The Nature and Meaning of near death experince for Patients and Critical Care Nurses

JOURNAL OF NEAR-DEATH STUDIES Specific Aims of This Study The NDE is a very personal and individual experience that has great meaning to those who experience it. Critical care practitioners care for people at significant moments of crisis in their lives. They hear stories from their patients who have experienced NDEs. NDEs hold great meaning for the patients as well as the practitioners who care for these patients. Although the subjective experiences of the patients and the nurses regarding the nde are described in this study it was the degree to which people were changed and the way in which they were changed that is the major focus. For this study, a near-death event was the condition that caused the patient to be near to death: for example, cardiac or respiratory arrest severe shock, or trauma. The term NDE referred to the report of fea- tures associated with a period of unconsciousness due to a near-death This research was designed to develop a conceptual framework for the near-death experience reflecting its meaning and significance for the patient and the nurse The study used naturalistic inquiry to ex- amine the question: What is the nature and meaning of a near-death experience and how has it influenced the individual s view of the self, the future, and feelings and beliefs about life and death? Specific aims that guided the collection of data included: (1)describing the experience of the patient surrounding the period of unconsciousness; (2)describing the nature and meaning that this experience holds for the patient, in terms of the individual's view of the self, the future, and relationships with others; (3)describing the experience of critical care nurses in car- ing for patients before, during, and after the period of unconsciousness which was not linked to anesthesia; (4)describing the nature and mean- ing that this experience holds for the nurse, in terms of the nurse s view of the self, the future, and the caregiver role; and (5)comparing the re- sponses of nurses and patients with regard to perception, meaning, and significance of these experiences. One goal of this study was to address some of the shortcomings of previous research on the subject. Subjects were sought purposefully, rather than relying on self-selection as in many of the previous studies Second, the state of near-death was specifically defined and subjects who met the criteria were included. Third. the state of near -death was verified in most instances. Fourth, there was an equal sampling of men and women, and a sample of ethnic diversity was purposively sought Finally, the instruments used were clearly described

P1: GRA Journal of Near-Death Studies ph167-jond-455246 November 22, 2002 9:37 Style file version September 27, 2002 144 JOURNAL OF NEAR-DEATH STUDIES Specific Aims of This Study The NDE is a very personal and individual experience that has great meaning to those who experience it. Critical care practitioners care for people at significant moments of crisis in their lives. They hear stories from their patients who have experienced NDEs. NDEs hold great meaning for the patients as well as the practitioners who care for these patients. Although the subjective experiences of the patients and the nurses regarding the NDE are described in this study, it was the degree to which people were changed and the way in which they were changed that is the major focus. For this study, a near-death event was the condition that caused the patient to be near to death: for example, cardiac or respiratory arrest, severe shock, or trauma. The term NDE referred to the report of fea￾tures associated with a period of unconsciousness due to a near-death event. This research was designed to develop a conceptual framework for the near-death experience reflecting its meaning and significance for the patient and the nurse. The study used naturalistic inquiry to ex￾amine the question: What is the nature and meaning of a near-death experience and how has it influenced the individual’s view of the self, the future, and feelings and beliefs about life and death? Specific aims that guided the collection of data included: (1) describing the experience of the patient surrounding the period of unconsciousness; (2) describing the nature and meaning that this experience holds for the patient, in terms of the individual’s view of the self, the future, and relationships with others; (3) describing the experience of critical care nurses in car￾ing for patients before, during, and after the period of unconsciousness, which was not linked to anesthesia; (4) describing the nature and mean￾ing that this experience holds for the nurse, in terms of the nurse’s view of the self, the future, and the caregiver role; and (5) comparing the re￾sponses of nurses and patients with regard to perception, meaning, and significance of these experiences. One goal of this study was to address some of the shortcomings of previous research on the subject. Subjects were sought purposefully, rather than relying on self-selection as in many of the previous studies. Second, the state of near-death was specifically defined and subjects who met the criteria were included. Third, the state of near-death was verified in most instances. Fourth, there was an equal sampling of men and women, and a sample of ethnic diversity was purposively sought. Finally, the instruments used were clearly described

