ABSTRACT

Objective

Identify the social, spiritual and ethical implications that have the death process and die for nursing students.

Methodology

A qualitative approach, of a descriptive character. Sample comprised of 19 fifth-year nursing students. The data collected were submitted to content analysis precepts, analyzed in the light of the principles of bioethics and related to the Theory of the Peaceful End of Life, by Ruland and Moore.

Results

Social implications are mainly related to experiences and the family approach, the spiritual meaning is linked to the transcendence of the spirit with an explanation that people are composed of a biological body that ends with death, and the stories about ethical implications show the importance of humanized care and the meaning of a dignified death.

Conclusion and implications for practice

Self-reflection about the meaning of death and its process, helps the student to respect the values and beliefs of the patient and his family regarding the process of finitude, and thus the dignified care. It is highlighted the nursing education process in relation to ethical aspects and the end of life.

Keywords:
Attitude to Death; Nursing Education; Hospital Care; Ethics Nursing

RESUMEN

Objetivo

Identificar las implicancias sociales, espirituales y éticas que tiene el proceso de muerte y morir para estudiantes de enfermería.

Metodología

Abordaje cualitativo, de carácter descriptivo. La muestra estuvo compuesta por 19 estudiantes de enfermería de quinto año. Los datos recolectados fueron sometidos a los preceptos de Análisis de Contenido, analizados a la luz de los principios bioéticos y relacionados con la Teoría del Final Tranquilo de la Vida, de Ruland y Moore.

Resultados

Las implicancias sociales se relacionan con las experiencias previas y el abordaje familiar, el significado espiritual está ligado a la trascendencia del espíritu como una explicación de que la persona se compone de un cuerpo biológico que termina con la muerte, y los relatos sobre las implicancias éticas muestran la importancia del cuidado humanizado y el significado de una muerte digna.

Conclusión e implicación para la práctica

La autorreflexión acerca del significado de la muerte y su proceso, ayuda al estudiante a respetar los valores y creencias del paciente y su familia con respecto al proceso de finitud, y por lo tanto, a propiciar un cuidado más digno. Destacamos el proceso de educación en enfermería con respecto a los aspectos éticos implicados en el final de la vida.

Palabras clave:
Actitud Frente a la Muerte; Educación en Enfermería; Atención Hospitalaria; Ética en Enfermería

RESUMO

Objetivo

Identificar as implicâncias sociais, espirituais e éticas que tem o processo de morte e morrer para estudantes de enfermagem.

Método

Abordagem qualitativa, de caráter descritivo. Amostra composta por 19 estudantes de enfermagem do quinto ano. Os dados coletados foram submetidos aos preceitos da Análise de Conteúdo, analisados à luz dos princípios da bioética e relacionados com a Teoria de Final de Vida Tranquilo, de Ruland e Moore.

Resultados

As implicâncias sociais são relacionadas com as experiências prévias e a abordagem familiar, o significado espiritual está ligado à transcendência do espírito com a explicação de que as pessoas se compõem de um corpo biológico que termina com a morte, e os relatos sobre as implicações éticas mostram a importância do cuidado humanizado e o significado de uma morte digna.

Conclusão e implicação para a prática

A autorreflexão acerca do significado da morte e seu processo, ajuda o estudante a respeitar os valores e crenças do paciente e de sua família em relação ao processo de finitude, e assim a entrega de um cuidado mais digno. Destaca-se o processo de educação em enfermagem em relação aos aspectos éticos que envolvem o final de vida.

Palavras-chave:
Atitude Frente à Morte; Educação em Enfermagem; Assistência Hospitalar; Ética em Enfermagem

INTRODUCTION

Currently, the criterion used to define death is brain function, because technological advances have made it possible to maintain cardiac and respiratory functions through life support measures, while nothing can be done to maintain brain functions. Death is not only the end of human existence, but it is preceded by different forms of losses that are part of human development. Many authors consider death as one of the few certainties in life that derives from a progressive phenomenon that begins at the time of conception.¹1 Oliveira ES, Agra G, Morais MF, Feitosa IP, Gouveia BLA, Costa MML. O processo de morte e morrer na percepção de acadêmicos de enfermagem. Rev. Enferm UFPE. 2016 May;10(5):1709-16.

