Background
Engaging in conversations about death can be challenging, even for individuals who identify as religious or consider themselves to have strong faith. Discussions about death are often avoided, including among communities of people with faith or religion. In Chinese culture, talking about death and dying was considered as inviting bad luck (Xu, 2007). This matter is troublesome due to its uncontrollable and unpredictable nature. However, NICE guidelines suggest healthcare professionals consider any needs related to the person’s cultural, religious, social, and spiritual at the end of their life (Hodgkinson et al., 2016). Consequently, healthcare professionals need to develop their understanding of what peaceful death may mean in persons from diverse religious backgrounds (Choudry et al., 2018).
Perspectives on good death could be different based on the experiences and cultural aspects. Nurses, as the front health care professionals, are the ones who are directly or closely involved in patient care and may give a particular definition of peaceful death. Multiple studies have been undertaken to examine the concept of a “good death” or “peaceful death” from the viewpoint of nurses in certain nations (Aksoy & Kasikçi, 2023; Chaiyasit et al., 2020; Chen et al., 2022; Türkben Polat, 2022). The nurses’ viewpoints on a good death were described as devoid of suffering, receiving care from family members, having no worries, and passing away with dignity (Chen et al., 2022). According to Vanderveken et al. (2019), no suffering or being completely free from pain is emphasized as a crucial aspect of satisfactory death. Additional research has also examined the perspectives of Muslim patients regarding a desirable death as being passed away in their preferred location (Pribadi et al., 2023) and death during a sacred time and place (Tayeb et al., 2010).
Defining death might differ according to cultural and religious background. Having some perspectives on peaceful death from a religious perspective, such as Christianity as the minority population in Indonesia, might bring a new viewpoint that might differ from other religions. Christianity is a monotheistic faith that centers around the life, teachings, and miracles of Jesus Christ. Given that the pursuit of eternal life with God is a central tenet of Christianity, it is not unusual that there is a recognized connection between death and religion (Choudry et al., 2018). Nevertheless, for the Christian, death presents a juxtaposition of the anticipation of everlasting life and the fear of the unknown (Shelly et al., 2021). The Christian community frequently avoids discussing the topic of death due to the belief that fear of death indicates an issue in faith (Shelly et al., 2021). Therefore, attaining an understanding of a peaceful death from Christian nurses’ perspectives could aid healthcare professionals in improving the quality of end-of-life care services. As no literature has explored the perspective of Christian nurses on peaceful death in Indonesia, our study aimed to explore this topic in depth. Peaceful death or good death will be used interchangeably throughout this article.
Methods
Study Design
This qualitative descriptive study engages with the context of participants by exploring their experiences and enabling them to explore the phenomena of peaceful death. A qualitative descriptive design is considered the most suitable as it acknowledges the subjective nature of the problem and considers the diverse experiences of each participant (Bradshaw et al., 2017). This study followed the Consolidated Criteria for Reporting Qualitative Research/COREQ (Tong et al., 2007).
Participants
Purposive sampling was used to select the participants. Participants were all Christian nurses from hospitals in Jakarta, Tangerang, and Purwakarta. Nurses who met the following criteria were recruited: 1) identify as Christian, 2) minimum age of 18 years old, 3) minimum of two years working in a hospital, 4) speak and write in Bahasa Indonesia, 5) agreed to participate in this study and provided the informed consent. Recruitment of the participants started with the distribution of an e-flyer via social media consisting of all information about the study, including the IRB number, researchers’ contact number, risks and benefits associated with the study, and a link to Google Form that directed them to be the potential participants. The researchers contacted the individuals who expressed interest in participating and provided further explanation about the study.
Data Collection
The study was conducted between January to April 2024. All eighteen Christian nurses were recruited, interviewed, and scheduled individually in a private room, as agreed upon by both parties. A pilot study was conducted on one participant from the study sample to ensure there were no issues with the interview guide and the validity and credibility of the semi-structured questions. Six interview questions were used in both the pilot and initial study. The researcher and participants would select quiet rooms within the office area or hospital for the interviews.
At the start of each interview, the researcher introduced the purpose of the intended study, the measures to ensure data security and confidentiality, the voluntary nature of study participation, and the requirement for informed consent. Each respondent was asked to complete the demographic questionnaire through an online survey and to sign the informed consent.