LINDA L. MORRIS AND KATHLEEN KNAFL Study Design and Methods This study used the qualitative approach of naturalistic inquiry (Lincoln and Guba, 1985), which is the process of exploring naturall occurring phenomena in order to gain understanding. For the purpose of this study, an NDe was defined as the report of"unusual recollec- tions associated with a period of unconsciousness during either serious Iness or injury, or during resuscitation from a cardiac or respiratory arrest. In order to enhance completeness of the topic and validity of the findings, triangulation of methods was used. This included the use of intensive interviewing in conjunction with a structured instrument, the Near-Death Experience Scale( Greyson, 1983), in order to elicit the perspectives of both patients and nurses Credibility of the findings was enhanced by the use of multiple sites, multiple subjects, and multiple modes of data collection Participant Participants were recruited from eight hospitals within the Chicago metropolitan area. Multiple sites were targeted to assure a diverse sample with regard to demographic characteristics, including ethnic- ity, gender, and socioeconomic status. The patient sample included 12 adults, age 18 and older, who had either survived and had recall of a cardiac or respiratory arrest, or who had survived a serious ill- ness with a period of unconsciousness that was not linked to anesthe- sia. The nurse sample included 19 critical care nurses who had cared for at least one patient who had experienced an NDE. Thirty-five au- diotaped interviews were conducted and transcribed verbatim. An ad- ditional group interview consisted of nurses' discussion at a contin- uing education program for nurses on NDEs that one of us (LL M) Patients. The patient sample included six men and six women. One subject who had no recall of the experience was used for compara- tive purposes. Patients were recruited from eight hospitals within the Chicago metropolitan area. The patients ranged in age from 24 to 73 years, with a mean of 48. 1 years. The age of the men ranged from 32 to 73 years, and the age of the women ranged from 24 to 66 years ix patients were married, four were divorced, and two were single Ethnic background included eight Caucasian subjects, two African- American, one Asian, and one Syrian. Religious affiliations included

P1: GRA Journal of Near-Death Studies ph167-jond-455246 November 22, 2002 9:37 Style file version September 27, 2002 LINDA L. MORRIS AND KATHLEEN KNAFL 145 Study Design and Methods This study used the qualitative approach of naturalistic inquiry (Lincoln and Guba, 1985), which is the process of exploring naturally occurring phenomena in order to gain understanding. For the purpose of this study, an NDE was defined as the report of “unusual recollec￾tions associated with a period of unconsciousness during either serious illness or injury, or during resuscitation from a cardiac or respiratory arrest.” In order to enhance completeness of the topic and validity of the findings, triangulation of methods was used. This included the use of intensive interviewing in conjunction with a structured instrument, the Near-Death Experience Scale (Greyson, 1983), in order to elicit the perspectives of both patients and nurses. Credibility of the findings was enhanced by the use of multiple sites, multiple subjects, and multiple modes of data collection. Participants Participants were recruited from eight hospitals within the Chicago metropolitan area. Multiple sites were targeted to assure a diverse sample with regard to demographic characteristics, including ethnic￾ity, gender, and socioeconomic status. The patient sample included 12 adults, age 18 and older, who had either survived and had recall of a cardiac or respiratory arrest, or who had survived a serious ill￾ness with a period of unconsciousness that was not linked to anesthe￾sia. The nurse sample included 19 critical care nurses who had cared for at least one patient who had experienced an NDE. Thirty-five au￾diotaped interviews were conducted and transcribed verbatim. An ad￾ditional group interview consisted of nurses’ discussion at a contin￾uing education program for nurses on NDEs that one of us (L.L.M.) led. Patients. The patient sample included six men and six women. One subject who had no recall of the experience was used for compara￾tive purposes. Patients were recruited from eight hospitals within the Chicago metropolitan area. The patients ranged in age from 24 to 73 years, with a mean of 48.1 years. The age of the men ranged from 32 to 73 years, and the age of the women ranged from 24 to 66 years. Six patients were married, four were divorced, and two were single. Ethnic background included eight Caucasian subjects, two African￾American, one Asian, and one Syrian. Religious affiliations included

