Aim: To identify evidence in the literature on the significance of death conferences for nurses. Method: This is an integrative literature review, consisting of scientific articles published on “Ichushi-Web”, an Internet-based retrieval service by the Japan Medical Abstracts Society (JAMAS), PubMed, Medline, Cochrane library, and Google Scholar for ‘the whole year,’ combining the keywords “death conference”, “nurse”, and “KJ method”. The significance of death conferences was reviewed by comparison of prior qualitative studies analyzed by the KJ method. Result: Seven studies, all from Japanese, were identified. The significance of death conferences showed “refraction”, “cooperation”, “directionality of nursing”, “caring for patient”, “caring for family”, “specific methods of nursing”, and “feelings of nurses”. Conclusion: The significance of death conferences is considered to be the effect on nurses for amelioration in the quality of patient and family care, development of human relations, and growth as a nurse. The quality of death conferences should be enhanced based on the guidelines for its clear definition.
Death conferences, which occur after the death of patients, are when the medical staff (nurses, doctors, and paramedics) gather and reflect on the care for them with a view to improving quality of care. Through discussions, it also encourages the growth of individual nurses [
For the purposes of this review, the definitions of terms are shown below. Death conference was defined as a place for looking back on the care given to a dying patient or family member. It is intended to lead to better care [
To conduct a literature review relating to the significance of death conferences for nurses in qualitative studies using the KJ method.
The review includes the result of observational (cross-sectional/longitudinal) studies which explored the significance of death conferences being a main outcome variable on nurses by comparison of prior qualitative studies analyzed by the KJ method. Through September 2016, the following databases, ‘Ichushi-Web,’ the Internet-based retrieval service by Japan Medical Abstracts Society (JAMAS) [
Articles were excluded if they were case reports, the research subjects who were not nurses, not focusing on the significance on the nurses, not with the KJ method, interviews, and re-listing of duplicate documents. No further restrictions were made.
Based on the preferred responding items for systematic reviews (PRISMA 2009) [
In terms of analytical method, as for the significance of DC, items to be aimed at each survey and the categories extracted by the KJ method are described. The categories in this research, the categories in each article are reclassified, indicated by [ ] as new main categories, and subcategories are shown in italics.
The selection process of the object to be analyzed and containing search terms and pre-research fraction is shown in
Even if documents were searched under ‘all’ conditions, they were only documents between 2007 and 2014 (
Authors, yr.* | Extraction category |
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Tanaka et al. 2014 [ | 1) Thoughts of nurses who support the decision-making of terminal cancer patients 2) Nursing intervention to support decision-making |
Adachi et al. 2012 [ | 1) Involvement with the patient’s family a) Respect family’s wishes b) Worry about the behavior and expressions of the patient’s family c) Responding to the first meet in a patient’s family at End-of-life care 2) Anxiety of postmortem treatment |
Koyama et al. 2012 [ | 1) Learning how to help terminally ill patients a) Learning through DCs b) Nurse’s thought towards End-of-life care c) Nurse’s anxiety and confusion 2) Self-reflection a) Reflection and future relations b) Skill level raise up 3) Concern with palliative care a) Learning of palliative care b) Patient-centered End-of-life care c) Nursing for End-of-life care d) Worthwhile 4) Team sharing and collaboration a) Sharing b) Cooperation c) Follow-up between staff d) Team solidarity 5) Collaboration with other professions Staff meeting and exchanges of views 6) Future direction of nursing care Continuing DC |
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Ishikawa et al. 2010 [ | 1) An inability to relieve a patient’s pain 2) Involvement with patients who have a gap in perceptions of the condition 3) The act of responding to a patient’s emotional expression and questions about patient’s remaining life 4) Dealing with family members of patients who seem to have difficulty involved 5) Involving ethical issues |
Kobayashi et al. 2010 [ | 1) Care review 2) Deepening of human understanding 3) Fulfillment of a patient’s wishes 4) Challenges for the future 5) Positive opinion for holding DCs 6) Ephemeral feelings for dying patients |
Tsuchie et al. 2010 [ | 1) Significance of expectations for DCs a) Sharing of values and specific measures b) Improvement of self-efficacy as a nurse and catharsis c) Sharing peace of mind, healing through conversation 2) A malfunctioning problem a) How to provide patient care b) How to plan (progress) DCs 3) Specific measures a) Planning of DCs b) A way of proceeding with a fixed purpose c) Considering member structure according to a purpose d) Respect, trust, and understand companionship 4) Aim a) Improvement of the practice of nursing in a hospital ward b) Growth of individual nurses |
Hasegawa et al. 2007 [ | 1) Care review 2) Sharing information and case studies with medical teams 3) DC learning 4) View of life and death 5) Expressing emotions |
*publishing year; DC: Death Conference.
