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This is a study of the manner in which death is organised in the city of Belfast. It is concerned with the analysis of the principles, practices, and forms of knowledge which serve to organise the dead from the moment at which physical death is pronounced until the moment of disposal. The thesis is presented in two parts. Part One is entitled Public Bodies. It focuses, in the main, upon the discourse through which individual deaths in particular, and mortality patterns in general, are explained, described, and analysed by state agents and agencies. Chapter One examines the principles according to which causes of death are discovered and allocated. Chapter Two switches attention to modes of death, and examines the use of categories of natural and unnatural death. Chapter Three focuses upon the discourse of modern pathology as it operates within the confines of the city mortuary. And, Chapter Four, concentrates upon the General Register Office, and the principles according to which it collects, collates, and produces data on Belfast mortality patterns. The second part of the thesis is entitled Private Death. Here, the point of focus shifts to the examination of the activities and forms of thought which operate outside of, and beyond the official state agencies. Chapter Five presents an investigation of the organisational principles through which death is ordered within the cemetery, the city, and the hospital. Chapter Six, investigates the ways in which sentiments of the bereaved are structured in relation to the dead. Whilst Chapter Seven focuses upon the organisation of body, soul, and social being during the phase of disposal. The final chapter examines the interpenetration of Belfast politics and political ideologies with the social practices which surround the disposal of the dead. The methodological basis of the study is outlined in Appendix A.

Background: Many deaths in intensive care involve difficult decisions about withholding and withdrawing therapy and consenting to organ donation, with the potential to trigger moral distress in those involved. Moral distress occurs when an individual feels constrained from acting in accordance with their moral choice or acts against their moral judgement. The resulting sense of wrong-doing and remorse generates an exquisitely painful feeling of anguish and sense of fractured sense of identity; with detrimental consequences in the long-term. Moral distress remains a poorly recognised and understood phenomenon and little is known of the factors that trigger it in ICU end-of-life decisions. Prior research focused largely on nurses, less was known about doctors' experiences and moral distress in relatives' was an underinvestigated area. Study Aim: This study aimed to identify the key triggers and constraints involved in the development of moral distress in end-of-life decisions in ICU and the resulting consequences of moral distress for the clinical staff and relatives involved. Method: A qualitative narrative thematic analysis end-of-life case approach was used to undertake in-depth interviews with 20 bereaved relatives and 45 nurses and doctors closely involved in 21 patient cases of non-escalation and withdrawal of therapy, and organ donation following brain-stem death and circulatory death. The study was funded by the Research and Development division of the Public Health Agency and conducted in a large tertiary referral ICU in Northern Ireland, from August 2012- November 2013. Key Findings: ICU nursing and medical staff experienced a considerable amount of moral distress in end-of-life care decisions. Bedside nurses and junior medical trainees with perceived lower levels of knowledge, experience and influence in end-of-life decisions experienced more moral distress than did consultants and senior nurses. At least half of relatives experienced moral distress at some point along the ICU end-of-life care trajectory. Triggers specific to all three participant groups included, breaches in consistency and continuity of care delivery and end-of-life decisions and insensitive and lengthy organ retrieval procedures. Failure to ensure 'The Good Death' left a powerful sense of failed obligation. Some relatives remained ' stuck in the chaos' of moral distress several months after the death. Conclusion: Findings have important implications for the educational preparation of new ICU nurses and doctors to prepare them for the complexities of the ethically challenging ICU environment. An educational intervention could be tested in future research based on case studies and vignettes from the study findings and from relatives interviews uploaded onto the Healthtalkonline website. Finding also have implications for the support of relatives in ICU with follow-up after the death. There are also implications for improvement in organ retrieval services in Northern Ireland.