The importance of this guide

Many graduate nurses encounter their first patient deaths in emergency departments and acute care settings. In these cases, death is often sudden, emotionally intense, and formative.

Although undergraduate programs teach palliative care, this education often reflects planned, well-resourced environments that differ greatly from the realities of acute care, where end-of-life care unfolds amid noise, time pressures, competing clinical demands, and limited specialist support. This gap between preparation and practice can leave graduate nurses unsure how to deliver the care they know matters most.

As one graduate nurse reflected, “We learned that end-of-life care should be peaceful and private. But in the emergency department, there were open curtains, constant monitor alarms, and three other patients sharing the space.”

Graduate nurse experiences within acute end-of-life care

Graduate nurses typically practise at novice or advanced beginner levels, where care is guided by learned rules and emerging pattern recognition, and confidence in prioritisation and complex judgement is still developing.

End-of-life care can be particularly challenging because it requires a shift from rapid intervention to a patient-centred and comfort-focused approach. This is often opposed by a graduate nurse's emerging professional mindset of treating swiftly.

These tensions are an expected reality of professional growth and reflect how clinical judgement is shaped by both experience and theory.

As some graduate nurses have shared:

“I wasn’t sure when it was appropriate to discontinue interventions.”

“I didn’t want others to think I was giving up on the patient.”

“I didn’t realise this was actually the end of the patient’s life.”

Death in acute care is routine and not rare

Death during or soon after emergency presentations or acute care admissions is relatively common, especially amongst older adults within our aging population. Many patients have pre-existing complex comorbidities, unmet palliative needs, unclear care goals, or no advance care planning.

This leaves nurses to recognise dying, manage symptoms, support families, communicate concerns, and make decisions in time critical scenarios.

Graduate nurses therefore face significant emotional and ethical responsibilities whilst they are still developing their clinical confidence. One graduate nurse shared with me, “Handling medications was manageable for me, but communicating with the family was far more challenging because I was so scared I might say something wrong.”

End-of-life care can feel difficult

End-of-life care within acute settings presents unique challenges. As emphasis is placed on rapid interventions and active treatments, comfort-oriented approaches are often considered expendable and relegated to the back seat.

For underprepared graduate nurses, these settings can create conflicts between principles of dignified end-of-life care and the practical, high-pressure realities, limited palliative experiences, and considerable emotional demands.

Early experiences that stay with nurses

First patient death encounters are often vividly remembered, with many graduate nurses describing feelings of being overwhelmed, frozen, or unsure if they responded appropriately.

This reflects my own early experience caring for a patient who died shortly after comfort care was initiated. The challenge for me was that, for the first time in my early career, I was not concerned about the clinical complexity; rather, I felt unprepared for what followed.

Caring for the body, supporting family members, and managing my own responses.

As I was not in a formal graduate program, and the emergency department was very busy, I did this without guidance or debriefing. Certainly a humbling experience which has stayed with me.

In the years that have followed, graduate nurses have shared similar reflections with me, such as “I didn’t know if I was doing it right”, and “Everyone else seemed calm, and I felt like I shouldn’t be affected.”

When these pivotal moments are supported and recognised, they can become powerful and transformational learning opportunities. If left unaddressed, however, they may lead to ongoing emotional distress and resentment towards career choices.

Creating a supportive culture for end-of-life care

Supporting graduate nurses in end-of-life care doesn’t require specialist palliative expertise. It requires thoughtful role-modelling and open conversations. By normalising death as an expected part of acute care, we can reduce shock and self-doubt in graduate nurses.

This can reinforce the idea that comfort-focused care should always be considered a legitimate and skilled component of nursing practice. This is an important shift in mindset for many nurses, not just graduates.

My go-to insights for supporting graduate nurses in acute end-of-life care

Over time, through my own experiences and by listening to graduate nurses reflect on theirs, I have developed a set of practical insights for supporting end-of-life care in acute and emergency settings.

These insights are not about gaining specialist skills; rather, they are designed to help graduate nurses navigate the emotional and professional challenges they face during some of the most formative moments of their careers.

Below are some key principles I rely on.

1. Normalise death as an expected part of acute care

By framing death as a routine outcome in acute settings, we help graduate nurses anticipate and accept it as part of the care they provide. This also lessens feelings of uncertainty and validates comfort care as a critical part of their role.

2. Make the cure to comfort shift more visible

Graduate nurses learn by observing how experienced nurses recognise and rationalise changes in care goals. Making this clinical reasoning visible helps bridge the theory-to-practice gap.

Explaining why monitoring is ceased, observations are reduced, and a quiet presence is prioritised helps graduate nurses understand that these decisions are deliberate and patient-centred.

As one graduate said to me during handover, “If someone had explained to me why we stopped taking obs, it would have made more sense.”

3. Slow it down and make your presence feel genuine

In efficiency-driven environments, graduate nurses often interpret nursing tasks without active treatment as a lack of care. Purposefully reassuring them that it is appropriate to pause and stay with patients and families helps reframe presence as active and meaningful care.

End-of-life care can be taught through small, focused moments, one decision or action at a time, without overwhelming the graduate nurse.

4. Acknowledge emotional impacts

Quietly recognising that a patient’s death was significant helps graduate nurses process the experience without judgement.

Simple acknowledgements of the moment, or of how first deaths often stay with nurses, can make a meaningful difference and normalise these extreme feelings, without requiring formal debriefing in this moment.

5. Be mindful of our own communication

Well-intended comments or actions, such as minimising a death, rushing post-death care without explanation, or treating palliation as a disruption, can unintentionally diminish these experiences for graduate nurses.

These signals are often interpreted as reflections of what is genuinely valued in practice, consequently influencing how graduate nurses understand and approach end-of-life care.

Acute end-of-life care practice support tool

The following table reflects these go-to insights and offers real-time support for reflection and discussion during acute end-of-life care.

• Before end-of-life care, acknowledge that it may occur and that support is available.
• During the experience, focus on one moment at a time.
• Afterwards, reflect briefly on single moments rather than entire events.

Clinical moment	Graduate nurse perceptions	Supportive focus	Useful prompts
Recognising dying	Uncertainty, fear of being wrong	Shared thinking	“What changes are you noticing?”
Shift in goals	Discomfort with de-escalation	Reassurance	“Let’s prioritise comfort now.”
Family distress	Anxiety about communication	Co-presence	“Be genuine, no one expects perfection.”
Symptom care	Task fixation	Prioritisation	“What is most important right now?”
Withdrawing interventions	Moral uncertainty	Context	“This is what is important for the patient.”
Death	Shock, emotional load	Calm and collected	“I’ll help you through this.”
Body care	Unfamiliarity	Gentle instruction	“This is like caring for any other patient.”
Reflection	Lingering doubt	Normalisation	“What do you think will stay with you about this?”

Reflection on end-of-life care

End-of-life care in acute and emergency settings is a pivotal component of nursing practice and is likely to increase as the population ages.

Graduates commence their careers with the intention of delivering quality, compassionate care. Providing them with structured end-of-life guidance, characterised by clarity, presence, and empathy can grow their confidence, judgement, and professional identities.

When we effectively support graduate nurses in end-of-life, everyone benefits; patients, families, colleagues and the positive advancement of nursing as a profession.