2 Praxedes AM, Araújo JL, Nascimento EGC. A morte e o morrer no processo de formação do enfermeiro. Psicol Saude Doencas. 2018;19(2):369-76.^-33 Ivo OP, Pedroso KO. O processo da morte e do morrer: uma visão dos acadêmicos de enfermagem. Rev Psicol. 2017;11(34):305-21.

According to the above, death is not strictly a biological event, but a socially and culturally constructed process. The concepts of death have changed over time, which has already been considered as a natural process. From the twentieth century, death began to be seen as something that simply must be hidden, forbidden and denied, leaving aside the mourning and farewell rituals that were usual mainly in the home environment. Currently, death as a process has been medicalized. Therefore, in Western society, death ceased to be part of social life, dissipating the exchange of experiences among people about the process of dying.⁴4 Perboni JS, Zilli F, Oliveira SG. Profissionais de saúde e o processo de morte e morrer dos pacientes: uma revisão integrativa. Pers. Bioét. 2018;22(2):288-302.

Death has been treated by society as a condition of life, whose analogy between man and death is different from what it has with other transitory phenomena. It represents the temporary being that we all are, and our existence, as beings, is directly connected in this perspective.⁵5 Kempfer S, Carraro T. Temporality: existing and the perspective of finiteness for nursing students when experiencing death. Rev. Texto e Cont. Enferm. 2014 Jul;23(3):728-34. http://dx.doi.org/10.1590/0104-07072014001980013.
http://dx.doi.org/10.1590/0104-070720140...

The approach with the death of the other during the care process can generate concerns for the nursing professional because this contact can generate fear and anguish due to the awareness of the end and the fragility of life. Therefore, the nurse should try to deal with the feelings raised by this approach and everyone has to live or experience the sensation of seeing their patients die, in many cases, with few psychological tools, little institutional support and ignorance of techniques and therapeutic strategies of coping and self-help that they should have acquired during the nursing education process.⁶6 Mondragon-Sánchez E, Cordero EAT, Espinoza MLM, Landeros-Oliveira EA. Comparación del nivel de miedo a la muerte entre estudiantes y profesionales de enfermería en México. Rev. Latino-Am. Enfermagem. 2015 Mar;23(2):323-8. When the nursing student enters the field of hospital care in his academic training process, when witnessing the death of the other, he reflects on his own death and that of his loved ones, perceiving as finite and mortal.⁵5 Kempfer S, Carraro T. Temporality: existing and the perspective of finiteness for nursing students when experiencing death. Rev. Texto e Cont. Enferm. 2014 Jul;23(3):728-34. http://dx.doi.org/10.1590/0104-07072014001980013.
http://dx.doi.org/10.1590/0104-070720140...

Throughout the training process, the professional is trained to commit to the preservation of the patient's life, therefore, his academic education is directed by the care of the patient's cure, and this result is a sign of professional satisfaction, this characteristic reinforces how presence of death in general care routine feelings of lack of preparation and abstinence.⁷7 Luz KR, Vargas MAO, Barlem ELD, Schmitt PH, Ramos FRS, Meirelles BHS. Coping strategies for oncology nurses in high complexity. Rev Bras Enferm. 2016;69(1):59-71. http://dx.doi.org/10.1590/0034-7167.2016690109i. PMid:26871217.
http://dx.doi.org/10.1590/0034-7167.2016...

It is known that there are shortcomings in academic training in relation to the issue of death which leads to student insecurity in relation to the experiences of the death and death process. Facing this process is a unique experience for students, which goes far beyond technical and scientific knowledge or academic training, but influences their cultural values and their life history, which will be responsible for addressing the possibility of the finitude.⁸8 Sampaio AV, Comassetto I, Faro ACM, Santos RM, Monteiro FS. The experience of nursing students facing death and dying. Invest Educ Enferm. 2015;33(2):305-14. http://dx.doi.org/10.17533/udea.iee.v33n2a13. PMid:26535851.
http://dx.doi.org/10.17533/udea.iee.v33n...