All researchers took turns in interviewing the participants. The researchers are all nursing faculty, with two researchers with a palliative nursing expertise background and one with spiritual care expertise and some experience in conducting qualitative studies. Both researchers interviewed Christian nurses using Bahasa Indonesia using six open-ended questions (Table 1). Each participant was interviewed by one researcher. All the interviews were recorded with the participant’s consent, and field notes were also made to observe the nonverbal behaviors of the participants during the interview. Each interview lasted between 30 and 45 minutes. Data collection was ended when the interview did not convey new themes. The survey includes a total of 18 Christian nurses. Participants’ characteristics, including gender, age, work experience, domicile, marital status, educational background, church denomination, and training on end-of-life care were collected.
| Questions |
|---|
| Tell us about yourself and your nursing practice |
| When you hear the word “good death,” what comes to mind? |
| As a Christian, what would you say about a good death? |
| What do you think would be the most desirable things to do for patients if they are dying? Please explain |
| What do you think would be a good thing for them to do? Please elaborate. |
| As a Christian, how would you approach a dying patient to facilitate a good death? |
Data Analysis
All the interviews were audiotaped and transcribed by the researchers after each interview. The audiotape was listened a few times to ensure the data accuracy. All interviews and transcriptions were done in Bahasa Indonesia. Thematic analysis was used to analyze the qualitative data. Thematic analysis is a method for qualitative study that allows the researcher to identify, report patterns, and interpret the meaning (Liebenberg et al., 2020). Three researchers went through the same data analysis process manually. The themes were then coded, discussed, compared, and matched to see the accuracy of the analysis process. Translation into English language was done for publication purposes. Data analysis emerged in 70 codes. All three researchers reached a consensus, and themes were finalized.
Trustworthiness
This study adopted four criteria to ensure the rigor of the analysis, including credibility, dependability, confirmability, and transferability (Guba & Lincoln, 1994). To maintain the credibility of this study, the three researchers did not have any relationship with the participants before the study was conducted. Further, both parties agreed upon the interview location to ensure the participants were free to explore their experiences. For transferability, the participants who were Christian nurses were recruited based on the inclusion criteria. Member checks were done by returning the statement to the nurses to ask whether the statement written was reflecting their experiences. Field notes were used by the researcher to ensure confirmability and dependability were maintained by ensuring each interview was performed by one researcher alone. To maintain consistency of the interview, two researchers with expertise in the qualitative study were the main interviewers of this study. To reduce bias, all researchers reviewed all data, discussed the findings, and reached an agreement on the study’s results.
Ethical Considerations
Ethical approval was granted by the ethics committees of Universitas Pelita Harapan (No. 003/IRB-UPH/II/2024). All participants have been informed of voluntary participation in this study and provided oral and written consent. To ensure confidentiality, participant information was deidentified, and unique study codes were used to protect anonymity. Additionally, participants were assured that their responses would be used solely for research purposes and that any identifying details would be securely stored and handled in accordance with ethical guidelines.
Results
Eighteen Christian nurses participated in this study, consisting mainly of females, with an age range of 20-30 years old. The majority of the participants were not married at the time of the interview. Of all the participants, 77.8% held a bachelor’s degree in nursing, with 5-15 years of working experience, and mostly have not had End of Life training. Table 2 illustrates the sociodemographic characteristics of the respondents.
| Demographic | n | % |
|---|---|---|
| Age | ||
| 20-30 | 11 | 63.15 |
| 31-40 | 2 | 10.5 |
| 41-50 | 4 | 21.05 |
| >50 | 1 | 5.3 |
| Sex | ||
| Male | 3 | 16.7 |
| Female | 15 | 83.3 |
| Marital Status | ||
| Marriage | 6 | 33.3 |
| Not Married | 12 | 66.7 |
| Education Background | ||
| Diploma III Nursing | 2 | 11.1 |
| Bachelor of Nursing | 14 | 77.8 |
| Master of Nursing | 2 | 11.1 |
| Work Experience | ||
| <5 years | 5 | 27.8 |
| 5-10 Years | 7 | 38.9 |
| >10 Years | 6 | 33.3 |
| End-of-Life Care Training | ||
| Yes | 2 | 11.1 |
| No | 16 | 88.9 |
Three major themes were developed through analysis: 1) the component of peaceful death, 2) companionship and care, and 3) knowing the final destination. These themes were further broken down into subthemes in Table 3.
