1. Death and Dying Teresa Rogers Butler County ATC Summer 2010 Summer 2010

2. Objectives The student will: Explain the stages of death and dying including the philosophy of hospice careExplain the stages of death and dying including the philosophy of hospice care

3. Contents Stages of Death and DyingStages of Death and Dying Right to Life IssuesRight to Life Issues Advance DirectivesAdvance Directives Living WillLiving Will Medical Power of AttorneyMedical Power of Attorney

4. Terminal Illness Any disease that cannot be cured and will result in death.Any disease that cannot be cured and will result in death. Everyone reacts differently to news of a terminal illness. Everyone reacts differently to news of a terminal illness. Some react with fear and anxiety.Some react with fear and anxiety. Many fear pain, abandonment, loneliness, and the unknown.Many fear pain, abandonment, loneliness, and the unknown. They may become anxious about their loved ones, unfinished work, or dreams.They may become anxious about their loved ones, unfinished work, or dreams.

5. Emotional and Physical Reasons People May Fear Death. HelplessnessHelplessness Dependence on othersDependence on others Physical facultiesPhysical faculties Mutilation by surgery or diseaseMutilation by surgery or disease Uncontrollable painUncontrollable pain Being unprepared for deathBeing unprepared for death

6. Social Reasons People May Fear Death Fear of separation from family or homeFear of separation from family or home Fear of leaving behind unfinished tasks or responsibilitiesFear of leaving behind unfinished tasks or responsibilities

7. Dr. Elizabeth Kubler-Russ Identified five stages of grieving that dying patients and their families and friends may experience.Identified five stages of grieving that dying patients and their families and friends may experience. They may not be in order and may overlap or repeat a stage at times.They may not be in order and may overlap or repeat a stage at times. Others may not experience all stages.Others may not experience all stages. Stages include denial, anger, bargaining, depression, and acceptance.Stages include denial, anger, bargaining, depression, and acceptance.

8. Denial Usually occurs when the person is first told of the illness.Usually occurs when the person is first told of the illness. Individual’s may say,Individual’s may say, “The tests are wrong.”“The tests are wrong.” “This can’t be happening to me.”“This can’t be happening to me.” “I don’t believe it.”“I don’t believe it.” Others don’t talk about it.Others don’t talk about it. Health care workers should listen without confirming or denying it.Health care workers should listen without confirming or denying it.

9. Anger This stage occurs when the patient can no longer deny death.This stage occurs when the patient can no longer deny death. The patient may blame themselves, their loved ones, or health care workers for their illness.The patient may blame themselves, their loved ones, or health care workers for their illness. Health care workers must understand this is not a personal attack.Health care workers must understand this is not a personal attack.

10. Bargaining Usually occurs when patient accepts death but wants more time to live.Usually occurs when patient accepts death but wants more time to live. Patients turn to religion and spiritual beliefs during this period.Patients turn to religion and spiritual beliefs during this period. They want to see their child gradate, get married, or hold a grandchild.They want to see their child gradate, get married, or hold a grandchild. Making promises to God to try and obtain more time sometimes occurs.Making promises to God to try and obtain more time sometimes occurs.

11. Depression This stage occurs when the patient realizes that death will come soon and they won’t be with their families any longer.This stage occurs when the patient realizes that death will come soon and they won’t be with their families any longer. They realize that some goals they set will not be met.They realize that some goals they set will not be met. Health care workers need to let the patient know that depression is “OK”.Health care workers need to let the patient know that depression is “OK”.

12. Acceptance This is normally the final stage.This is normally the final stage. The patient understands that they are going to die.The patient understands that they are going to die. May complete unfinished business and try to help those around them deal with death.May complete unfinished business and try to help those around them deal with death. Patients will slowly get farther away from the world and other people.Patients will slowly get farther away from the world and other people. They need emotional support during this stage.They need emotional support during this stage.