Most nursing schools have many contents dedicated to promoting, maintaining and recovering health, but few contents related to the end-of-life process. There are several studies that conclude that nursing students do not feel prepared to face this process and therefore, deliver quality care to the dying patient, due to the lack of preparation in academic training.³3 Ivo OP, Pedroso KO. O processo da morte e do morrer: uma visão dos acadêmicos de enfermagem. Rev Psicol. 2017;11(34):305-21.^,99 Bandeira D, Cogo SB, Hildebrandt LM, Badke MR. Death and dying in the formation process of nurses from the perspective of nursing professors. Texto Contexto Enferm. 2014;23(2):400-7. http://dx.doi.org/10.1590/0104-07072014000660013.
http://dx.doi.org/10.1590/0104-070720140...

10 Dias MV, Backes DS, Barlem EL, Backes MT, Lunardi VL, Souza MH. Nursing undergraduate education in relation to the death-dying process: perceptions in light of the complex thinking. Rev Gaúcha Enferm. 2014 Dec;35(4):79-85. http://dx.doi.org/10.1590/1983-1447.2014.04.45177. PMid:25842784.
http://dx.doi.org/10.1590/1983-1447.2014...

11 Stochero HM, Nietsche EA, Salbego C, Pivetta A, Schwertner MVE, Fettermann FA et al. Feelings and difficulties experienced by nursing students in coping with death and the process of dying. Aquichan. 2016 Jun;16(2):219-29. http://dx.doi.org/10.5294/aqui.2016.16.2.9.
http://dx.doi.org/10.5294/aqui.2016.16.2... ^-1212 Costa AP, Poles K, Silva AE. Palliative care education: experience of medical and nursing students. Interface. 2016 Oct;20(59):1041-52. http://dx.doi.org/10.1590/1807-57622015.0774.
http://dx.doi.org/10.1590/1807-57622015.... And this situation is problematic since there is a very high degree of emotional involvement of the nurse in the care of the dying patient and the quality of care may be conditioned to the attitude and the fear of death.¹³13 Pogrányivá AH, López MVG, Serrano MRC, Sánchez BLDS, Martín JMB, Conty JLM. Nursing student’s reflections on the death process. Enferm Glob. 2014;13(33):133-44.

Nursing plays an important role in health services, since it falls to the health care of the individual and society, for the moral qualities and virtues and for the sacred character of human life. However, information and knowledge have no major impact on patient care, because ethics and moral values have been lost and consequently the prestige and recognition of nursing does not progress in society, as it seems that professionalism and the update of new technologies exceed the values of the care delivered.¹⁴14 Blasco-León M, Ortiz-Luis SR. Ética y valores en enfermería. Rev Enferm Inst Mex Seguro Soc. 2016;24(2):145-9.

Thus, as the science of care, an existing theory of the human relationship, guides the nursing profession with the understanding and application of an ethical-moral praxis that promotes, protects and provides human dignity throughout life. For the past 30 years or more, the science of care has transformed nursing by demanding a higher ethical perspective of human dignity in the way nurses practice, educate, research and develop the profession.¹⁵15 Rosa RNW, Estes BAT, Watson RNJ. Caring science conscious dying: an emerging metaparadigm. Nurs Sci Q. 2017 Jan;30(1):58-64. http://dx.doi.org/10.1177/0894318416680538. PMid:28899296.
http://dx.doi.org/10.1177/08943184166805...

Theory of the Peaceful End of Life (TPEL) by Ruland and Moore proposes that the objective is to provide the best possible care through the optimization of care, which can be understood as integral care, aimed at provide well-being, quality of life and, consequently, a peaceful death, prioritizing the family as fundamental to the final process of life and moving away from a technologically advanced treatment.¹⁶16 Zacara AAL, Costa SFG, Nóbrega MML, França JRFS, Morais GSN, Fernandes MA. Analysis and assessment of the peaceful end of life theory according to fawcett’s criteria. Texto Contexto Enferm. 2017 Jan;26(4):e2920017.

This theory is appropriate for the theme of the death process, based on the classic Donabedian model of process and outcome structure, where the structure-context is the family system (the terminal patient and his relatives) that is receiving care from professionals in a hospital unit, and the process is defined as nursing actions aimed at promoting the following results: 1) absence of pain; 2) feel well-being; 3) feel dignity and respect; 4) feel peace, and 5) feel the proximity of your relatives and caregivers.¹⁶16 Zacara AAL, Costa SFG, Nóbrega MML, França JRFS, Morais GSN, Fernandes MA. Analysis and assessment of the peaceful end of life theory according to fawcett’s criteria. Texto Contexto Enferm. 2017 Jan;26(4):e2920017.