146 JOURNAL OF NEAR-DEATH STUDIES eight Protestants, two Christian, one Jewish, one Catholic, and one pa tient who did not identify a religious affiliation The events that precipitated the NDE included a combination of ute and serious health problems, as well as traumatic events. The serious health problems included septic shock, hypovolemic shock, dia- betic coma, and hepatic coma. The acute events included cardiac ar rest, ventricular fibrillation, respiratory arrest, respiratory distress, and ruptured ectopic pregnancy. The traumatic events included a bicy cle accident in which one patient was hit by a truck, and a stab wound to the heart cluded 19 critical care nurses. All of th arses indicated that they had cared for patients who had an NDE Their age ranged from 31 to 53, with a mean of 43.6 years. Religious affiliations included 9 Catholics. 8 Protestants and 2 who did not affili ate with any particular religion. Years of experience in nursing ranged from 3 to 26, with a mean of 16. 4 years ure Six patients were interviewed within one month of their NDe and six patients were interviewed within two years of the experience. In order to examine the process of recovery from the event, three of the patients from the first group were interviewed a second time four to six months after the event. For comparative purposes, one of us (LL M) also used theoretical sampling for one interview in selecting a subject who experienced a near-death event but had no memory of the of unconsciousness All 12 patients were asked to sign an informed consent agreement and were assured of the voluntary nature of the study. arrangements were then made for a taped interview and completion of the NdE Scale In seven patients, the medical records were reviewed in order to pro- vide background information so that potential confounding variables (such as drugs, length of arrest, and type of near-death event)could be identified. The records of the remaining patients were unavailable for review, most often because the patient was cared for at a nonparticipat- ng hospital Patients and nurses were interviewed at a time and place of their choice. One of us (LL M)conducted all interviews. The interview guides were used in a flexible manner, with the primary objective of encouraging all subjects to recount their experience in detail

P1: GRA Journal of Near-Death Studies ph167-jond-455246 November 22, 2002 9:37 Style file version September 27, 2002 146 JOURNAL OF NEAR-DEATH STUDIES eight Protestants, two Christian, one Jewish, one Catholic, and one pa￾tient who did not identify a religious affiliation. The events that precipitated the NDE included a combination of acute and serious health problems, as well as traumatic events. The serious health problems included septic shock, hypovolemic shock, dia￾betic coma, and hepatic coma. The acute events included cardiac ar￾rest, ventricular fibrillation, respiratory arrest, respiratory distress, and ruptured ectopic pregnancy. The traumatic events included a bicy￾cle accident in which one patient was hit by a truck, and a stab wound to the heart. Nurses. The nurse sample included 19 critical care nurses. All of the nurses indicated that they had cared for patients who had an NDE. Their age ranged from 31 to 53, with a mean of 43.6 years. Religious affiliations included 9 Catholics, 8 Protestants, and 2 who did not affili￾ate with any particular religion. Years of experience in nursing ranged from 3 to 26, with a mean of 16.4 years. Procedure Six patients were interviewed within one month of their NDE and six patients were interviewed within two years of the experience. In order to examine the process of recovery from the event, three of the patients from the first group were interviewed a second time, four to six months after the event. For comparative purposes, one of us (L.L.M.) also used theoretical sampling for one interview in selecting a subject who experienced a near-death event but had no memory of the period of unconsciousness. All 12 patients were asked to sign an informed consent agreement and were assured of the voluntary nature of the study. Arrangements were then made for a taped interview and completion of the NDE Scale. In seven patients, the medical records were reviewed in order to pro￾vide background information so that potential confounding variables (such as drugs, length of arrest, and type of near-death event) could be identified. The records of the remaining patients were unavailable for review, most often because the patient was cared for at a nonparticipat￾ing hospital. Patients and nurses were interviewed at a time and place of their choice. One of us (L.L.M.) conducted all interviews. The interview guides were used in a flexible manner, with the primary objective of encouraging all subjects to recount their experience in detail

