---

The term: SID syndrome applies to sudden and unexpected death of the infant for which no diagnostic fetal factor has been found. It is also applied to sudden death of a less than one year old baby, the cause is not recognizable after complete post mortem study, and review of disease records. Such a death will be a very bitter and sorrowful experience for the family, therefor the nurses are bound to support the family both mentally and spiritually.

---

Introduction: Death of a patient is an unavoidable stage of nursing and in many cases nurse is the only person who takes care of the patient at the time of death. An experienced and committed nurse obliges her/himself to care for the patient before and after death in the best way possible.           

Materials and Methods: This research is a descriptive study that carried out in order to determine knowledge and attitude of the nurses about pre and post-death cares. The samples were 227 nurses of Imam Khomeini Complex Hospital. The number of subjects chosen from each hospital was proportional to the number of nurses of that hospital. The samples were selected randomly. Data were collected by a questionnaire, validity of which was confirmed by content validity and reliability of it was confirmed by test-retest method. Data were analyzed with descriptive statistics.

Results: Results showed that in majority of the nurses level of knowledge about pre-death cares was moderate and was poor about post-death cares. The majority of the nurses had a positive attitude about pre-death cares and a relatively positive attitude about post-death cares. There was not any sample with negative attitude about pre or post-death cares.

Conclusion: Regarding the undesirable level of knowledge and positive attitude of the nurses under study concerning pre and post-death cares and considering that the necessity for improving the knowledge is training and education, the results of this research can help authorities to provide training and educational programs for enhancing nurses’ knowledge regarding pre- and post-death cares.

---

Background & Aim: Increasing understanding of death anxiety among different cultures and patient populations is critical to provide quality patient care. Researchers who investigate death anxiety, are looking for a reliable and valid instrument compatible with culture in order to achieve this goal. The aim of the study was to evaluate the psychometric properties of the Templer’s Death Anxiety Scale-Extended (TDAS-E) among a sample of chemical veterans of Iran–Iraq warfare.

Methods & Materials: In this methodological study, 300 veterans completed the Persian version of the 51-item TDAS-E in 2015. The face, content and construct validity (convergent and discriminant validity) of the TDAS-E were assessed. Also, its reliability was measured using Cronbach’s alpha coefficient, construct reliability and intra correlation coefficient.

Results: Results of exploratory and confirmatory factor analyses extracted four stable distinct factors including fear of the hereafter, fear of facing death, fear of the shortness of life, fear of dying following an incident and mishap. The fitness of the four-factor model of the Templer’s death anxiety construct was approved based on standard indices (c²/df=2.832, GFI=.915, AGFI=.873, PCFI=.657, PNFI=.612, RMSEA=.078). Discriminant and convergent validity of all factors were acceptable. Also, scale reliability was confirmed using Cronbach’s alpha coefficient (0.88), construct reliability (higher than 0.70) and intra correlation coefficient (0.87).

Conclusion: The results of the current study revealed that the four-factor construct of TDAS-E had suitable validity and reliability among Iranian chemical warfare veterans. Given the proper psychometric properties, this scale can be used in future research to evaluate death anxiety in this population.

Background & Aim: Increasing understanding of death anxiety among different cultures and illness populations is critical to provide quality patient care. Researchers who investigate death anxiety, are looking for a reliable and valid instrument compatible with culture in order to achieve this goal. The aim of the study was to evaluate the psychometric properties of the Templer’s Death Anxiety Scale-Extended (TDAS-E) among a sample of chemical veterans of Iran–Iraq warfare.

Methods & Materials: In this methodological study, 300 veterans completed the Persian version of the 51-item TDAS-E in 2015. The face, content and construct validity (convergent and discriminant validity) of the TDAS-E were assessed. Also, its reliability was measured using Cronbach’s alpha coefficient, construct reliability and intra correlation coefficient.

Results: Results of exploratory and confirmatory factor analyses extracted four stable distinct factors including fear of the hereafter, fear of facing death, fear of the shortness of life, fear of dying following an incident and mishap. The fitness of the four-factor model of the Templer’s death anxiety construct was approved based on standard indices (c²/df=2.832, GFI=.915, AGFI=.873, PCFI=.657, PNFI=.612, RMSEA=.078). Discriminant and convergent validity of all factors were acceptable. Also, scale reliability was confirmed using Cronbach’s alpha coefficient (0.88), construct reliability (higher than 0.70) and intra correlation coefficient (0.87).

