentiated in the questionnaire. The first partincluded one principal item about death perception: “At this moment,how far do you perceive your own death?” measured by a visual analog-ical scale (VAS, 10cm) from something very distant to something veryimmediate.

The second part assessed some aspects that could help a person to diein peace with the following question: “In the case that you were reallydying, to what extent do you believe that the following aspects couldhelp you to die in peace?” Alist of eleven aspects related to the process ofdying was presented; the professionals had to rate them separately in afive-point Likert-type scale, from 1 (not helpful at all) to 5 (very helpful).Later, professionals were requested to choose those two aspects from thepresented list that they considered as most important. Internal consis-tency for these eleven items was .80 (Cronbach’s alpha).

The third part assessed concerns about death, related to four differenttopics: own death, own process of dying, a loved one’s death, and aloved one’s process of dying. Participants had to answer to the following

Ulla et al. / COPING WITH DEATH 323

TABLE 1 Descriptive Characteristics of the Participants

Group A Group B Whole SampleCharacteristic (n = 37) % (n = 33) % (N = 70) %

GenderMen 37.8 14 9.1 3 24.3 17Women 62.2 23 90.9 30 75.7 53

Mean age (SD) years 38 39 38.4Profession

Physicians 70.3 26 15.2 5 44.3 31Nurses 10.8 4 57.6 19 32.9 23Nurse assistants 10.8 4 27.3 9 18.6 13Social workers 8.1 3 — 4.3 3

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

question: “To what extent do the following aspects related to the deathand the death process worry you?” The professionals had to rateresponses, also in a five-point Likert-type scale from 1 (not at all) to 5 (verymuch).

Internal consistency coefficient (Cronbach’s alpha) of this sample inthe twelve items from this third part was .82. In the four subscales—worries about death—coefficients were .65, .60, .76, and .69; correspond-ing to own death, own death process, death of the loved person, and thedeath process of the loved person, respectively.

PROCEDURE

The questionnaire UAB-99c was administered to both groups ofhealth care professionals in similar contexts, enclosed in training pro-grams. Participants of the group A (working with elderly) were allattending a counseling training meeting, where they were asked toanswer the questionnaire. Participants of the group B (working withchildren) were all attending a specific counseling training program,and they were asked to fill in the questionnaire at the beginning of thetraining course. Every participant of both groups agreed to partici-pate voluntarily, and they took approximately 10 minutes to fill out thequestionnaire.

DATA ANALYSIS

Descriptive analysis and nonparametrical tests were computed toobtain samples characteristics and to identify distribution differences.T-scores for death proximity perception were calculated with referenceto gender and groups data. To analyze differences in aspects that couldhelp one to die in peace, and in death-related concerns, t tests or z tests(attending to sample and variables characteristics) were computed toidentify gender, profession, and groups’ influences.

RESULTS

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

324 ILLNESS, CRISIS & LOSS (October 2003)

Addressing the perception about the proximity of own death, resultsfor 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 prox-imity of own death are related to the type of patient with the professionalwork, so those who worked with elderly people perceived their owndeath nearer than those who worked with children.

We could also detect gender differences (t = –2.021; p = .047) in the per-ception of the proximity of their own death. Men reported to perceivetheir own death as something nearer (mean = 3.88) than women did(2.54). We tested the possible influence of interaction by means of aregression analysis, but the variable group-gender interaction did notpredict perceived proximity of the own death. So we can affirm that gen-der-mediated differences were independent from group-mediateddifferences.

Regarding those aspects that could help people to die in peace—assessed in the second part of the questionnaire—we could detect somedifferences between groups A and B, as can be seen in detail in Table 2.Those professionals who worked with children reported the followingaspects 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 controlthoughts and psychological functions; item d, think that their own deathwill not be an unbearable burden for loved ones; item e, be able to com-municate with loved ones; item f, not to have their own life artificially

Ulla et al. / COPING WITH DEATH 325

0

1

2

3

4

5

A B C D E F G H I J K

Groups (A vs. B) differences

Group A

Group B

FIGURE 1 Aspects That Could Help One to Die in Peace in BothGroups of Professionals.

NOTE: Group A = professionals who work with the elderly. Group B = professionals whowork with children.

326 TABLE 2 Aspects That Could Help One to Die in Peace

Group Group Contrast Contrast OnlyItem A B (z) Men Women (z) Womena

A. To think that doctors can control my pain and otheruncomfortable symptoms 3.8 4.2 n.s. 3.76 4.1 n.s. n.s.

B. To think that my process of dying, if it makes me suffer,will be short 3.5 4.5 –3.777*** 3.47 4.13 –2.34* –2.913**

C. To think that I will be able to control my thoughts andpsychological functions until the end 4 4.3 –2.132* 4.17 4.17 n.s. n.s.