Therefore, the objective of this article is to identify the social, spiritual and ethical implications of the death process and dying in the nursing student.

METHOD

The research was carried out with a qualitative approach, allowing to describe the perception, beliefs, experiences of nursing students in the face of the death process and the acquisition of skills for practice when faced with this process. Descriptive in nature, allowing to investigate and deepen a phenomenon little studied in the university area, such as the perception that the undergraduate student experiences in relation to death and the process of dying, related to the social, spiritual and ethical implications.

The study was conducted in the city of Punta Arenas, in the XII Region of Magallanes and Antártica Chilena, at the University of Magallanes, School of Health Sciences, Department of Nursing. The research was approved by the Commission of Scientific Ethics in Human Beings of the University of Magallanes through document No 047/CEC/2018.

The choice of the sample was intentional. The universe was composed of 61 students enrolled in ninth and tenth semesters in the Nursing School of the University of Magallanes, during the academic year 2018. The student who participated in the study should be studying the first and/or second period of Professional Internship at the Clinical Hospital of Punta Arenas at the time of data collection, as an inclusion criterion, this is how the number of possible participants in the study was reduced to 36 cases. The sample size was carried out through the inclusion criteria mentioned above and met the theoretical saturation criteria, which was composed of 19 students.

For the data collection, it was carried out in stages that are detailed below: first, the students of the Nursing School who met the criteria for inclusion of the sample were selected, the contact was made personally in their places of Professional Internship and others through telephone communication, where the day and time of the interview was also coordinated, which was carried out in university rooms previously requested for this purpose, the mobilization payment in transportation was offered in order not to cause monetary expenses of transfer for the student. Students who signed the informed consent approving to participate in the study, were informed of the objectives to be achieved, doubts and questions that were expressed were clarified, and they were informed of the confidentiality commitment of the investigation.

The data collection technique was carried out through the semi-structured interview, which was recorded with the participant's authorization, performed between the months of September and October of the year 2018. After the recording of the interviews, these were transcribed in Word Program and saved on external hard disk, to help the treatment and analysis of the data, after transcription, the interviews were organized according to each objective of the study, that is to say grouped by similarity in thematic sets.

The data collected were submitted to the content analysis precepts, and the data collected during the entire investigation was interpreted and recorded to facilitate its study,¹⁷17 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2016. under the gaze of bioethical principles and briefly related to the Theory of the Peaceful End of Life, by Ruland and Moore, developed in 1998.

RESULTS

According to demographic data collected from the 19 cases: 16 female, 3 male; ages ranged from the range of 22 to 38 years old; all single, 3 of them in living with partners, of these, 14 students declared themselves having a religious belief; 13 of them belonging to the city of Punta Arenas, while the remaining others belong to other regions of the country. All of them had completed or were performing the Professional Internship in different hospitalization services. Three categories were developed from the data analysis: The process of death and die: a social view from the students; The process of death and die and its spiritual meaning and Ethics accompanying the end of life.

The process of death and die: a social view from the students

Nursing students begin hospital care practices in the fifth semester, it is here that they begin their first contacts with people who require various nursing care. All students interviewed reported having had experiences with the process of die and death, either with close people or with patients:

In the questions about the meaning of death and the death-die process, the students mentioned various ideas, among which the understanding of death as an integral part of the human life cycle is highlighted, as an event inherent to the vital process according to the following statements:

The emotions that accompany the shock of witnessing a death in the hospital context sometimes accompany the interviewees to the home.

The bond created with the patient is recognized by the students interviewed as an important factor when accepting death.

One of the difficulties pointed out among students is caring for family members. In this instance they report that they experience emotional conflicts when they face family members.

The emotional conflicts that the students present do not prevent values such as empathy, putting oneself in the place of the other.

Students show that age is an aggravating factor when accepting death, pointing out that the deaths of younger people are more shocking.