Conclusion: The results of the current study revealed that the four-factor construct of TDAS-E had suitable validity and reliability among Iranian chemical warfare veterans. Given the proper psychometric properties, this scale can be used in future research to evaluate death anxiety in this population.

---

Background & Aim: Concerns about death may negatively affect health-related quality of life. However, little is known about the relationship between death anxiety and quality of life in life-threatening illnesses especially in hemodialysis patients. This research aimed to determine the relationship between death anxiety and quality of life in hemodialysis patients.

Methods & Materials: In this descriptive correlational study, 200 hemodialysis patients were selected via stratified random sampling from hospitals affiliated with Zanjan University of Medical Sciences from April to May 2016. Data collection instruments included a demographic questionnaire, the Templer Death Anxiety Scale and the McGill Quality of Life questionnaire. Data analysis was performed by descriptive statistics, correlation test and linear regression model using SPSS v.22.

Results: The average score of death anxiety and quality of life were respectively 46.54±10.85 and 82.55±19.01. There was not a significant relationship between death anxiety and quality of life (P>0.05, r=0.044). In the regression analysis, gender was the only significant predictor for death anxiety. This model explained 11.3% of the variance of death anxiety. Moreover, the results of regression model indicated that social support and religious beliefs were only significant predictors for quality of life in hemodialysis patients, and 17.2% of its variance was explained by this model.

Conclusion: In the current study, no significant relationship was observed between death anxiety and quality of life in hemodialysis patients. Therefore, it is suggested that further research should be conducted in this area.

---

Statistics show that brain death constitutes 1-4% of hospital deaths and 10% of the deaths occurred at the intensive care units (1). In the United States, brain death accounts for less than 1% of all deaths (about 15000 to 20000) (2). According to Iranian statistics, more than 15000 brain deaths occur every year in Iran, and driving accidents are one of its main causes (3-6). Then, these patients are taken to the ICUs to be cared for by nurses (7).

Considering the great number of brain deaths in Iran, and also the great number of patients needing transplant who die due to lack of obtaining an appropriate transplant organ, the Ministry of Health has notified to the universities of medical sciences the regulation number 54/100 dated 23.01.1394. In the 4^th clause of this regulation, accurate and specialized medical care in accordance with the instructions, preserving the vital organs of brain death patient (maintaining electrolytes, kidneys, liver, heart, lungs, and stabilizing vital signs) are emphasized which shows the necessity and importance of accurate training for all staffs specially nurses involved in caring for the brain death patients.

Given the high rate of brain death, most patients that ICU nurses face are the brain death patients (8). The caring process of brain death patients has different challenging and undiscovered dimensions due to its difficult and complicated nature which has attracted attention of researchers from all over the world to study its different dimensions. Some of the most important challenges which ICU nurses referred to in the caring process of brain death patients in studies are as follows: understanding the concept of brain death by the ICU nurses is one of the most challenging dimensions of this process (9). Although the meaning of brain death and caring for these patients is one of the vital components of nursing practice at the ICUs (10), understanding the concept of brain death is very difficult for most nurses and challenges all their previous beliefs about death and dying (11) because the concepts and implications for understanding brain death are beyond the understanding of the normal death of a person. This phrase is translated as actual death which means there is no hope for improvement, while the physical appearance of brain death patients, the presence of family members and nurses’ caring activities at the bedside of patients give the impression that they are alive, and all of these contribute to this ambiguity. But this conflict is naturally emotional and experimental for nurses (12). Ronayne in their study found that despite the knowledge about the physiology of brain death, its experience is stressful for nurses even long after facing these patients (8).

One of the other challenges is the announcement of brain death to the patient’s family. Although this is one of the physician’s responsibilities, nurses are also involved in because of their constant presence at the hospital and easy access of patients’ family members to them. This announcement is very stressful and challenging for nurses and is one of the most important parts of caring process (13) because nursing care is not only limited to the patient but also includes facing the specific needs of patient’s family members who are in crisis and experiencing an acute, complex and stressful clinical situation (14). Other nurses’ challenges in the caring process of brain death patients are ethical and legal aspects especially in the field of brain death and organ donation (4). Studies in Iran show that only half of physicians and medical staffs have sufficient awareness about organ donation and its laws, but they do not attempt to encourage organ donation for the fear of increasing mental pressure on patient’s family members (4). However, training is considered an effective factor in facilitating organ donation process (15).

