Signs and symptoms

Signs and symptoms of death anxiety are multifaceted and people can present with a variety of them. Although they can be synonymous with other anxiety disorders, thanatophobia signs and symptoms are considered to be distinct from those of general anxiety, and authors such as Sliter et al (2014) suggest that there is only a moderate overlap of symptoms.

A number of more common thanatophobia signs and symptoms are listed in Table 2. Recognition of these should be part of critical debriefing sessions in the immediate aftermath of traumatic incidents in the community or emergency departments (EDs).

Table 2

Signs and symptoms of thanatophobia

Although studies of death anxiety among healthcare professionals who work in cancer and end of life care have been made (Boyle and Carter 1998), there is a paucity of research into the condition among emergency nurses and paramedics. Several authors suggest that emergency healthcare workers are more susceptible to death anxiety (Grant and Wade-Denzoni 2009, Peters et al 2013a, 2013b, Sliter et al 2014), so this lack of research places more onus on healthcare providers, university staff and employers to identify the risks and try to prevent them.

Mortality salience

Mortality salience, which is on-going and unrelenting knowledge of one’s own mortality, can cause regret and thoughts about the meaning of death that influence death anxiety (Lehto and Stein 2009). These responses can be triggered by stressful, but not necessarily death-related, events, such as the diagnosis of an illness, news about a death or a traumatic resuscitation attempt. For most people such events are uncommon, but for emergency nurses and paramedics they can be everyday events, and therefore constant reminders of mortality.

In a review of 25 articles about stress and anxiety among emergency healthcare workers, Hegg-Deloye et al (2013) conclude that paramedics are susceptible to a myriad of psychopathologies, including acute and chronic stress, anxiety disorders, and PTSD. Similarly, in a qualitative study of 248 emergency nurses from 15 different EDs, Adriaenssens et al (2012) found that a substantial proportion of emergency nurses, between about 29% and 37%, had more than sub-clinical levels of psychological distress and somatic complaints. The researchers recognised that frequent confrontation with traumatic events, serious injury and death play a part in these pathologies.

Because death-related thoughts can trigger death anxiety, people are motivated to avoid them (Echebarria-Echabe 2013). Emergency healthcare workers are confronted regularly with mortality, however, and so are less able to avoid the triggers and more at risk of high levels of stress and anxiety (Boyle and Carter 1998). Moreover, staff in emergency and unscheduled healthcare environments are more susceptible than colleagues in other healthcare disciplines to mortality-salient cues and the effects of death anxiety (Payne et al 1998, Peters et al 2013b, Sliter et al 2014).

Sliter et al (2014) examined the effects of mortality salience and death anxiety on the occupational health of 162 female general nurses and 128 male firefighters in the United States, where firefighters are usually also emergency medical technicians or paramedics. The firefighters appeared to have experienced symptoms of death anxiety, such as absenteeism to avoid mortality-salience cues, burnout and a lack of engagement in work, more than the nurses. These findings suggest that university staff and employers should include death anxiety in risk assessments and sickness absence reviews.

Peters et al (2013b) reviewed 15 studies of nurses’ attitudes towards death that had been published between 1990 and 2012. They found that emergency nurses reported lower coping skills and a greater tendency to avoid mortality-salience cues than, for example, staff in palliative care services.

After sending out questionnaires to staff working on the wards of a hospital, Payne et al (1998) held structured interviews with 23 palliative care nurses and 20 emergency nurses to compare their levels of death anxiety with those of other hospital staff.

The researchers report that emergency nurses had higher levels of death anxiety, and a greater need for accessible and confidential support networks at work, than their colleagues in palliative care. It follows that people who provide support networks for emergency care workers must understand their susceptibility to death anxiety and the associated risks in their daily work.

These three studies (Payne et al 1998, Peters et al 2013b, Sliter et al 2014) are limited by their methods of gender analysis and sample size, and because there have been changes in staff attitudes and technology since they were published. However, they raise important questions about the prevalence and effects of mortality salience and death anxiety among emergency healthcare workers, and how an inability to manage them can lead to other psychopathologies.

Terror management

According to terror-management theory, if people become conscious of their vulnerability and mortality, their sense of anxiety can become debilitating unless it is controlled, or buffered, effectively (Grant and Wade-Denzoni 2009, Abdollahi et al 2011). According to anxiety-buffer disruption theory, psychopathologies such as death anxiety and PTSD are associated with reduction of the epistemological distance, or buffer, that people put between themselves and thoughts of death (Abdollahi et al 2011, Pyszczynski and Kesebir 2011, Brady 2013b).

This means that, when people become aware of their vulnerability and of the transient nature of life, they require a buffering system to protect them against anxiety and function (Greenberg et al 1986).

Emergency nurses can become aware of mortality every working day and so they are less likely than other people to have such buffering systems, and so are more at risk of the associated psychopathologies (Shakespeare-Finch et al 2003).