into seven categories. [Reflection] Care review [
As mentioned from the definition of death conferences, the definition included the terms ‘nursing/care’ and ‘look back/review.’ The timing of a death conference review is divided into the concept of patient death, when the patient is dying, and post-patient death. No definitions included words about what nurses should do after death conferences.
In the literature search, some of the documents did not include the definition of death conferences. In those cases, it was unclear how each of the writers understood death conferences. In the future, the definitions of death conferences will need to be presented in order to make objective comparisons based on whether or not those states are true. Furthermore, ‘death conference’ was not a hit in the search for literature in English (using PubMed, Medline, and the Cochrane library), and it is likely that a guideline for definitions on death conferences will be necessary in the future.
In the context of DC’s significance, DC is seen as a place to share the future [direction] of nursing in the [Reflection] and [Cooperation] of patient care. It is also necessary to consider how to [respond to patients and families] and [specific measures for nursing] for nursing through discussion, and above all, to control [emotion of nurses] (
1) [Reflection] Care review-Self-reflection
Hasegawa [
In a questionnaire survey on the change in the staff members’ behavior by the DC in an acute ward [
above, in DCs, it may be possible to improve the quality of care and increase the motivation to work as a nurse by aiming to improve skills by evaluating and sharing nursing practices that were evaluated to have been good at the same time as the reflection. Care review and self-reflection conducted at DCs seem to improve the quality of patient and family care.
2) [Cooperation] Team sharing and collaboration, Collaboration with other professions, Sharing information and case studies with medical teams, and Deepening of human understanding.
Koyama et al. in his study indicated the effectiveness of sharing and cooperation. Among teams in DCs from the nurses’ opinions that talked about their problems, they felt encouragement and compassion among the nurses, and their teams grew more united [
Hasegawa reported that all 11 nurses at the mammary surgical ward replied before the DC that they felt ‘insufficient information sharing and collaboration with doctors,’ but at the post-DC interview, everyone was glad to have done it. Moreover, by analyzing the DC word-per-word, the researchers reported a change in the field of nurses’ opinions that they could recognize the amount of information each person had and confirm the importance of collaboration. The author describes the significance of the DC as a motivator to build close ties with the medical teams and as an opportunity to learn about each other from many different types of work [
3) The future [Direction] of nursing Future direction of nursing care, Challenges for the future, and Significance of expectation for DC (Sharing of values and specific measures).
Koyama et al. have cited Continuing DC as a subcategory for Future direction of nursing care [
4) [Response to patients] An inability to relieve a patient’s pain, Involvement with patients who have a gap in perceptions of the condition, and The act of responding to a patient’s emotional expression and questions about patient’s remaining life.
Stresses in nursing care of these nurses need to be expressed in concrete terms at DCs and supported by staff to reduce stress on the staff. In case the nurse has stress concerning unrelieved mental and physical pain in a patient, involvement with patients who have a gap in perceptions of their condition, and the act of responding to a patient’s emotional expression and questions about the patient’s remaining life, DCs have the significance as a place to present their stressful situations and share information. Moreover, understanding the status quo by the team can deepen the bonds between patients and family members and improve the quality of patient and family care.
5) [Response to patients’ family] Involvement with the patient’s family, Dealing with family members of patients who seem to have difficulty involved, and Involving ethical issues.
