1. Death and Dying Dr. Belal Hijji, RN, PhD May 5 & 6, 2012

2. 2 Learning Outcomes After these this lecture, students will be able to: Describe the stages of death a dying patient goes through. Discuss the ethical implications of death. Describe the nursing process for end of life care. Discuss the nursing interventions designed for meeting the physiological needs of a dying patient.

3. 3 Stages of Death and Dying There are five stages associated with death and dying. These are denial, anger, bargaining, depression, and acceptance. Every person does not move sequentially through each stage. These stages are experienced in varying degrees and for varying lengths of time. The client may express anger and, a few minutes later, express acceptance of the inevitable, then express anger again. The five stages will be discussed next.

4. 4 Denial Denial, which is an immediate response to loss experienced by most people, is a useful tool for coping. It is an essential mechanism that may last for only a few minutes or may manifest itself for months. Anger The initial stage of denial is followed by anger. The client’s security is being threatened by the unknown. All the normal daily routines have become disrupted. The client has no control over the situation and thus becomes angry in response to this powerlessness. The anger may be directed at self and others such as nurses.

5. 5 Bargaining The anticipation of the loss through death brings about bargaining through which the client attempts to postpone or reverse the inevitable. The client promises to do something (such as be a better person, change lifestyle) in exchange for a longer life. قال الله تعالى في سورة المنافقون: (وَأَنْفِقُوا مِمَّا رَزَقْنَاكُمْ مِنْ قَبْلِ أَنْ يَأْتِيَ أَحَدَكُمُ المَوْتُ فَيَقُولَ رَبِّ لَوْلاَ أَخَّرْتَنِي إِلَى أَجَلٍ قَرِيبٍ فَأَصَّدَّقَ وَأَكُنْ مِنَ الصَّالِحِينَ). صدق الله العظيم

6. 6 Depression When the realization comes that the loss can no longer be delayed, the client moves to the stage of depression. This depression is different from dysfunctional depression in that it helps the client detach from life to be able to accept death. Acceptance This stage may not be reached by every dying client. However, “most dying persons eventually accept the inevitability of death. Many want to talk about their feelings with family members”. Verbalization of emotions facilitates acceptance. With acceptance comes growing awareness of peace and contentment. The feeling that all that could be done has been done is often expressed during this stage.

7. 7 Ethical Implications Death is fraught [full of] with ethical dilemmas that occur almost daily in health care settings. Many hospitals have ethics committees to develop and implement policies that deal with end-of-life issues. One of the most difficult dilemmas is determining the difference between killing and allowing someone to die by withholding life-sustaining treatment methods.

8. 8 Nursing Process for End of Life care Assessment: Nursing interventions are based on a thorough assessment of the client’s holistic needs. Assess the patient’s awareness of the terminal nature of illness, physical condition, and emotional status. Nursing Diagnoses: Powerlessness is a nursing diagnosis that is applicable for many dying patients. It is “the perception that one’s own actions will not significantly affect an outcome; a perceived lack of control over a current situation. Helplessness is another nursing diagnosis that is often experienced by the dying patient. It is “a subjective state in which an individual is unable to mobilize energy on own behalf”.

9. 9 Outcome Identification and Planning: The dying client must be treated as a unique individual worthy of respect. Essential elements to consider when planning care of the dying patient include: –Schedule time to be available to client. –Offer to contact clergy. –Balance the client’s need for independence and need for assistance. –Respect the client’s confidentiality. –Answer all questions and provide factual information to client and family.

10. 10 Implementation: The nurse’s first priority is to communicate a caring attitude to the client. Establishment of rapport facilitates the client’s verbalization of feelings. The nurse establishes a safe environment in which the client does not feel chided [يَُوَبخ] or chastised [يعاقب] for experiencing those feelings. Nonverbal communication can be used very effectively with dying patients. “You don’t always have to have conversation or be doing something for them. Just be there and hold hands and listen”.

11. 11 Physiological Needs of the Dying Patient The dying patient’s physiological needs must be met first because they are essential for existence. Such needs include nutrition, hygiene, and comfort. Discussion of these areas will follow.

12. 12 Nutrition Presence of nausea and vomiting decreases appetite. Psychological factors may interfere with appetite. Therefore, the nurse should administer antiemetic drugs (primperan) as prescribed. In addition, the nurse should use specific measures that promote food intake, such as offering frequent, small amounts of favorite foods that is easy to swallow.

13. 13 Hygiene The dying patient may have diaphoresis and incontinence. Provide bed bath as necessary. Perform oral care and change linens frequently to keep client dry (promotes maintenance of skin integrity).

14. 14 Comfort The nurse should: –encourage client to verbalize presence of pain. –discuss pain relief options with client and family. –administer medication on a regular schedule instead of PRN to ensure maximum pain relief. –assist client and family to identify the stressors that influence pain. –teach noninvasive pain relief measures: Relaxation techniques such as deep breathing, imagery. Use of heat and cold. Massage.