| Themes | Subthemes |
|---|---|
| The Component of Peaceful Death | Die with dignity |
| Minimal suffering and burden | |
| Patients and family’s acceptance | |
| Religious and spiritual concerns | |
| Facilitating patients’ needs | |
| Companionship and Care | Accompanied by family members |
| Receiving full care during end-of-life | |
| Knowing the Final Destination | Know who Jesus is |
| Accepting God |
Theme 1. Component of Peaceful Death
The first theme, “component of peaceful death,” was described as a state where the patient experiences no suffering, is assisted in their needs, and is honored. Subthemes include 1) dying with dignity, 2) minimal suffering and burden, 3) religious and spiritual concerns, and 4) facilitating peaceful death.
Subtheme 1.1. Dying with dignity
Dying with dignity was noted as an essential subtheme, referring to patients being in the last days of life. As humans, nurses view dying with dignity as important, with one nurse connecting one’s readiness for death with “he/she ready to die with dignity, feeling at peace” [P8]. Another nurse also noted that “the patients or the person being prepared dies with dignity, so he/she dies peacefully with what he/she wants” [P12], highlighting a dying person’s agency and the importance of honoring their wishes as a way of facilitating death with dignity.
Subtheme 1.2. Minimal suffering & burden
Nurses also associate pain with suffering at the time of death; therefore, “good death is when the patient does not feel any pain at the time of death” [P7]. Drawing from a prior example of a good death, a nurse stated that “in my perspective, he was devoid of any physical discomfort and did not experience protracted agony” [P13]. For this reason, it becomes essential for the nurse to ensure that when a patient dies, the patient “…died not because of pain” [P14]. In addition to being associated with pain, suffering was seen as having not ‘letting go’ of burdens; hence, “Good death is when people in the process of dying…. without burden such as burden from the responsibility of the world” [P16].
Subtheme 1.3. Patients’ and families’ acceptance
Four nurses expressed that being in a peaceful death means that both patients and families accept that death is near, being ready and that the family could accept they have “reached the maximum level of treatment, it means that they have also tried well” [P4]. Two nurses poignantly describe the importance of acceptance from both the patients and the families in ensuring a peaceful transition towards death: “There is already a good acceptance from the one who wants to die… meaning that the person is ready whenever the time comes, there is no more doubt in him or something that he is afraid to leave.” [P11]; “Yes, another aspect might be the acceptance of the family… Sometimes, there are patients with a critical condition, but they don’t die. There is someone they want to meet…or there is a problem that they haven’t solved. When it’s finished, then they die” [P13]
Subtheme 1.4. Religious and spiritual concerns
While discussing minimal suffering and burden, participants also discussed the needs of religion and spirituality. Several nurses expressed that spiritual care is essential in the dying process. They attend to the needs of prayer and ensure that “every patient who is heading for a good death need to be prepared religiously” [P6]. In some cases, nurses go further than simply facilitating resources for spiritual care and take on the role of teaching friends/family to pray: “When he dies, we will provide facilities…teach friends/family to pray (Dzikir)….” [P1]
Subtheme 1.5. Facilitating patients’ needs
Facilitating patients’ needs was seen as essential, encompassing biological, psychological, social, and spiritual needs. “We have to look at all sides, from bio-psycho, social and spiritual, we facilitate the environment until he dies, he remains comfortable and people around him” [P5]; “So we ask the patient who they want to bring in…I can help to facilitate…” [P4].
Theme 2. Companionship and Care
The nurses discussed that being accompanied and receiving care as death approached was another essential point of a good death. Family members could accompany patients, spend time with their loved ones, and be involved in the patient’s care.
Subtheme 2.1. Accompanied by family members
Participants voiced that being accompanied by family members was seen as a crucial thing for patients with terminal illnesses, providing space for them and being around patients. “As nurses, we are aware that the time is running out for the terminally ill patient. Thus, it would be best to provide a space for their family to attend or come to the patient’s side….so that the family can gather in one place” [P12]. “It is necessary to involve his family so that they are also willing to let go and, of course, can go more peacefully” [P7]. The presence of family members was also considered important by participants as the death approached. “The family can come like giving a little encouragement…so that the family and the patient could communicate for a longer time” [P6].