LINDA L. MORRIS AND KATHLEEN KNAFL Separate interview guides were developed and pilot tested for pa- tients and for nurses. The patient interview guides were developed to explore the period of unconsciousness as well as the meaning and significance of the NDE. A follow-up interview guide was developed to determine whether participants'feelings and beliefs changed over time The nurse interview guide explored a variety of issues related to life and death and patients' thoughts and feelings surrounding resuscita- tion questions on the interview guides reflected the aims of the study the literature, and our clinical experience. For this study, the purpose in utilizing the Near-Death Experience Scale( Greyson, 1983)was to provide a foundation for the depth of the NDE itself. The NDE Scale was based on previous work(Noyes and Slymen, 1978-79; Ring, 1980)and was developed in order to provide a specific measure of depth of and NDE. The final NDE Scale of 16 items was derived from responses of 67 individuals describing 74 NDEs. Four item clusters were identified: cognitive, affective, paranormal, and tran- cendental. Crohnbach's alpha was 88 for the entire scale and ranged from 66 to 86 for each cluster. Test-retest reliabilities after four to six months were. 92 for the entire scale and ranged from 79 to 95 for each cluster Data Management and analysis Each of the 35 interviews was transcribed verbatim, resulting in more than 900 pages of transcripts. Each line of text was analyzed for content and meaning and assigned an appropriate descriptive code, based on the aims of this research Codes were then further reduced nd grouped, first into major themes, and then into major category domains. two categories of themes were short-term meaning and long term meaning. In order to verify consistency and reliability of coding, three tran scripts were checked with a doctorally prepared colleague with exper tise in qualitative technique. Coding two transcripts each, the initial reliability rate of the interviewer(LL M ) and the expert was 76 per cent. In order to ensure completeness and reliability of coding, we re- ewed all of the transcripts and recoded each one. This was a helpful xercise. in that we were able to correct several instances of codes that were too specific, and several additional codes were added. The expert was asked to code a third transcript, which was compared to that of the interviewer: The final percent agreement was 96 percent

P1: GRA Journal of Near-Death Studies ph167-jond-455246 November 22, 2002 9:37 Style file version September 27, 2002 LINDA L. MORRIS AND KATHLEEN KNAFL 147 Separate interview guides were developed and pilot tested for pa￾tients and for nurses. The patient interview guides were developed to explore the period of unconsciousness as well as the meaning and significance of the NDE. A follow-up interview guide was developed to determine whether participants’ feelings and beliefs changed over time. The nurse interview guide explored a variety of issues related to life and death and patients’ thoughts and feelings surrounding resuscita￾tion. Questions on the interview guides reflected the aims of the study, the literature, and our clinical experience. For this study, the purpose in utilizing the Near-Death Experience Scale (Greyson, 1983) was to provide a foundation for the depth of the NDE itself. The NDE Scale was based on previous work (Noyes and Slymen, 1978–79; Ring, 1980) and was developed in order to provide a specific measure of depth of and NDE. The final NDE Scale of 16 items was derived from responses of 67 individuals describing 74 NDEs. Four item clusters were identified: cognitive, affective, paranormal, and tran￾scendental. Crohnbach’s alpha was .88 for the entire scale and ranged from .66 to .86 for each cluster. Test-retest reliabilities after four to six months were .92 for the entire scale and ranged from .79 to .95 for each cluster. Data Management and Analysis Each of the 35 interviews was transcribed verbatim, resulting in more than 900 pages of transcripts. Each line of text was analyzed for content and meaning and assigned an appropriate descriptive code, based on the aims of this research. Codes were then further reduced and grouped, first into major themes, and then into major category domains. Two categories of themes were short-term meaning and long￾term meaning. In order to verify consistency and reliability of coding, three tran￾scripts were checked with a doctorally prepared colleague with exper￾tise in qualitative technique. Coding two transcripts each, the initial reliability rate of the interviewer (L.L.M.) and the expert was 76 per￾cent. In order to ensure completeness and reliability of coding, we re￾viewed all of the transcripts and recoded each one. This was a helpful exercise, in that we were able to correct several instances of codes that were too specific, and several additional codes were added. The expert was asked to code a third transcript, which was compared to that of the interviewer. The final percent agreement was 96 percent