D. To think that my death or my disappearance won’t supposean unbearable burden (economic, affective, or of another type)for my loved ones 3.9 4.5 –2.846** 3.88 4.32 –1.979* n.s.

E. To feel near, to communicate and to narrow affective bondswith my loved ones 4.2 4.7 –2.496* 4.29 4.52 n.s. n.s.

F. To think that if I don’t have a real hope of recovery, my lifewon’t be prolonged artificially 3.8 4.6 –3.596*** 3.82 4.34 –2.592** –2.441*

G. To think that my life has made some sense 4.2 4.2 n.s. 4 4.3 n.s. n.s.H. To believe in another life after death 2.4 2.7 n.s. 2.82 2.52 n.s. n.s.I. Not feeling guilty (or be forgiven) for personal conflicts of the

past 3.7 4.1 –2.018* 3.64 4.03 n.s. n.s.J. To think that if the situation is unbearable, I will have help to die 3.3 4.3 –3.76*** 3.11 4.03 –2.684** –3.189***K. To think that I will be able to die at home 3.3 2.7 n.s. 3.35 2.98 n.s. –2.269*

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

prolonged; item i, not to feel guilty; and item j, have help to die, ifunbearable. These differences can also be observed in Figure 1, where wecan see similar patterns for both groups, although the professionals whoworked with children reported higher scores.

Also, some of these differences were detected between men andwomen (see Table 2). Particularly, significant differences were observedin items b, d, f, and j. Thus, to identify interaction group-sex effects, weagain performed these analyses selecting only women from bothgroups; if every effect was modulated by group variable, differencesshould disappear. We observed that some differences also remained inthis case (items b, f, and j). Also, a new difference appeared, related toitem k that addresses the thought about dying at home, in which womenwho worked with the elderly reported it as more helpful than those whoworked with children. The last column of the Table 2 shows these statis-tical differences that women from groups Aand B reported to perceive inaspects that could help to die in peace.

Table 3 shows the answer percentages, presenting the priority of thedifferent aspects perceived as helpful to die in peace for the wholegroup. Apparent differences were found when taking into account per-centages of priority between groups and gender, except in item e (to feelnear, communicate, and narrow affective bonds with loved ones) thatwas selected in first place for everyone (see Table 4).

To analyze concerns in the perceptions of death and death process forthe whole sample—assessed in the third part of the questionnaire—wecomputed 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 aloved one; these are presented graphically in the Figure 2. Apparentdifferences are supported with statistical differences, as presented inTable 5, and the most remarkable ones are those established betweentheir own death and whichever other topic. It is also remarkable thatthere are no differences between a loved one’s death and a loved one’sdeath process being both the highest concerns.

To verify differences moderated by the people professionals assistdaily, we contrasted both groups of professionals: A versus B. As pre-sented in Table 6, considering the questions about the worries related todeath and the death process, some significant differences were foundbetween the groups. Gender-modulated differences only were observedin relation to the following items, where women reported a higherconcern: “an unbearable continuous pain” (z = –1.997; p = .046), “notbeing 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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328 ILLNESS, CRISIS & LOSS (October 2003)

TABLE 3 Percentages and Priority Ranking of the Different AspectsPerceived as Helpful to Die in Peace for the Whole Group

PercentageWhole Group Priority

To feel near, to communicate, and to narrow affectivebonds with my loved ones (item e) 22.0 1

To think that my death or my disappearance won’tsuppose an unbearable burden (economic, affective,or of another type) for my loved ones (item d) 15.2 2

To think that doctors can control my pain and otheruncomfortable symptoms (item a) 13.6 3

To think that my life has made some sense (item g) 12.1 4To think that I will be able to control my thoughts and

psychological functions until the end (item c) 11.4 5To think that my process of dying, if it makes me suffer,

it will be short (item b) 8.3 6To think that if I don’t have a real hope of recovery,

my life won’t be prolonged artificially (item f) 5.3 7Not feeling guilty (or be forgiven) for personal conflicts

of the past (item i) 4.5 8To believe in another life after death (item h) 3 9To think that if the situation is unbearable, I will have

help to die (item j) 3 9To think that I will be able to die at home (item k) 1.5 11

TABLE 4 Percentages and Priority Ranking of the Different AspectsPerceived as Helpful to Die in Peace for Both Groups andfor Each Gender