Caring for a brain death patient and possible potential members to donate is another nurses’ challenge in caring process. Caring for a brain dead patient has been always a big challenge for the ICU nurses (14). According to different studies, most nurses believe that they are not ready enough to care for a patient who is a candidate for organ donation (16). So, one of the most difficult responsibilities of ICU nurses is caring for a brain dead patient who is a candidate for organ donation after her/his family’s consent (12). Studies showed that nurses feel hopelessness, inadequacy and depression after caring for a brain dead patient. These feelings may interfere in the quality of patient care and lead the nurse to be burnout (17). Ronayne found that because of the stress of caring for the brain dead patients, some nurses experience cognitive dissonance (8). One of the most important and controversial aspects of caring process is to give the request form of organ donation to the patient’s family. Given that caring process at the ICU involves both the patient and her/his whole family (18), the attitude of staffs especially nurses towards organ donation is very important since their positive attitude leads them to try more to prepare families for organ donation consent (13).

Some research has shown that providing opportunities for training nurses in this area, promotes organ donation and transplant rates since potential donors are timely identified and introduced to the organ bank (19). Nurses found that they need training and support on all aspects of caring for a brain death patient, organ donation and supporting her/his family (15). So, accurate and comprehensive understanding of the caring process of brain death patients especially from the nurses’ perspectives is very important for high quality and comprehensive caring. Due to the shortage of organ donation and the importance of organ health for transplantation, accurate and high quality caring for patient is necessary to make sure that organs remain healthy. Therefore, it is necessary to consider the caring process of the brain dead patient in order to develop an appropriate caring program for these patients.

Thus, considering that nurses are responsible for one of the most stressful caring processes including both caring for a brain dead patient and facing her/his family members (who may not be able to accept their patient’s brain death), and given the necessity of increasing the organ donation rate, and as well as the lack of targeted education on caring for the brain dead patients and insufficient nurses’ knowledge in this area, there is a need for accurate training on this caring process more than before.

---

Background & Aim: Quality of life indicates the level of individual’s satisfaction or dissatisfaction with the different aspects of life and has specific characteristics at each stage of life. The quality of life in the elderly may be influenced by death anxiety and depression. The aim of this study was to evaluate the relationship of depression and death anxiety to the quality of life among the elderly population.

Methods & Materials: This study was a cross-sectional research conducted on 294 elderly living in Saghez in 2016. Samples were selected through convenience sampling. The 12-Item Short Form Health Survey (SF-12), Geriatric Depression Scale (GDS) and Death Anxiety Scale were used to gather the data. Data were analyzed using descriptive statistics, the Kolmogorov-Smirnov test, Pearson correlation coefficient and linear regression by Enter method. The level of significance was considered P<0.05.

Results: The mean (and standard deviation) scores for the quality of life, depression and death anxiety among the studied elderly were respectively 33.22±7.81, 4.92±3.82 and 33.63±7.40. There was a significant relationship between depression and the quality of life (P<0.0001) but there was no significant relationship between the quality of life and death anxiety.

Conclusion: Depression is a common problem among the elderly and related to their quality of life. When assessing the quality of life in the elderly, paying attention to their depression is necessary. Appropriate diagnosis and management of depression can improve the quality of life in the elderly.

---

Background & Aim: Spiritual care along with other nursing interventions balance body and soul. This study aimed to determine the effect of spiritual care on death anxiety in hemodialysis patients with end-stage of renal disease.
Methods & Materials: A clinical trial (IRCT2016308226961N1) was performed in Hamadan’s Shahid Beheshti and Besat hospitals in 2016. A total of 60 hemodialysis patients with end-stage of renal disease were randomly assigned into two groups of intervention (30 patients) and control (30 patients). In the intervention group, the spiritual care program consisted of protective care, supporting the patient’s rituals and using the support systems, was performed in hemodialysis ward at the patient’s bedside. The control group only received routine nursing care. The Templar’s death anxiety questionnaire was completed by both groups before and after the intervention. Data were analyzed by descriptive and inferential statistics using the SPSS software version 16.
Results: The average score for death anxiety before the intervention between the intervention group (8.10±2.26) and control group (8.53±2.47) had not significant difference (P=0.482), while the average score for death anxiety after the intervention had statistically significant difference (P=0.004) between the intervention group with median value of 8.0 (6.00-8.25) and control group with median value of 9.0 (7.00-10.25), and the patients’ death anxiety reduced in the intervention group.
Conclusion: Spiritual care program reduced death anxiety in hemodialysis patients with end-stage of renal disease. Nurses can use spiritual care program to reduce patients’ death anxiety.
 