Subtheme 2.2. Receiving full care during end-of-life
The participants addressed receiving full care during the end of life: “We fulfill him with all his needs, bio-psycho-socio-spiritual and don’t forget to respect him as a person” [P5]. “As much as we can, we accompany him; for example, if the family is not present, we accompany him” [P17]. One nurse was also concerned about the environment around the patients and the need to provide comfort and keep loved ones close. “We have to look at all sides; we facilitate the environment until the person dies, ensure they remain comfortable and people he loves to be around” [P5]. “So, we ask the patient who they want us to bring …we can help to facilitate…” [P4].
Theme 3. Knowing the Final Destination
According to the participants, who were all Christians, peaceful death was defined as knowing their last destination by knowing who God is, accepting God, and being saved by God and that they would have eternal life.
Subtheme 3.1. Know who Jesus is
Nurse participants expressed that knowing Jesus means surrendering everything and recognizing that there is a life after death, which comes with eternal life. “From the perspective as a Christian nurse, I believe in life after death, which is eternal life” [P3]. “If you meet a Christian [patient], he is more to God [believes in God] and surrenders everything, and when the time comes to die, that’s it” [P17]. So… dying is not just dying of the flesh, but instead, the soul and spirit live to meet God” [P13].
Subtheme 3.2. Accepting God
Some participants expressed that peaceful death is when one accepts Jesus as the Lord and that God has saved the soul. “From a Christian perspective…he [the patient] died having accepted the Lord Jesus…” [P2]. “Good death, good death is…. in Christianity maybe… the death that he already knows Christ” [P13]. It is interesting that another nurse also expressed that peaceful death is when the patient’s soul is saved. “In my opinion … it prepares this patient to die well. In the sense that his soul must also be saved, so … don’t lose it” [P10].
Discussion
Perspectives from Christian nurses bring new insight into how a religious minority group views end-of-life nursing. Participants expressed their perception of what constitutes peaceful death. Most participants stated that peaceful death is dying without physical discomfort, without burden, dying with dignity, and receiving all the care needed. Keratichewanun et al. (2023) reflected that good death means having symptoms-free, consistent with earlier studies which characterized good death as being pain-free (Kastbom et al., 2017; Mamun et al., 2023; Meier et al., 2016; Pribadi et al., 2023; Tenzek & Depner, 2017). Emotional wellness is also important, as being free from suffering and sadness is crucial at the end of life (Mamun et al., 2023). Furthermore, elements identified in this study are also mentioned in other studies, such as the importance of dying with dignity (Akechi et al., 2012; Chen et al., 2022; Hattori & Ishida, 2012; Mamun et al., 2023) receiving care (Chen et al., 2022; Pribadi et al., 2023), and religious and spirituality needs (Krikorian et al., 2020). These results indicate that good death is perceived similarly by nurses across cultures.
This study also highlights the importance of companionship and care. The participants acknowledged that the presence of family members and the provision of care are additional essential aspects of peaceful death. They emphasized the need to provide companionship to patients and not to leave them alone as they near death. This conclusion is corroborated by a previous study highlighting that a satisfactory demise does not entail being abandoned (Kongsuwan et al., 2012). Additionally, Borgstrom (2020) noted that being in familiar surroundings and among close relatives and friends is one of the positive attributes of a good death. This is supported by a recent study in which many nurses emphasized the importance of family members helping with patients’ care and setting aside time to spend with patients who are terminally ill (Chen et al., 2022). Looking after sick family members can be an opportunity for family members to communicate the emotions and show appreciation and support for the patients. Consequently, this could improve the quality of patients’ deaths (Chen et al., 2022).
Palliative care and acknowledging death as a normal part of life are inextricably linked to good death (Zimmermann, 2012). Thus, it is essential to know that the patient and their relatives are prepared and aware of impending death, as the acceptance of death is vital to facilitating a peaceful death. Support from family members could play an essential role in helping patients achieve a good death (Hattori & Ishida, 2012). A study in Thailand supports the notion that a peaceful death can be achieved when family members and relatives can come to terms with the impending or ultimate death of their loved ones (Kongsuwan et al., 2012). This is to emphasize that family involvement during the death and dying process is important (Borgstrom, 2020). Therefore, it is recommended that family members be involved in the patient’s care to let them understand the patient’s condition and accept death and dying. Hence, healthcare providers have to educate and engage family members in the caregiving process, enabling them to emotionally and mentally prepare for the impending loss of their loved ones.