Children Elderly Women Men

Item % Priority % Priority % Priority % Priority

A. 13.3 3 16.2 2 14.3 3 11.8 3B. 10.3 4 6.8 6 9.2 5 5.9 6C. 8.6 5 13.5 4 9.2 5 17.6 2D. 17.2 2 13.5 4 16.3 2 11.8 3E. 20.7 1 23 1 19.4 1 29.4 1F. 6.9 7 4.1 7 6.1 7 2.9 7G. 8.6 5 14.9 3 12.2 4 11.8 3H. 3.4 10 2.7 9 3.1 10 2.9 7I. 5.2 9 4.1 7 5.1 8 2.9 7J. 6.9 7 — — 4.1 9 —K. 1.7 11 1.4 10 1 11 2.9 7

DISCUSSION

The main objectives of this work were to describe death-related per-ceptions in health care professionals and to analyze personal and situa-tional factors that could modulate these perceptions. An early and broadanalysis led us to affirm that professionals who work with patients incritical situations and with the terminally ill appraise emotional aspectsin a higher degree and priority than biomedical aspects in the process ofdying. These results coincided with previous studies (Bayés 2000). How-ever, as we could see in items priority, each person—according to his orher different worries or necessities—perceives the process of dying indifferent 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

Ulla et al. / COPING WITH DEATH 329

21,07

21,25

20,12

14,65

0 5 10 15 20 25

Death process of thedearest one

Death of dearest one

Own death process

Own death

FIGURE 2 Scores in the Four Assessed Areas of Death-RelatedConcerns

TABLE 5 Differences between Concerns in the Death-Related AreasAssessed

Own Own Death Loved One’sDeath Process Death

Own death process z = –6.822***Loved one’s death z = –6.919*** z = –2.642**Loved one’s death process z = –6.996*** z = –2.439* n.s.

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

330 ILLNESS, CRISIS & LOSS (October 2003)

TABLE 6 Differences between Group of Health Professionals inDeath-Process-Related Concerns

Means

Whole Group Group ContrastGroup A B (z Test)

About one’s own deathTo lose everything you have in this

life 2.39 2.0 2.8 –2.375*Not being able to feel or think any

more 2.81 2.9 2.6 n.s.The total impossibility of

communication 3.04 3.1 2.9 n.s.That nobody remembers you after

your death 2.95 2.7 3.1 n.s.To die young 3.61 3.9 3.9 n.s.

Own process of dyingAn unbearable, continuous pain 4.47 4.3 4.6 –2.264*To lose control of my physiologic

functions 4.0 3.9 4.0 n.s.The deterioration of my mental

capacities 4.25 4.0 4.4 –2.486*The possibility to die alone, without

the presence of loved ones 4.26 4.1 4.4 –2.197*Uncertainty involved in the processof dying 3.6 3.4 3.7 n.s.

The loved one’s deathHis/her definitive loss 4.53 4.5 4.4 n.s.The fact that I won’t be able to see, to

feel, or to hear him/her any more 4.48 4.4 4.5 n.s.Not being able to communicate with

him/her any more 4.31 4.2 4.4 n.s.To regret not to have taken more

advantage of his/her companywhen they were alive 4.44 4.3 4.5 n.s.

To feel lonely without him/her 3.91 3.5 4.3 –3.405***The process of dying of the loved one

To watch his/her pain and suffering 4.63 3.5 4.7 n.s.To watch him/her losing control of

physiological capacities 3.52 3.3 3.7 n.s.To watch his/her mental deterioration 4.08 3.7 4.4 –3.047**To think that he/she could die alone

without the presence of loved ones 4.47 4.1 4.8 –3.337***To feel powerless to help him/her 4.75 4.6 4.8 n.s.

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

influenced by the type of patient the professional works with. Thus,those who worked with elderly people perceived their own death nearerthan those who worked with children. We could also see that menreported to perceive their own death as something nearer than womendid. This seems to be incoherent with those studies that have reported ageneralized higher death related anxiety in women (Rigdon and Epting1985; Thorson and Powell 1988), therefore more research is neededbecause some intervenient variables may be modulating both death-related dimensions.

We could identify which were the most and the least helpful issues todie in peace. We could see that the first- and second-ranked circum-stances perceived as helpful to die in peace were related to the relation-ships with the loved persons: to feel near, to communicate and to narrowaffective bonds with loved ones, and to think that their own death willnot suppose an unbearable burden for the loved ones. On the other side,least valuable aspects were related to have help to die if the situationbecomes unbearable and to have the possibility to die at home. We wantto remark also that we could detect important differences related towork context and related to gender so that professionals who work withelderly people have different perceptions than professionals who workwith children. We could also observe that men and women have somedifferent perceptions about death and the death process. For women,some aspects are worthier than for men, and we can affirm that womenwould rather have a short process of dying, which is not prolonged arti-ficially, they would like to have help to die if it is unbearable, and are spe-cially concerned about relatives’ pain.

