1. Emotional and Physiologic Elements of Death and Dying

2. Strange as it may seem, death is a part of living
Strange as it may seem, death is a part of living. Where did you learn your ideas or views about death?
Family
Religious beliefs
Superstitions
Experiences with death
Attitude toward life
Mental health
Media
Science

3. How would you define Death?
the irreversible cessation of all vital functions especially as indicated by permanent stoppage of the heart respiration and brain activity

4. Where do Sparrow’s Go to Die?
Writing Situation
As you listen to this story pay particular attention to your own emotions and attitudes about death.
Also pay attention to the things that come to your mind concerning death.

5. Where do Sparrow’s Go to Die?
A question I often asked myself as a child was? “Where do the sparrows go when they die?” I didn’t know the answer then and I still wonder about it. Now I see a dead bird silenced by some evil force, and I know He didn’t die. Something killed him: the elements took him away, a lost soul in the night.
When I was six, my best friend was a boy on my street. We used to play in my sandbox, taling of things long forgotten by grown ups. Like never growing up, or the monsters under out beds and in dark closets. His name was Tommy, but I called him Sparrow because he was small for his age. It’s ironic to think of that name now because he died, too.
I remember the day I found out Tommy was dying. I waited in the sandbox for hi, half-heartedly building the castle we began the day before. Without Tommy I was only half, so I waited I for what seemed like forever, and it began to rain. Then I heard a distnat ring from the house. About 10 minutes later may mother came out, sheltered by her umbrella but her face wet just the same. We walked to the house. Just before we entered, I turned around and watched the rain beat down the sand castle Tommy and I built.
Once I was inside and had a cup of hot chocolate in my belly, my mother called me to the table. She put her hands on mine. They were shaking. I immediately felt it: something had happened to Tommy. She said doctors had performed some blood tests awhile back. When they received the test results, something showed up wrong. That something was leukemia. I didn’t know what it was and I looked at my mother with confused eyes, but with a knowing and heavy heart. She said that people who had what Tommy got-no: what got Tommy-had to go away. I didn’t want him to go away. I wanted him to stay, with me.
The next day I had to see Tommy. I had to see if it was all true, so I had the bus driver drop me off at his house instead of mine. When I reached the door, Tommy’s mom said that he didn’t want to see me. She had no idea how easily she could hurt a little girl. She broke my heart like a piece of cheap glass. I ran home in tears. After I returned home, Tommy called. He said to meet him at the sandbox after our parents went to bed, so I did.
He didn’t look different, maybe a little paler, but it was Tommy. He did want to see me. We talked of those subjects incomprehensible to adults, and all the while we rebuilt our sand castle. Tommy said we could live in one just like it and never grow up. I believed him wholeheartedly. There we fell asleep, engulfed in true friendship, surrounded by warm sand and watched by our sand castle.
I woke up just before dawn. Our sandbox was like a desolate island surrounded by a sea of grass, interrupted only by the back patio and the street. A child’s imagination is never ending. The dew gave the imaginary sea a reflective shimmer, and I remember reaching out to touch the dew to see if it would make the make-believe water ripple, but it did not. I turned around, and Tommy jolted me back to reality. He was already awake, staring at the castle. I joined him, and there we sat, locked in the awesome magic in the sand castle held for two small children.
Tommy broke the silence and said, “I’m going to the castle now.” We moved like robots, as if we knew what we were doing, and I guess in some small way we did. Tommy laid his head on my lap and said drowsily, “I’m going to the castle now. Come visit; I’ll be lonely.” I promised him with all my heart that I would. Then he closed his eyes, and my sparrow flew away to where I knew at that moment all the other sparrows went when they died. And there he left me, holding a soulless, crippled little bird in my arms.
I went back to Tommy’s grave 20 years later and placed a small toy castle on it. On the castle I had engraved, “To Tommy, my sparrow. I’ll come to our castle someday, forever.”
When I am ready, I’ll go back to the place where our sandbox was and imagine our sand castle. Then my soul, like Tommy’s, will turn into a sparrow and will fly back to the castle, and to Tommy, and to all the other little lost sparrows. A six-year-old again, who will never grow up.

6. 2. Why do most people dislike talking and thinking about death?

7. 3. What positive and negative statements could you make about your life thus far?

8. 4.What are some ways people deny that death is part of everyone's life?
MANY PEOPLE AVOID USING THE WORD DEATH OR DEAD,
PEOPLE DO NOT MAKE WILLS,
PEOPLE DO NOT MAKE ARRANGEMENTS FOR WHAT WOULD HAPPEN IF THEY DIED, ETC.