13. Interventions for Health Care Professionals Talk as neededTalk as needed Avoid superficial answers, i.e. “It’s God’sAvoid superficial answers, i.e. “It’s God’s will.” or “It will be OK.” will.” or “It will be OK.” Provide religious support as appropriateProvide religious support as appropriate Stay with the patient as neededStay with the patient as needed Work with the family so they might beWork with the family so they might be strong enough to offer support to the dying person. strong enough to offer support to the dying person.

14. Physical Changes OfDeath

15. 1.Unable to oxygenate the body enough for adequate gas diffusion 2.Respirations become stridorous or noisy, leading to “death rattle” 3. Cheyne-Stokes respiration sign of pulmonary system failure a. Consists of alternate hyperpneic and apneic phases Respiratory System

16. Cardiovascular System Heart unable to pump strongly enough to keep blood movingHeart unable to pump strongly enough to keep blood moving Decreased blood causes decreased circulation to the bodyDecreased blood causes decreased circulation to the body oSkin becomes cool to the touch, pale oPerson appears cyanotic, possibly mottled oFailure of peripheral circulation frequently results in a drenching sweat cooling the body surface. sweat cooling the body surface. Pulse becomes weak and thready, ultimately irregularPulse becomes weak and thready, ultimately irregular oA stronger pulse typically means death is hours away oA weak, irregular pulse typically means that death is imminent in the next couple of hours. oAn apical pulse might be required.

17. Other Changes Metabolism rates decrease.Metabolism rates decrease. The person might retain feces or become incontinent.The person might retain feces or become incontinent. Urinary output decreases.Urinary output decreases. Dying person may turn toward light as sight diminishes.Dying person may turn toward light as sight diminishes. Dying person may hear only what is distinctly spoken.Dying person may hear only what is distinctly spoken. Dying person may remain consciousness or become unconscious/comatoseDying person may remain consciousness or become unconscious/comatose

18. Other Changes Some dying people rally in clarity and consciousness just prior to their deathSome dying people rally in clarity and consciousness just prior to their death A person’s eyes might be open even if unconscious A person’s eyes might be open even if unconscious Dying people might turn toward or speak to someone who is not visible to anyone else in roomDying people might turn toward or speak to someone who is not visible to anyone else in room Pain might be presentPain might be present Pain medication should not be withheld as person nears death.Pain medication should not be withheld as person nears death.

19. Right to Die Most people with terminal illness believe that someone with a terminal illness should be allowed to refuse measures that would prolong their life.Most people with terminal illness believe that someone with a terminal illness should be allowed to refuse measures that would prolong their life. This is the right to die.This is the right to die. Respirators, pacemakers, and other medical devices can be withheld and the person can die with dignity.Respirators, pacemakers, and other medical devices can be withheld and the person can die with dignity. DNR – Do Not Resuscitate OrderDNR – Do Not Resuscitate Order

20. DNR Do Not Resuscitate OrderDo Not Resuscitate Order

21. Hospice Care This philosophy is to allow the patient to die with dignity and comfort.This philosophy is to allow the patient to die with dignity and comfort. Pain is controlled so that the patient can remain active as long as possible.Pain is controlled so that the patient can remain active as long as possible. Specially trained volunteers are an important part of many hospice programs.Specially trained volunteers are an important part of many hospice programs.

22. Advance Directives A general term that describes two types of legal documents.A general term that describes two types of legal documents. Living WillLiving Will Healthcare (Medical) Power of AttorneyHealthcare (Medical) Power of Attorney

23. Living Will Allows a person their wishes about medical treatments for the end of life in writing in the event that they cannot communicate those wishes directly.Allows a person their wishes about medical treatments for the end of life in writing in the event that they cannot communicate those wishes directly. Different states may use different names.Different states may use different names.

24. Healthcare Power of Attorney Also know as a “healthcare proxy,” “ appointment of a healthcare agent,” or “durable power of attorney for healthcare.”Also know as a “healthcare proxy,” “ appointment of a healthcare agent,” or “durable power of attorney for healthcare.” The person you appoint will be authorized to deal with all medical situations when you cannot speak for yourself.The person you appoint will be authorized to deal with all medical situations when you cannot speak for yourself.