From a questionnaire survey of nurses for the introduction of DCs, Adachi et al. point out subcategories of Involvement with the patient’s family: Respect family’s wishes, Worry about the behavior and expressions of the patient’s family, and Responding to the first meet in a patient’s family at End-of-life care. They report that nurses were worried about when to talk to a patient’s family, how to explain, and what to say [
Ishikawa et al., report concerning dealing with family members of patients who seems to have difficulty involved, stressful situations in which family members’ aggressive feelings, speech, and behavior change, and when family members cannot accept the patient’s condition to the end. They also described Involving ethical issues, the stress of having nurse calls that are often made during night shifts when there are fewer nurses and the stressful feeling about whether it was really good to have detained a patient and sedated him because of delirium [
A study of Hasebe [
6) [Specific measures for nursing] Learning how to help terminally ill patients, DC learning, Anxiety of postmortem treatment, and Nursing intervention to support decision-making.
In a survey of 19 nurses at a DC on how they feel to support decision-making before dying for terminal cancer patients and their families, the decision-making support provided by nurses suggests “Continue to keep track of the patient’s family’s mood since the decision was made in daily communication and support through team medical care” [
7) [Feeling of nurses] Thoughts of nurses who support the decision-making of terminal cancer patients, Fulfillment of a patient’s wishes, Positive opinion for holding DCs, Ephemeral feelings for dying patients, View of life and death, Expressing emotions, Improvement of self-efficacy as a nurse and catharsis, and Concern with palliative care.
In post-DCs, Koyama et al. cited sub-categories of Learning of palliative care, Patient-centered End-of-life care, Nursing for End-of-life care and Worthwhile about concern with palliative care. They also said from their study that Nurses have come to think about what they should do from the heart of their patients and their families, felt a sense of challenge and achievement, have been able to face their life and are proud of their job [
Thoughts of nurses who support the decision-making of terminal cancer patients, awareness of the emotional reaction to a dying patient, satisfaction with satisfying patients’ wishes should be shared at DCs in order to stabilize the mind through talking. DCs should not be a place where nurses are denied and blamed through their constant reflection. DCs can raise nurses’ interest in palliative care, improvement in the quality of care and deepen their view of end-stage patient care. Reviewing the situation regarding improvement of nurse’s self-efficacy and their catharsis by the team’s support will lead to their growth of human relationships.
Nurses are expected to improve patient and family care, encourage their growth as nurses and human relationships, and maintain their motivation for nursing. For this reason, it will be necessary to reflect on terminal care and nursing at DCs. In the future, quantitative research on the effect of DCs on nurses, with self-evaluation of nursing at Terminal Care and DCs especially. Moreover, it is necessary to make guidelines on the definition of DCs and to develop an index or an evaluation scale capable of objectively measuring the effect of DCs on a nurse, concretely, nurses’ growth and change of behavior, mood, and the quality of care for patients.
1) This is an integrative literature review clarifying the definition and the significance of death conferences reviewed by comparison of seven prior studies analyzed mainly by the KJ method in the Internet-based retrieval service by Japan Medical Abstracts Society (JAMAS);
2) DCs are seen as a place to share the future [direction] of nursing in the [Reflection] and [Cooperation] of patient care. It is also necessary to consider how to [respond to patients and families] and [specific measures for nursing] for nursing through discussion, and above all, to control [emotions of nurses];
3) Improving the quality of DCs promotes the improvement of patient care quality and growth as a nurse, leading to the growth of human relationships.
The authors declare no conflicts of interest regarding the publication of this paper.
Harding, Y., Ando, M. and Yano, M. (2019) Literature Review on the Significance of Death Conferences for Nurses in Japan. Open Journal of Nursing, 9, 521-533. https://doi.org/10.4236/ojn.2019.95044
Category 1
a) Conception and Design: Harding Yuko;
b) Acquisition of Data: Harding Yuko, Michiyo Ando, Masako Yano;
c) Analysis and Interpretation of Data: Harding Yuko, Michiyo Ando, Masako Yano.
Category 2
a) Drafting the Article: Harding Yuko;
b) Revising for Intellectual Content: Harding Yuko, Michiyo Ando, Masako Yano.
Category 3
Final Approval of the Completed Article: Harding Yuko, Michiyo Ando, Masako Yano.