The process of death and die and their spiritual significance

Some participants gave this process of death and die a meaning of transcendence to death, dissociating body and soul/spirit:

Some of the participants consider death simply as the end of life:

Ethics accompanying the end of life

In the stories of the students, it is observed that they identify the process of dying with dignity, mainly through accompaniment, control of symptoms such as pain, tranquility and without the use of unnecessary invasive measures, concepts also found in the TPEL. Thus, according to this, the reports are:

Another important issue raised by the students is the preservation of the principle of autonomy, which guarantees that information about the evolution of the disease and the outcome should be favored, so that the patient and/or family member can make decisions in relation to treatment and management. The stories of the students show the importance of delivering information to the family, as an essential part when respecting the principle of autonomy, which is sometimes violated:

Students also point out the principles of non-maleficence/beneficence. Students' stories show that they perceive the violation of this principle through therapeutic testing, disproportionate measures, excessive expenses of material resources:

Students show that they are able to recognize these disproportionate measures, experiencing frustration for not having greater interference in the management of patients, and in turn, criticize these experiences by delivering a meaning of human suffering:

Students are able to recognize behaviors that lead to dehumanizing care:

Students are able to narrate clinical cases where ethical conflicts arise, of experiences analyzed in the classroom or lived during the clinical practice of which they have participated in the resolution or only observed, although the majority presented difficulties in narrating a case and its solution.

DISCUSSION

Nursing is a profession that deals with the human being throughout the life cycle and is also present at the time of death, or at home, hospital or emergency care.¹⁸18 Bellaguarda MLRB, Ventura G, Silva B, Heinzen KV, Canever BP, Pereira VP. Enfrentamiento de enfermerosa la muerte em el proceso de cuidado em la sala de emergência. Rev. Enferm Actual Costa Rica. 2019 Jul;37:1-13.

Despite understanding death as part of the life cycle, students recognized unpleasant emotions and feelings when facing the death of patients. This process triggers brain mechanisms, outlining feelings/references of life, because there is a need to accept the fact that the existence itself, as well as that of the people with whom we interact, has an end, a “period of validity”.¹⁹19 Costa EKC, Silva SB, Silva JB. O impacto do estresse na assistência do enfermeiro ao paciente terminal – revisão literária. Rev. Inic Cient e Ext. 2019;2(1):51-6. In this study the emotion that is most recognized is the impact on the news of death, followed by nervousness, discomfort and anguish. These feelings arise because although death is part of life, during training and during professional practice, these issues have not been worked on, mainly they are study programs related to life, therapy, healing, not preparation of students to deal with human finitude.²⁰20 Alves EATD, Cogo ALP. Percepção de estudantes de enfermagem sobre o processo de aprendizagem em ambiente hospitalar. Rev Gaúcha Enferm. 2014 Mar;35(1):102-9. http://dx.doi.org/10.1590/1983-1447.2014.01.42870. PMid:24930279.
http://dx.doi.org/10.1590/1983-1447.2014...

According to the stories, the difficulty in preparing the losses of the patients with whom it has established more intense ties, the greater the union created, the more difficult to accept the death of the patient.¹¹11 Stochero HM, Nietsche EA, Salbego C, Pivetta A, Schwertner MVE, Fettermann FA et al. Feelings and difficulties experienced by nursing students in coping with death and the process of dying. Aquichan. 2016 Jun;16(2):219-29. http://dx.doi.org/10.5294/aqui.2016.16.2.9.
http://dx.doi.org/10.5294/aqui.2016.16.2...

The lack of preparation to deal with the situation of death, linked to the lack of experience in caring for family members who have experienced the loss causes emotional conflict, for fear of not being prepared to satisfactorily fulfill the role in the care of family members who are experiencing the loss, there is awareness that care should include the family, considered as a fundamental part of nursing care.⁸8 Sampaio AV, Comassetto I, Faro ACM, Santos RM, Monteiro FS. The experience of nursing students facing death and dying. Invest Educ Enferm. 2015;33(2):305-14. http://dx.doi.org/10.17533/udea.iee.v33n2a13. PMid:26535851.
http://dx.doi.org/10.17533/udea.iee.v33n... On the other hand, the TPEL proposes the concept of proximity of close friends and caregivers, where it is emphasized to provide opportunities for the family, to approach them, to make them part of care and attend to pain, concerns and questions from family and/or relatives.¹⁶16 Zacara AAL, Costa SFG, Nóbrega MML, França JRFS, Morais GSN, Fernandes MA. Analysis and assessment of the peaceful end of life theory according to fawcett’s criteria. Texto Contexto Enferm. 2017 Jan;26(4):e2920017.

