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

3. 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

4. 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

5. 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

6. 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

7. 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

9. 5 stages of Grief Dr. Kubler-Ross The Five Stages: -Denial -Anger
-Bargaining
-Depression
-Acceptance

10. 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

11. 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.

12. 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

13. 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

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

15. 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!

17. 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

18. 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

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

20. 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

22. 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

23. 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

24. 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

25. -Blood transfusions
-Surgery
-Radiation therapy
-chemotherapy

26. 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

27. 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

29. 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

30. 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.

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

32. 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

33. 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.

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

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

44. Morgue Kit
Shroud
Clean gown
ID Tags
Gauze squares
Safety pins

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