---

Background & Aim: Breast cancer is one of the most prevalent cancers in women and is regarded as a chronic disease with various psychological complications including death anxiety. This study aimed to examine the effect of Benson’s relaxation technique on death anxiety among women with breast cancer.
Methods & Materials: In this randomized clinical trial, 100 patients with breast cancer referred to Velayat Hospital in Qazvin in 2017 were selected using the consecutive sampling and randomly assigned into groups of experimental and control. A questionnaire on demographic information and the Templer Death Anxiety Scale were used. Benson’s relaxation technique was taught to the patients in the experimental group. Afterward, they were asked to perform the technique for three months and were monthly followed up using checklists. The Templer Death Anxiety Scale was completed again by both groups. Data were analyzed via the SPSS software version 23 using descriptive and analytical statistics.
Results: There was no significant difference in demographic variables between the two groups (P>0.05). Before the intervention, no statistically significant difference was observed between the mean scores of death anxiety in the patients of the experimental group (46.4±10.3) and the control group (49.6±10.07) (P>0.05). However, after the intervention, a statistically significant difference was observed between the mean scores of death anxiety in the experimental group (44.5±10.2) and the control group (48.9±11.2) (P<0.05).
Conclusion: According to the results of the study, it can be concluded that Benson’s relaxation technique is effective in reducing death anxiety among patients with breast cancer.
Clinical trial registry: IRCT20170610034435N8
 

---

Background & Aim: The experience of approaching death is one of the undeniable facts of aging that can cause fear and anxiety in the elderly. Given that spirituality as a solid base can be a powerful factor in controlling tense situations, this study was conducted to examine the effect of spiritual group therapy on death anxiety in the elderly.
Methods & Materials: This quasi-experimental study was conducted on 50 elderly people attending the elderly daily center in Aliabad Katoul (Golestan Province) in 2018. Sampling was done using the convenience method and participants were randomly assigned into either experimental- or control group. The experimental group received spiritual group therapy in 8 sessions within eight weeks. The data were collected using a demographic characteristics questionnaire and the Templer death anxiety scale. Using the SPSS software version 16, data were analyzed through independent t-test, paired t-test and covariance test at a significance level of less than 0.05.
Results: The rate of death anxiety before the intervention in the experimental- and control group were 7.36±3.67 and 7.32±1.65 respectively, which did not show a statistically significant difference (P=0.961). After the intervention, the average score of death anxiety for the experimental group was 5.24±3.28 and for the control group was 7.84±1.92 which showed a statistically significant difference (P<0.001).
Conclusion: According to the results, it is recommended to provide the necessary conditions to the elderly to participate in spiritual activities, which can be effective in improving the psychological state of the elderly.
Clinical trial registry: IRCT20181207041877N1
 

---

Background & Aim: Family caregivers of COVID-19 patients in the Intensive Care Units (ICUs) face numerous challenges that can affect their well-being. Spiritual health represents a crucial component for coping with such stressful conditions. Therefore, this study aims to determine the relationship between spiritual health and attitude towards death in family caregivers of COVID-19 patients post-discharge from the ICUs.
Methods & Materials: This descriptive-correlational study conducted between April and November 2021, focused on family caregivers of COVID-19 patients discharged from the ICUs. The sample comprised 260 family caregivers selected through convenience and purposive sampling methods. Data collection tools included a demographic and clinical questionnaire, Polotzin and Ellison's Spiritual Health Questionnaire, and Wong's Death Attitude Questionnaire. Data were analyzed using SPSS version 24 encompassed chi-square tests, one-way analysis of variance and Spearman correlation coefficient.
Results: The results showed a significant inverse relationship between total spiritual health score and the total score of attitude towards death (rs=-0.101, P<0.05). The attitude towards death findings revealed fear as the highest scoring dimension, with active acceptance scoring the lowest. Moreover, religious health exhibited a significant inverse relationship with avoidance of death (rs=-0.93) and fear of death (rs=-0.64, P<0.05).
Conclusion: The study highlighted an inverse relationship between the level of religious health and negative dimensions of attitude towards death. Individuals with higher religious health scores exhibited lower average scores for negative attitudes towards death, including fear and avoidance of death. This underscores the importance of emphasizing the religious dimension within families, and among patients discharged from the ICU, showcasing the role of religion in mitigating negative attitudes towards death.