On the topic of the results about death-related worries, it is importantto remark that the highest concern associated with own life was to dieyoung, and the least valued was to lose everything one has in this life.About the own death process, the highest concern was suffering unbear-able pain, and the lowest was the uncertainty associated with death. Inrelation to the death of the person that professionals felt closest to, themost important issue was his or her definite loss, and the least importantwas to feel lonely without him or her. Also linked to a loved one, but nowto the process of death, the highest concern was to feel without resourcesto help him or her, and the least important was to watch him or her losingcontrol of physiological functions.

We could also detect that aspects related to a loved one’s death and hisor her death processes were perceived as the most important worries,higher than those related to own death. This is a relevant finding for theconsideration of the relatives in the death process in different situations,such as emergency departments, geriatric institutions, palliative ser-vices, and those places where people find death. According to the per-ception found in this study, we can affirm that a loved one’s death is

Ulla et al. / COPING WITH DEATH 331

perceived as much more important than their own death. Undoubtedly,this must be a central point of attention to guide intervention withpatients’ relatives before, during, and after the bereavement.

We want to emphasize the necessity of continuous research on theconditions that help people in the process of dying, bearing in mind eachindividual’s values, to help them to find a peaceful death. In this work,we studied the perception of health professionals who work directlywith terminally ill patients because we believe that it is a good way tomotivate these professionals to think and work out a comprehensivecare program to help people die in peace.

Nevertheless, we have to mention some methodological limitationsof this study that should be addressed and explored in future studies. Aswe have explained, we have compared two groups, but these presentedsome differences that could affect some of the results. One of them wasalready mentioned, and it concerns the imbalance within groups regard-ing sex and profession; women mostly composed both groups, but oneof them had a predominant group of physicians and in the other mostparticipants were nurses. We have taken it into account and we havecomputed analyses to control it, but we are conscious that an experimen-tal control is better than a statistical one. The second issue is related to thework environment; we have compared geriatric and pediatric profes-sionals, but the first group develops its work principally with chronicpatients, while the second does it with children in acute situations. Thebetter comparison would be between four groups, with children andelderly care professionals, and in chronic and acute situations. But theproblem in finding those comparable groups has to do with the normallifecycle and also with health care guidelines. Most children who arechronically ill are not attended to continuously in a hospital or medicalinstitution. The medical policy tends to attend to them at a hospital onlyin critical situations and develop the daily care at children’s home. Onthe other hand, the elderly are more frequently attended to in institu-tions, also when they are not in a critical situation; and even when theyare ill and they have any kind of crisis, they are less frequently attendedto in an intensive care unit than younger people because this would bean 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 indepen-dent from other cognitive, behavioral, and affective structures and pro-cesses of each person; otherwise, these perceptions are perfectly insertedin a pretty complex frame of attitudes, behaviors, expectancies, attribu-tions, and emotions—which are undoubtedly modulated by the envi-ronment and the different contexts in which each person develops,works, and lives. So, every intervention, training design, program

332 ILLNESS, CRISIS & LOSS (October 2003)

implementation, or any other structured action must be perfectlyadapted to psychological characteristics of the people who are going tobe affected. It is not easy to deal with death; it has a pretty high cost forthe patient, and also for relatives and professionals. Taking into accountall the knowledge that systematic research supplies us with, led by aqualified practice, we can provide professionals, familiars, and termi-nally ill patients the best strategies to deal with death at the lowest psy-chological price.

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Sara Ulla, Ph.D., is a professor in the Department of Psychology at the Universidad deCastilla–La Mancha (Spain). Her main lines of work and research are related to health-related behaviors, psychoneuroimmunology, and psychooncology.

Cristina Coca is a researcher at the Section of Psychology of the Hematology Departmentat the University Hospital La Paz (Madrid, Spain). She is a specialist in psychologicalassessment and treatment in palliative care.

Carolina del Rincón is a health psychologist at the Section of Psychology of the Hematol-ogy Department at the University Hospital La Paz (Madrid, Spain). She has a master’sdegree in palliative care and is a predoctoral student.

José L. Díaz is a health psychologist at the University Hospital La Paz. He works withchronically ill patients with hemophilia.

Eduardo A. Remor, Ph.D., is a health psychologist teaching at the UniversidadAutónoma de Madrid (Spain) and working as a researcher at the University Hospital LaPaz (Madrid).

Pilar Arranz, Ph.D., is a clinical psychologist at the Section of Psychology of the Hema-tology Department, University Hospital La Paz (Madrid, Spain). She is an associate pro-fessor at the Public Health National School, Madrid, Spain.

Ramón Bayés, Ph.D., is a renowned researcher of the Spanish psychology. He is today anemeritus professor at the Universidad Autónoma de Barcelona and has a wide career inthe study and research of health psychology.

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