In a study¹²12 Costa AP, Poles K, Silva AE. Palliative care education: experience of medical and nursing students. Interface. 2016 Oct;20(59):1041-52. http://dx.doi.org/10.1590/1807-57622015.0774.
http://dx.doi.org/10.1590/1807-57622015.... many students interviewed said they identify with family members and their suffering by losing their loved one, imagining their situations.

In the students' perception, life consists of a mortal physical body with an immortal soul. This is strengthened by most religions and spiritual schools that believe in the concept of immortality and the indestructibility of the soul. This vision of death linked to religion is supported by the results of research with nursing students,⁸8 Sampaio AV, Comassetto I, Faro ACM, Santos RM, Monteiro FS. The experience of nursing students facing death and dying. Invest Educ Enferm. 2015;33(2):305-14. http://dx.doi.org/10.17533/udea.iee.v33n2a13. PMid:26535851.
http://dx.doi.org/10.17533/udea.iee.v33n... which indicated that they tend to associate death with the significance of transcendence.

The TPEL, proposes within its concepts, to be at peace, that is to say a state of tranquility, a feeling free of anxiety, agitation, worries and fear, including this concept, the physical, psychological and spiritual dimensions.¹⁶16 Zacara AAL, Costa SFG, Nóbrega MML, França JRFS, Morais GSN, Fernandes MA. Analysis and assessment of the peaceful end of life theory according to fawcett’s criteria. Texto Contexto Enferm. 2017 Jan;26(4):e2920017.

Spirituality occupies an important space in the process of confronting diseases by the human being. In a study with a multiprofessional team, spirituality is marked as something that influences this coping process. Professionals who face the death and die process are urged to think about their own terminality, therefore, it is pointed out that spirituality is capable of making sense of the work done.²¹21 Arrieira ICO, Thofehrn MB, Porto AR, Moura PMM, Martins CL, Jacondino MB. Spirituality in palliative care: experiences of an interdisciplinary team. Rev Esc Enferm USP. 2018;52:e03312. http://dx.doi.org/10.1590/s1980-220x2017007403312. PMid:29668791.
http://dx.doi.org/10.1590/s1980-220x2017...

The spiritual dimension is not always contemplated or attended from the professional field, it is often the least contemplated in the care given to people in the final phase of life and their families although this aspect is emerging in this attention phase at the end of life.²²22 Ibáñez-Masero O, Ortega-Galán AM, Carmona-Rega MI, Ruiz-Fernández MD, Cabrera-Troya J, García-Cisneros R et al. El significado de morir dignamente desde la perspectiva de las personas cuidadoras: estudio fenomenológico. Enferm Clin. 2016 Nov;26(6):1-9. http://dx.doi.org/10.1016/j.enfcli.2016.07.003. PMid:27522539.
http://dx.doi.org/10.1016/j.enfcli.2016....

The spiritual dimension allows a dignified death that may be associated with a specific religiosity. It is from this dimension that affective relationships can be strengthened by building emotional moments that facilitate the end of life process and, consequently, the pain experienced by family members.²²22 Ibáñez-Masero O, Ortega-Galán AM, Carmona-Rega MI, Ruiz-Fernández MD, Cabrera-Troya J, García-Cisneros R et al. El significado de morir dignamente desde la perspectiva de las personas cuidadoras: estudio fenomenológico. Enferm Clin. 2016 Nov;26(6):1-9. http://dx.doi.org/10.1016/j.enfcli.2016.07.003. PMid:27522539.
http://dx.doi.org/10.1016/j.enfcli.2016.... In addition, it is common that with the proximity of death comes the appreciation of life. Faith and support promoted by spirituality provide better internal control over terminality through the sense of God's presence, which is experienced by people in palliative care in different ways that are understood through love, strength, faith, tranquility, protection, the ability to overcome obstacles.²³23 Arrieira ICO, Thofehrn MB, Milbrath VM, Schwonke CRGB, Cardoso DH, Fripp JC. The meaning of spirituality in the transience of life. Esc Anna Nery. 2017 Jan;21(1):1-6. http://dx.doi.org/10.5935/1414-8145.20170012.
http://dx.doi.org/10.5935/1414-8145.2017...