9. EMOTIONAL TRANSITIONS AT LIFE’S END
Although there are many theories about the emotional transitions encountered by dying people, the best known is

10. ELISABETH KUBLER-ROSS
Landmark work entitled On Death and Dying
Identified five emotional stages experienced by dying individuals

11. FIVE EMOTIONAL STAGES Dr. Elisabeth Kubler-Ross:
Well known thanatologist who did extensive research on process of death & dying
Developed 5 stages of dying/grief process
Stages may not occur in order
May overlap or be repeated
May not progress through all stages
May be in several at once
What is thanatologist? Study of death and its surrounding circumstances

12. Denial-or “no not me”
This is when they first find out

13. Anger- “why me?”
Comes when the person can no longer deny the fact that he she is going to die

14. Bargaining-“Yes, but. . .”
Bargains for more time to live

15. Depression-“It’s me!”
This is the most difficult of stages to deal with. Comes when the pt comes to full realization that he she will die soon

16. Acceptance-“It’s part of life. I have to get my life in order.”
Understands and accepts the fact that they are going to die

17. DEATH CAN INVOLVE FEARS THAT ARE PHYSICAL, SOCIAL, AND EMOTIONAL
PHYSICAL - Helplessness, dependence, loss of physical faculties, mutilation, pain
SOCIAL - Separation from family, leaving behind unfinished business
EMOTIONAL - Being unprepared for death and what happens after death

18. PHYSIOLOGY OF DYING Somatic death or death of the body
Series of irreversible events leading to cell death
Causes of death varies
However, there are basic body changes leading to all deaths

19. THESE BASIC BODY CHANGES RESULT IN THE DEATH OF ALL VITAL BODY SYSTEMS
PULMONARY:
Unable to oxygenate the body
Assess for poor oxygenation-skin pale, cyanotic, mottled, cool
in dark skinned - assess mucous membranes, palms of hands, soles of feet
Mottled skin-lacy or net like patches caused by changes in blood vessels found directly under the skins surface

20. CARDIOVASCULAR Large load on heart when lungs fail
Heart not getting needed oxygen
Pumping heart not strong enough to circulate blood
Blood backs up causing failure
Leads to pulmonary and liver congestion

21. BLOOD CIRCULATION Decreased, as heart less able to pump
May have a “drenching sweat” as death approaches
Pulse becomes weak and irregular
If pulse relatively strong, death is hours away
If pulse is weak and irregular, death is imminent

22. COMBINATION OF THESE EVENTS LEADS TO CELL DEATH, AND DEATH OF THE ORGANISM (HUMAN)
As pulmonary and cardiovascular systems fail, other body systems begin to fail, also

23. FAILING METABOLISM Metabolic rate decreases, almost stopping
Feces might be retained or incontinence might be present

24. FAILING URINARY SYSTEM
Urinary output decreases
Blood pressure too low for kidney filtration
Further load on cardiovascular system due to increase circulating volume

25. FAILING NERVOUS SYSTEM
Decrease oxygen to the brain, means decreasing brain function
Sensation and power lost in legs, first, then arms
May remain conscious, semi-conscious, or comatose

26. SPECIFIC SENSORY DECLINE
Dying person turns toward light - sees only what is near
Can only hear what is distinctly spoken
Touch is diminished - response to pressure last to leave
Dying person might turn toward or speak to someone not visible to anyone else
Eyes may remain open even if unconscious
Person might rally just before dying

27. FURTHER NEUROLOGIC DECLINE AT DEATH
Pupils might react sluggishly or not at all to light
Pain might be significant
Assess for pain if person unable to talk: restlessness, tight muscles, facial expressions, frowns
Provide pain medication as needed

28. How is it possible that there can be disagreement concerning whether or not a person is dead.
(BECAUSE OF MEDICAL TECHNOLOGY, MACHINES CAN KEEP A BODY FUNCTIONING EVEN THOUGH THE INDIVIDUAL IS NO LONGER AWARE OF HIS/HER EXISTENCE. MANY PHYSICIANS DISAGREE AS TO HOW LONG CERTAIN MEDICAL TESTS SHOULD BE PERFORMED TO DETERMINE IF DEATH HAS INDEED OCCURRED.

29. Right to Die Issue
Came about with ability to sustain life of terminally ill
Conflict occurs between ethical concerns of promotion of life & allowing pts to die

30. Laws Allowing “Right to Die”
Patient Self Determination Act of 1990:
Established advance directives
Living Will:
DNR (Do Not Resuscitate)
Durable power of Attorney
Supportive care
Providing oxygen
Food and fluids
Medication for pain, nausea, and other discomforts
Physical care and personal hygiene

31. Suicide Self-inflected, self-intentional cessation of life Victims:
Adolescents: 3rd leading cause of death
White, male, >45, divorced, separated, or widowed
Causes:
Social isolation
Inability to cope
Fear
Illness/ mental status

32. Suicide Signals of possible suicide: Verbal statements “When I’m gone”
“I won’t be around then”
Personality changes
Deep depression
Apathy
Giving away personal possessions
Places to call for help
Telephone hot lines
Mental health assoc
Clinics

33. Euthanasia Comes from Greek meaning “easy death”
Common term: mercy killing
Painlessly put to death pt who is terminally ill