JOURNAL OF NEAR-DEATH STUDIES Ethical considerations <& This study was approved by the Institutional Review Board (RB)of he University of linois at Chicago and by each cooperating hospital Each participant signed a consent form prior to the interview and com pletion of the NDE Scale. Participants were assured that theiridentities would be kept confidential and that no identifying information would be published in any reports resulting from this stuas,notions elicited A pilot study showed that there were some strong en ncluding crying, from the interviews. We assured the participants that they were free not to answer any questions that made them uncomfort- able, and that they were free to terminate or reschedule the interview at any time. However, none of the participants indicated that he or she wished to end the interview prematurely. Confidentiality was assured by assigning each participant a code lumber. A master list of participants names and code numbers was kept in a locked office in the event that a participant needed to be con- tacted for further information, or scheduled for a follow-up interview. Results Patients'Level of Consciousness All 12 patient participants experienced a period of unconsciousness however, in many cases, it was difficult to assess the duration of the unconsciousness because the documentation in the medical record of- ten did not specifically identify level of consciousness. For seven of the 12 patients, the interviewer(L L M ) reviewed the records and corrobo- rated the patient's account of the experience. The remaining five med ical records were not available, most often because the patient was not recruited through a hospital Patients' NDE Scale scores Eleven patients completed the NDE Scale(Greyson, 1983), which was Ised to identify relative depth of the NDE. Determination of depth was made by sment of the number of features that were experienced during the nde and the degree to which they were experienced. The mean score of these 11 participants on the nde Scale was 14.5 (S D= 6), with a range of 4 to 25. The mean score on the Cognitive Component of the scale was 2.2(S D.= 2), with a range of 1 to 6 the

P1: GRA Journal of Near-Death Studies ph167-jond-455246 November 22, 2002 9:37 Style file version September 27, 2002 148 JOURNAL OF NEAR-DEATH STUDIES Ethical Considerations This study was approved by the Institutional Review Board (IRB) of the University of Illinois at Chicago and by each cooperating hospital. Each participant signed a consent form prior to the interview and com￾pletion of the NDE Scale. Participants were assured that their identities would be kept confidential and that no identifying information would be published in any reports resulting from this study. A pilot study showed that there were some strong emotions elicited, including crying, from the interviews. We assured the participants that they were free not to answer any questions that made them uncomfort￾able, and that they were free to terminate or reschedule the interview at any time. However, none of the participants indicated that he or she wished to end the interview prematurely. Confidentiality was assured by assigning each participant a code number. A master list of participants’ names and code numbers was kept in a locked office in the event that a participant needed to be con￾tacted for further information, or scheduled for a follow-up interview. Results Patients’ Level of Consciousness All 12 patient participants experienced a period of unconsciousness; however, in many cases, it was difficult to assess the duration of the unconsciousness because the documentation in the medical record of￾ten did not specifically identify level of consciousness. For seven of the 12 patients, the interviewer (L.L.M.) reviewed the records and corrobo￾rated the patient’s account of the experience. The remaining five med￾ical records were not available, most often because the patient was not recruited through a hospital. Patients’ NDE Scale Scores Eleven patients completed the NDE Scale (Greyson, 1983), which was used to identify relative depth of the NDE. Determination of depth was made by an assessment of the number of features that were experienced during the NDE and the degree to which they were experienced. The mean score of these 11 participants on the NDE Scale was 14.5 (S.D. = 6), with a range of 4 to 25. The mean score on the Cognitive Component of the scale was 2.2 (S.D. = 2), with a range of 1 to 6; the