Death, Dying, and the Grieving Process Chapter 8 Death, Dying, and the Grieving Process

Common Fears of the Dying Patient The unknown Abandonment and loneliness Loss of relationships Loss of experiences in the future Dependency and loss of independence Pain 

Common Fears of the Dying Patient (cont.) Nursing Implications  The nurse is most helpful to the patient in just “being there” for the patient and expressing caring Provide comfort and strength for the patient Explain to the family that patients go through these stages and the behavior is normal Review own beliefs about death and dying and reaffirm those beliefs Take a periodic inventory of your ability to provide care without “burnout” Table 8-8 on p. 173 provides some common spiritual beliefs and practices.

Kübler-Ross’ Stages of Dying Denial (This can’t happen to me!) Anger (Why me?) Bargaining (Yes me, but. . .) Depression (It is me. I give up. . .) Acceptance (I’m ready. . .) Elisabeth Kübler-Ross introduced the world to the stages of grief and dying when her landmark book, On Death and Dying, was published in 1969. Kübler-Ross suggested that people go through several predictable junctures as they learn to adapt to the processes of loss or impending death. Not everyone goes through all the stages, nor do people go through stages in any set order. These five stages may apply to the grieving process when a body function or part is lost (such as a lost breast from cancer), a loved one dies, or one’s own death is approaching (Box 8-6).

Palliative Care Palliative care (comfort care) is directed at meeting the needs of the dying patient by providing comfort and maintaining a high quality of life

Palliative Care Anticipatory guidance and stages of dying Terminal hydration End-stage symptom management Pain Dyspnea Death rattle Delirium

Anticipatory Guidance Prepare the family and patient by anticipating the death Give guidance about physical changes, symptoms, and complications This may also aid the patient and family in deciding about possible hospice care Two stages of dying Pre-active, which may take weeks or months Active, which lasts only a few days Two stages of dying: Pre-active, which may take weeks or months. Patients know they are dying and exhibit this knowledge by withdrawing from social activities and attempting to put their affairs in order. Patients often report seeing loved ones who have already died. Patients in the pre-active phase become restless, have slow wound-healing, and begin to have dependent edema (swelling in extremities, or even the entire body). Active, which lasts only a few days (King & Klawitter, 2007). They exhibit specific signs in breathing patterns and other bodily functions which indicate that death is imminent.

Terminal Hydration A dying patient gradually reduces fluid intake Dehydration can increase due to disease process Dry mouth and thirst may be induced by drugs

Terminal Hydration (cont.) Nursing implications The nurse must educate the patient and family on the benefits and burdens of hydration Many times, the course is for patients to choose what to take, and also to be allowed to refuse further nourishment

End-Stage Symptom Management Comfort is the goal of palliative care Administering only oral medications is the preferred choice but this may not be possible as death draws near The goal is to allow a pain-free death In some cases it may be possible to administer transdermal and/or rectal pain medications

Pain Transdermal fentanyl has helped eliminate the burden of pain at the end of life Sometimes this regimen is supplemented with rescue doses of morphine Whatever the regimen, studies have shown that pain relief, either total or at least enough to make the pain tolerable, is possible 75% to 97% of the time

Dyspnea When patients are near death, they often subjectively feel as if they cannot get enough air It is difficult to determine what causes this feeling, but several measures can be taken Place in Fowler’s position Reduce activities Adjust air temperature Give bronchodilators and morphine to ease breathing It is important for the nurse to remember that this feeling can be very frightening for both the patient and family members, and aggressive treatment to lessen discomfort is important.

Death Rattle Noisy ventilation is heard when patients can no longer clear their throats of normal secretions Family members are often alarmed and are afraid the patient will choke to death In these cases, scopolamine or atropine, drugs that are known to reduce secretions, may be used to quiet the patient and bring breathing back to normal

Delirium Dying patients may experience hallucinations and/or altered mental status The nurse must first search for causes such as pain, positional discomfort, or bladder distention and address those physical problems The nurse should discuss the delirium with the patient’s family and encourage the family to talk to the patient in quiet tones while remaining calm

Audience Response Question 2 A terminally ill woman reminiscing about the “good old days” becomes increasingly confused and talks of seeing relatives who have died. Which nursing intervention(s) would be appropriate? (Select all that apply.) Discuss the patient’s behaviors with the family. Force oral fluids. Encourage the family to talk to the patient in quiet tones. Promote a calm environment. Apply physical restraints. Correct Answer: 1, 3, and 4