Unit 32- Death & Dying Adonis K. Lomibao, R.N.

Objectives Spell & Define terms Discuss differences in how people handle the process of death & dying List nursing assistant measures designed to promote a peaceful death experience List nursing assistant measures designed to comfort family & friends of people who are dying

Objectives Cont. List the stages of death & dying Differentiate between spirituality & religiousness List the signs of impending death Identify beliefs regarding death & dying in various cultures

Introduction POSTMORTEM-the after-death Death is the natural result of the life process Death & Dying is handled differently by different people TERMINAL-life-ending

Intro Cont. Different reactions to terminal illness: -Some have prepared for death & accept it -Some look forward to relief -some fearful or angry-denial/depression -Others reach out, verbalize thoughts & feelings -despair/anxiety---hostility to searching/groping questions

Intro Cont. Reaction states are not predictable Accept pt's behavior with understanding Interpret pt's need for family support Support family in meeting their needs

5 stages of Grief Dr. Kubler-Ross The Five Stages: -Denial -Anger -Bargaining -Depression -Acceptance

Denial Begins wn person is made aware that he is going to die May deny information Most must go through denial before reaching acceptance Do not try to convince pt. Of diagnosis or argue Professional counseling may be needed

Anger Comes when pt. Is no longer able to deny the fact that she is going to die May blame those around her for illness Added stresses are likely to upset pt. Remember pt. Is angry at diagnosis, not you. Remain calm & avoid making pt. Angrier Remedy problem that angers pt.

Bargaining The patient attempts to bargain for more time to live May be allowed to go home to finish a task before death pt. makes “deals” with a higher power Frequently involves an important event the patient has been looking forward to

Depression pt. realizes he will die soon\ Sad that he won't see family friends May have no accomplished goals Regrets of not going somewhere/doing something

Acceptance pt. understands & accepts he will die May complete unfinished business May help those around him deal with death

5 Stages of Grief Not all patients go trough stages in order Patients go back & forth between stages Staff must be able to identify pt's current reactions When all 5 are passed, pt. Is better able to accept the termination of life Family & staff also move through stages- difficult when pt. Is at different stage Post-funeral meals!

Preparation for Death Diagnosis of terminal illness difficult to conceal Staff may reveal information accidentally by: -exhibiting false cheerfulness -being evasive -making fewer visits -spending less time

Preparing for Death Each pt. Reacts to understanding of death in a unique way What feelings to share and with whom are personal decisions Be available to listen, but don't force issue

Common Fears Common fears with dying: -Dying alone -Fear of severe, unrelieved pain -Fear of inability to finish personal business or manage affairs

Reactions of Others In LTC Facility, other residents will be upset about death or terminal diagnosis Loss reminds residents of end of life They will cope with their own pain & grief Other residents will: -be sad & grieve loss of friend -reminisce about person who died -want to know about person who died Encourage others to express feelings. Be honest without breaking confidentiality

The Patient Self-Determination Act Requires healthcare providers to provide written info about state laws regarding advance directives ADVANCE DIRECTIVE-a document that is put into effect if the patient later becomes unable to make decisions Informed of right to execute advanced directive by at admission Act passed so pt.'s wishes are followed

Patient Self-Determination Act SUPPORTIVE CARE- patient's life will not be artificially prolonged but that the patient will be kept comfortable physically, mentally, & emotionally. Includes: -O2 if needed -food & fluids by mouth -meds for pain, nausea, anxiety, phys/emot discomfort

Cont. -physical care such as grooming,hygiene, positioning, ROM -caring & emotional support of staff LIFE-SUSTANING TREATMENT- giving medications and treatments for the purpose of maintaining life. -ventilator -CPR if cardiac arrest occurs -artificial nutrition through feeding tube or hyperalimentation device

-Blood transfusions -Surgery -Radiation therapy -chemotherapy

2 Types of Advanced Directives LIVING WILL: a request that death not be artificially postponed if the pt. Has an incurable, irreversible injury, disease or illness that the physician determines to be a terminal condition -must be witnessed by 2 persons that would not benefit from person's death

2 Types of Advanced Directives DURABLE POWER OF ATTORNEY FOR HEALTH CARE:assigns someone else the responsibility for making medical decisions for the patient if the patient becomes unable to do so himself. Must be signed by agent, principal, & witness. Power of attorney can decide if life should be prolonged, prolonged unless physician believes pt. In irreversible coma, or wants life prolonged regardless

DNR No-code order/DNR: no extraordinary means (CPR) will be used to prevent death. Person dies with maximum dignity Pt. discusses decision with family & physician. Placed in chart & staff made aware Order can be changed

Witnessing Advance Directives Become familiar with facility policies & state laws for witnessing Many states, caregivers cannot witness or be appointed to be the agent unless related by blood or marriage.

Withdrawing/Modifying AD Pt. can withdraw or modify advanced directives If pt. Informs you of changes that affect AD, notify nurse.

The Role of the Nursing Assistant Be a source of strength & comfort Instill confidence in pt. & family Keep in mind: -consistent response guided by pt. Attitude & careplan -be open & receptive,pt. attitudes change -report incidents related to pt. Moods & needs -don't force your own ideas -Resolve your own conflicts with accepting death

PCT Roles Cont. Give best & most careful nursing care, esp. mouth care & fluid intake Be quietly empathetic...carry out duties in calm, efficient way CRITICAL LIST-pt. Condition is critical & family/chaplain notified.

Providing for Spiritual Needs Spiritual faith comforts during difficult times Some religions have rituals when pt. Is ill or dying Allow for privacy for prayer, but be accessible Others have no formal religion, but need spiritual needs from chaplain Others don't believe in higher beeing Respect beliefs & religious items Catholic-Sacrament of the Sick (Confession) Bible or spiritual reading may be requested

Remember Family Allow privacy with loved one Allow to assist with care if desired Inform where food can be obtained Privacy for calls Offer comfort if staying the night Avoid being judgemental

Hospice Care Terminally ill with less than 6 mos to live Direct physical care when needed Supports family & pt. Provided in facilities & home Largely carried out by home health assistant Follow-up bereavement counseling Volunteers visit

Goals of Hospice Care Control pain so pt. Can remain active in life Coordinate psychological, spiritual, social support services for pt. & family Make legal & financial counseling available

Keep in mind... -report pain -encourage self-care -listen & spend time -get to know & support family -give same care as if no terminal diagnosis -always follow careplan -carry out activities with dignity & respect

Physical Changes as Death Approaches -less responsiveness -body functions slow -loses general voluntary & involuntary muscle control -may involuntarily void & defecate -the jaw tends to drop -irregular/shallow breathing -circulation slows-rapid/weak pulse -skin pales -eyes stare & do not respond to light -hearing last sense to be lost

As Death Approaches... Period before death, pt. Receives same care as if he was to survive. Pay attention to physical/emotional needs If death is near, call nurse

Signs of Death MORIBUND changes: changes that continue to take place in the body after death -pupils become permanently dilated -no pulse/respiration -heat gradually lost from body -patient may urinate/defecate/pass gas -blood pools in low areas (purple) -2-4 hours, rigor mortis (body rigidity) -protein breakdown unless embalmed in 24hrs -raise head of bed to 30 to prevent pooling

Postmortem Care POSTMOTEM CARE-care of the body after death -Standard precautions -Dignity -some leave alone till mortuary staff arrives -check hospital procedure

Morgue Kit Shroud Clean gown ID Tags Gauze squares Safety pins

Organ Donations Organ donor card Specifies specific organs or whole body HARVESTED