In a systematic review of 49 studies, Sterud et al (2006) show that emergency healthcare workers, such as nurses and paramedics, are exposed to high rates of critical incidents that can lead to post-traumatic and other psychiatric signs and symptoms. These rates are twice or three times higher than those reported by Gurevich et al (2007) for the general population.

The signs and symptoms of death anxiety should be understood and recognised by healthcare providers, university staff and employers, especially as staffing levels are reduced and remaining staff become more exposed to the events that can trigger such anxiety.

The relationship between PTSD and death anxiety, although unexplored compared with other areas of clinical psychology, has been discussed for years. Yalom (1980), for example, claims that death anxiety is the source of all psychopathologies and suggests that it could influence non-adaptive reactions to traumatic events, such as PTSD. Martz (2004) proposes that death anxiety is a predictor of PTSD, and that people who experience or witness traumatic events often develop deep death-related fears and anxieties associated with symptoms of later PTSD.

The precise relationship between death anxiety and PTSD, and whether one predisposes people to the other, remains unclear (Hoelterhoff and Chung 2013). That there is such a relationship, and that emergency healthcare workers are susceptible to both psychopathologies, should prompt further research, and the development of occupational risk-assessment tools for staff and students.

Student practitioners

Paramedicine, like emergency nursing, is taught in universities, which means that students who work in emergency healthcare services are exposed to mortality-salience cues, and are therefore susceptible to death anxiety and PTSD. Their relative lack of experience also puts them at risk of death anxiety, especially if they work in emergency settings where there often critical incidents (Bounds 2006, Fjeldheim et al 2014). This situation is compounded by the pressures placed on all undergraduates, such as academic, career-building, financial, and social pressures, which can contribute to their physical and mental ill health (Amritha et al 2013).

According to Quint’s (1967) theoretical model, students who lack knowledge about, caring for dying patients can develop death anxiety. This finding should be updated but may still be pertinent to the current model of healthcare education.

Students in healthcare environments where staff are encouraged to respond to death with composure, competence, efficiency and self-control may regard expressing their anguish as a form of weakness (Chen et al 2006). They may subsequently repress their feelings, which could hinder support and buffering interventions, so they should be encouraged to discuss their experiences with colleagues and to attend death-education programmes.

The purpose of death-education programmes, which are being introduced into healthcare education, is to enable students and practitioners to examine and resolve their feelings and beliefs about death. As such, they may reduce their death anxiety (Mooney 2005, Sliter et al 2014), although more research is needed before this can be ascertained.

Researching death anxiety among nursing students at the same academic level in Australia before and after they had undertaken a 13-week death-education programme, Mooney (2005) found lower levels of death anxiety among members of the experimental group (n=97), who had taken part in the programme, than among those of a control group (n=122), who had not.

Students at the same academic level undertaking health-science programmes of similar structure and design were tested before and after the programme. In addition, Sliter et al (2004) argued that workplace death-education programmes alongside vocational counselling could reduce death anxiety in qualified staff, which further supports their use.

Vocational counselling is an emerging concept which helps staff identify their vulnerabilities and the environmental factors that can trigger negative reactions at work, and to identify coping skills against barriers preventing them from remaining or returning to work.

Conclusion

This article introduces the concept, and the main risk factors and effects, of death anxiety, but is limited because of the lack of research into how the condition affects emergency healthcare workers. It also draws on studies from countries outside the UK.

It shows, however, that death anxiety is a psychopathology that can affect anyone, but particularly emergency nurses and paramedics. It also highlights the possibility that there is a link between high exposure to mortality cues, or existential slaps, and increased susceptibility to death anxiety and to PTSD, which some authors consider to be a precursor of death anxiety.

Emergency nurses should be made aware of the risks of death anxiety, therefore, and should have access to interventions that could prevent it from affecting their physical and mental health. Staff involved in critical incidents should be assessed against a trauma risk-management tool that includes measures for death-anxiety symptoms and should be given opportunities for appropriate debriefing, although demands on emergency services could make this difficult.

Staff involved in organising rotas should try to rotate emergency healthcare workers so that they are not over-exposed to mortality cues, although in areas such as paramedicine this may not always be possible. University staff and employers, meanwhile, should recognise the implications of high exposure to mortality cues on staff and students, and should investigate and consider these during disciplinary, absence and sickness procedures.

Finally, there should be investment in death-education programmes and vocational counselling sessions, which have been shown to reduce death anxiety in students and qualified practitioners, and further research to validate and improve the efficacy of these interventions.

According to national health and safety legislation, such as the Health and Safety at Work Act 1974, and European Union (2014) guidelines, employing organisations are responsible for reducing risks identified in assessments, and for promoting safer and healthier working environments. Health providers, trainers, universities and voluntary organisations should assess their compliance to such legislation in relation to death anxiety.

While many emergency nurses and paramedics may be unaware of death anxiety, they are exposed to it in their everyday practice. Healthcare providers, university staff and employers should understand and try to prevent the development of this potentially debilitating psychopathology to improve the health of their staff and the care of patients.