The aging of the population associated with advances in medicine, especially in technological resources, allows us to provide measures to prolong or maintain the life of a person, so the process of attention at the end of life involves several ethical conflicts.²⁴24 Arimany-Manso J, Torralba F, Gómez-Sancho M, Gómez-Durán EL. Aspectos éticos, médico-legales y jurídicos del proceso del final de la vida. Med Clin. 2017;149(5):217-22. http://dx.doi.org/10.1016/j.medcli.2017.05.004. PMid:28625515.
http://dx.doi.org/10.1016/j.medcli.2017.... From these changes, we observe every international debate on concerns about the rights of patients at the end of life.²⁵25 Ortega-Galán A. Cuidados compasivos en el final de la vida:una cuestión ética. Enferm Clin. 2018 Feb;29(1):1-2. http://dx.doi.org/10.1016/j.enfcli.2018.12.002.
http://dx.doi.org/10.1016/j.enfcli.2018....

In Chile, issues related to the end-of-life process have gained interest in the last decade, with Law 20,584 on the Rights and Duties that people have in relation to actions related to their health care and Decree 162 of The Inter-American Convention on the protection of the human rights of the elderly, promulgated in 2012 and 2017 respectively, both have articles that protect the dignity of people in terminal status, the right to comprehensive palliative care and the right to express Informed consent, protecting their autonomy.²⁶26 Ley 20.584 (CL). Regula los derechos y deberes que tienen las personas en relación con acciones vinculadas a su atención en salud. Biblioteca del Congreso Nacional de Chile [Internet], Santiago, 1 September 2012 [citado 2019 Feb 10]. Disponible en: https://www.minsal.cl/sites/default/files/files/Ley%2020584%20Derechos%20y%20Deberes.pdf
https://www.minsal.cl/sites/default/file... ^,2727 Decreto 162 (CL). Promulgala Convención Interamericana sobre la protección de los derechos humanos de las personas mayores. Biblioteca del Congreso Nacional de Chile [Internet], Santiago, 1 September 2017 [citado 2019 Feb 10]. Disponible en: https://www.leychile.cl/Navegar?idNorma=1108819
https://www.leychile.cl/Navegar?idNorma=...

The process of dying in a dignified manner can be considered in different ways, which may imply respect for the patient's autonomy to decide how to die, their last wishes, their privacy, the environment and the people with whom they want to share this moment, as well as the need for adequate control of symptoms. The concept of dignified death is closely related to humanized care, there are studies that show that students express great importance and interest about the humanized vision of care during patient care at the end of life¹²12 Costa AP, Poles K, Silva AE. Palliative care education: experience of medical and nursing students. Interface. 2016 Oct;20(59):1041-52. http://dx.doi.org/10.1590/1807-57622015.0774.
http://dx.doi.org/10.1590/1807-57622015.... ^,1313 Pogrányivá AH, López MVG, Serrano MRC, Sánchez BLDS, Martín JMB, Conty JLM. Nursing student’s reflections on the death process. Enferm Glob. 2014;13(33):133-44. in order to grant a dignified death.

On a daily basis the nursing professional faces complex issues, from relatively minor problems to serious life and death problems, coupled with the aggravated advance of technology that increases the survival of serious patients, in addition, we observe a greater autonomy of nursing professionals, which requires these decisions in complicated situations associated with routine of end-of-life care and life,²⁸28 Colbert A. Poner en práctica la ética. Nursing. 2018 Mar;35(2):7-8. all these factors expose the nursing professional to face conflicts ethical. Students who perform their Professional Internship in hospitalized people units are often witnesses of conflictive situations from the ethical point of view, since the care and survival of the patients require the application of procedures and treatments of high complexity, which are not exempt from risk for the patient, as in invasive procedures, for example, where situations can arise in which one can act causing evil, without pretending it, added to the possible iatrogenies of the hospital environment. Thus the principle of beneficence interacts with that of non-maleficence, joint with the need to respect the decision of the patient and/or family, in those cases of incapacity of autonomy, depending on third parties for any decision forcing prudence, especially in the case of assessment of risks and benefits before starting a therapeutic procedure. Finally, the principle of justice by providing the necessary care and treatment to the terminally ill, avoiding discriminating and promoting the impartiality of benefits in an environment where resource scarcity is common.