34. Euthanasia Performed in 2 ways: Active euthanasia Passive euthanasia:
An intentional act designed to bring about death
When pt takes own life or assisted
Illegal
Example: lethal injection
Passive euthanasia:
Allows pt to control dying experience
Allowed by law through advance directives

35. NEVER LOSE SIGHT. . . Death is the end, as we know it, for that person
We can only support, listen therapeutically, and
Make the person as physically comfortable as possible
We can also use our knowledge and expertise to strengthen, support, and prepare the family

36. Role of the Health Care Provider
First understand own personal feelings about death & come to terms with these feelings
Response should be consistent and guided by patient’s attitude and care plan
Should be open and responsive to patient’s attitude about terminal illness
Never try to force your own ideas about death on the patient

37. Hospice Care Philosophy
Hospice care is provided by teams who working with the terminally ill person and the family
The team:
Physician
Nurse
Nursing assistant
Social workers
Clergy

38. Hospice Care Philosophy
Goals of hospice care include:
Control of pain
Coordinate psychological, spiritual and social support service for the patient and family
Counseling for family for up to 1 year

39. Grief, Mourning, Counseling
Bereaved must face fears and changes
Special needs:
Companionship: allow to talk about deceased
Vent feelings: may lash out
Time to be alone: need to be alone for short periods to think, plan, make choices
Time: feelings of grief diminish with acceptance

40. Grief, Mourning, Counseling
Grieving is natural & healthy
Learn to grieve small losses to better cope with larger ones
No 2 people grieve alike-don’t judge
Children must be allowed to grieve

41. Grief, Mourning, Counseling
Skills need to aide the bereaved:
Be a good listener
Know what to say
It’s OK to cry
I’m thinking about you
Know what NOT to say
Cheer up
Time heals all wounds
God’s will
Offer presence, hugs, phone calls, food, run errands
Provide religious support as appropriate
Stay with the patient as needed
Work with families to strengthen and support

42. Disposition of Deceased
Forms of disposition:
Traditional funeral
Embalmment
Viewing
Services
Burial
Body donation
All to science
Organ donor
Cremation
Body burned & ashes place in urn or scattered
Cryonics
Corpse placed in liquid nitrogen
Body thawed when science discovers cure
Burial with personal possessions

43. Death and the Law Coroner/Physician: Death certificate issued
Must examine deceased & pronounce death
Homicide/suicide: investigation w/ autopsy
Death certificate issued
Name, date of & cause of death
Family grants permission for removal of body to funeral home
Obituary provided to newspaper

44. Medical Ethics

45. Ethics
A set of principles of conduct that establish standards and morals that govern decisions and behavior
Ethical decisions are based on moral values formed through influence of family, culture and society

46. ethics
The standards of behavior required by a health care provider to carry out their duties:
Confidentiality
Accuracy
Honesty
dependability

47. Ethics
Professional ethics should NOT differ from personal ethics

48. Ethics Formalized codes of ethics:
Govern behavior of health care members
Increases level of competence
Provides standards of care within the profession

49. Talking Points and Notes for Presenter
Hippocratic Oath
“I swear by Apollo the Physician…to keep according to my ability and judgment the following oath”
“I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone”
The Oath of Hippocrates of Kos, 5th Century BC
Talking Points and Notes for Presenter
The Hippocratic Oath established the Western paradigm of a profession as a “morally self-regulating” discipline. Authorship of the Oath is sometimes attributed to Hippocrates of Kos, but the document itself dates from anywhere between the fifth and third centuries BC.
The most substantive section of the Hippocratic Oath focuses on prohibiting certain conduct such as “prescribing a deadly drug” or giving “advice which may cause his death.” Thus, the medical profession is commonly considered by many to be guided by the Hippocratic maxim, “first do no harm” (which does not appear in the Oath itself but rather elsewhere in the Hippocratic corpus).
Reference:
1. Orr RD, Pang N, Pellegrino ED, Siegler M. Use of the Hippocratic oath: a review of twentieth century practices and a content analysis of oaths administered in medical schools in the US and Canada in J Clin Ethics. 1997;8:

50. Basic rules of ethics
Put saving of life and promotion of health above all else
Treat all patients equally
Maintain competent level of skill consistent with occupation
Maintain confidentiality and respect for privacy of others

51. Basic rules of ethics Refrain from immoral and illegal practices
Show loyalty to patients, co-workers, and employer
Be sincere, honest, and caring

52. Will
is a document that states who will get your money and property after you die.

53. Living Will
is a legal document stating a person’s wishes regarding life-prolonging medical treatments

54. Healthcare Power of Attorney
A document which allows you to appoint someone to make health care decisions for you if you’re incapacitated

55. Revocation of Power of Attorney
A document which allows you to revoke a power of attorney document

56. General Power of Attorney
Authorizes your Agent to act on your behalf in a variety of different situations.

57. “Durable”
A document which will remain in effect if you become mentally incompetent by adding the word “durable” to other documents.

58. Do not resuscitate (DNR)
A document filled out by the physician, patient, and family in cases where quality of life is severely decreased