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

2. 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 

3. 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.

4. 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 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).

5. 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

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

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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