Applying the principles of bioethics involves respecting the will of the terminal patient and deciding how long to continue using the means that current medicine allows, without exceeding reasonable limits to avoid reaching therapeutic obstinacy.²⁹29 Vettorato JG, Müller NTG, Silva DH. Bioética: vida humana como objeto de experiência científica. Rev. Interdisciplinar de Ciência Aplicada. 2019;4(7):47-53.

In order to contribute to a dignified and respectful patient care, it is necessary to include them, together with their families, in making treatment decisions, which must be offered in a respectful and empathetic manner, contemplating the needs and wishes expressed by the patients.¹⁶16 Zacara AAL, Costa SFG, Nóbrega MML, França JRFS, Morais GSN, Fernandes MA. Analysis and assessment of the peaceful end of life theory according to fawcett’s criteria. Texto Contexto Enferm. 2017 Jan;26(4):e2920017.

The principles of non-maleficence/beneficence imply adjusting the therapeutic measures provided to the desired objective, that is, the maximum well-being of the terminally ill patient and his family must be achieved. The principle of non-maleficence obliges professionals to use the means indicated by scientific knowledge to control the pain and suffering of patients but without falling into actions that only prolong an irreversible situation that in turn can increase pain.²⁹29 Vettorato JG, Müller NTG, Silva DH. Bioética: vida humana como objeto de experiência científica. Rev. Interdisciplinar de Ciência Aplicada. 2019;4(7):47-53.

The therapeutic obstinacy consists of “the application of measures not indicated, disproportionate or extraordinary with the aim of lengthening unnecessary the life. These measures can also be called useless or futile treatments.” These types of measures are considered as “a medical malpractice and a deontological fault”.³⁰30 Gómez-Sancho M, Altisent R, Bátiz J, Ciprés L, Corral P, González-Fernández JL et al. Atención médica al final de La vida. Rev Soc Esp Dolor. 2010 Apr;17(3):177-9. http://dx.doi.org/10.1016/S1134-8046(10)70028-8.
http://dx.doi.org/10.1016/S1134-8046(10)... ^:178

The Nursing School of the UMAG within its curriculum includes the subjects of Ethics and Legislation in the 5th semester and Bioethics in the 8th semester, providing the student with an ethics-oriented human formation that bases his personal development and that of his environment around the concept of human dignity, comprehensive nurse care manager for people of different healthy and sick age groups.

The TPEL rescues the humanized sense of our work, the complex and holistic care necessary to help a dignified and calm death, based on the fact that the experiences of the end of life are personal and individual, where nursing has an important and fundamental role through of the different actions to achieve and/or maintain an experience of the end of serene and peaceful life.¹⁶16 Zacara AAL, Costa SFG, Nóbrega MML, França JRFS, Morais GSN, Fernandes MA. Analysis and assessment of the peaceful end of life theory according to fawcett’s criteria. Texto Contexto Enferm. 2017 Jan;26(4):e2920017.

Among the limitations, the sample size can be considered. Data self-reported by participants of the research can also be classified as study limitations, because it cannot independently verify.

CONCLUSION

The reflection on the process of die and death, allows the student to give meaning to this experience in different fields, as well as in the social, spiritual and ethical that are experienced around this process, enriching the scenario in nursing professional care.

Understand that death is not only a single act, but rather a complex process to address, which in addition to including the terminal patient, care must also be family oriented, recognized as a fundamental pillar in the process.

As in other studies, the meaning of transcendence in the spiritual dimension, helps the student to a better acceptance of this experience, understanding death as a step to a new life.

Recognizing the meaning, allows the student respect for the values and beliefs of people, promoting sensitive and humanized care to allow a dignified death and alleviate the suffering of the patient in his process of finitude, under the gaze of the principlist bioethics.

The evidence shows that the theme of the end of life can be addressed in different ways both in the classroom and in practice, this is how innovative teaching in the theoretical class is suggested with the use of TPEL, which It is simple and with clear ideas, allowing the student their easy understanding, and therefore the delivery of tools for the best care at the end of life. In addition to this theory, this theory provides a guide for the skills that nurses must perform in front of patients and their families during end-of-life care.

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