Religious belief could affect how an individual defines good death, as religion is related to the concepts of life, death, health, and sickness (Chacko et al., 2014). Christians believe in the resurrection of the dead, and it is written in the Bible that “to live is Christ and to die is gain” (Philippians 1:21), as reflected by one participant who believes that death is gain (P4). Christians have the belief that their relationship with God remains unaffected by any physical changes that may occur to their body before or after death (Connolly et al., 2015). Therefore, a Christian’s journey toward the end of life centers around attaining peace, certainty in the forgiveness of sins, and trust in communion with the Holy Spirit and fellow believers (Vogt, 2004).
In Christian teachings, death is considered to be better than life, as it means that the person can be with Christ. In this study, Christian nurses’ point of view of having a peaceful death is knowing their last destination, where the patient would go after the death. Physical death is seen as a separation between the soul and the body. So, even though the body’s function has ceased, the soul will move to a new place where the body will be resurrected, as clearly stated in Ecclesiastes 12:7. After death, Christians believe that they will be in heaven, spending an eternity in the presence of God. Further, the ultimate aim of all Christians is that the soul is to be reunited with Jesus. When death occurs, it is the physical body that dies, but Christ’s soul will be given eternal life in Heaven (Revelation 20:11-15). It is interesting to know that some nurses discussed all these statements and were concerned about taking care of end-of-life patients.
Religion was a powerful force in understanding and coping with death (Moreman, 2017). In this study, the perspectives of Christian nurses about good death were explored, as well as their essential role in facilitating this process through good quality of care. Future studies will benefit from further gaining an understanding of how other professionals, patients, and families from different cultures perceive death. Quantitative and qualitative data would provide more understanding of how various groups see good death as a generalization from a more significant population.
Strengths and Limitations
The strength of this study was that the researcher explored the nurses’ perspectives on peaceful death. This study provided a deeper understanding of how the Christian perspective views good death from different hospitals, which could enrich the data on the perspectives of peaceful death. Nevertheless, as this study only recruited 18 respondents from a few hospitals, recruiting from more hospital settings in some areas also needs to be studied to obtain a general understanding of a peaceful death. Although this study focused solely on the viewpoint of Christian nurses regarding facilitating good death, some of the results can still guide nurses of any religious background on how to provide a good death for all patients. As Indonesia is a multicultural and multifaith country that believes death is something taboo to discuss, having known nurses’ and other health care providers’ views on good death from different religious backgrounds would develop a general concept of what it means to have a peaceful death in the Indonesian context. Although the findings of this study might not resonate with the experiences of nurses in another country, this study could represent the perspectives of Indonesian Christian nurses on good death.
Implications for Nursing Practice
Findings from this study can have important implications for the care of dying patients, regardless of their religious background. Additionally, these findings may benefit nursing practice by encouraging nursing students and young nurses to exercise empathy and provide comprehensive end-of-life care. Insights from the participants also point to aspects of end-of-life care that are seen as important and can serve as implications for professional development. For example, nurses need to be equipped to explore preferences and concerns with patients experiencing dying as well as navigating conversations around death. This would help nurses to ensure the patient’s preferences and needs are provided. These findings would help nurses to know what patients want, especially when dealing with Christian patients. Through this study, it is expected that nurses, particularly Christian nurses, will be able to provide support in a holistic aspect and facilitate dying patients to have a peaceful death and achieve their eternal life.
Conclusion
This study has sought to explore the perspectives of Indonesian Christian nurses on good death. Although the Indonesian culture often considers the subject of death as a taboo, it is nevertheless the responsibility of nurses to provide the best possible care to patients until their last moments. In addition, patients are entitled to be treated with dignity and given the highest quality of care till the end of their life. It is recommended that the subject of a good death be incorporated into the nursing curriculum. This would allow nursing students to be adequately equipped to handle end-of-life patients who are nearing death.
Declaration of Conflicting Interest
There is nothing to declare.