Republic act No.

344 or the Accessibility Law of 1982 – provides for the minimum

requirements and standards to make buildings, facilities, and utilities for public use
accessible to persons with disability, including older persons who are confined to
wheelchair and those who have difficulty in walking or climbing stairs, among others.

RA 7432 – known as “an act to maximize the contribution of senior citizens to nation
building, grant benefits and special privileges and for other purposes”.

Republic Act No. 7432 or “An Act Establishing a senior Citizens Center in all Cities and
Municipalities of the Philippines, and Appropriating Funds Therefore” – provides for the
establishment of senior Citizens Centers to cater to older persons’ socialization and
interaction needs as well as to serve as a venue for the conduct of other meaningful
activities.

Republic Act No. 8425 – provides for the institutionalization and enhancement of the
social reform agenda by creating the National Anti-Poverty commission (NAPC).
Through its multi-dimensional and cross- sectoral approach, NAPC provides a
mechanism for older persons to participate in policy formulation and decision-making on
matters concerning poverty alleviation.

Republic Act No. 9994. “Expanded Seniors Citizen Act of 2010”- an act granting
additional benefits and privileges to senior citizens, further amending Republic Act No.
7432 and otherwise known as “an act to maximize the contribution of senior citizens to
nation building, grant benefits and special privileges and for other purposes.

Republic Act No. 10155, “ The General Appropriations Act of 2012” – under
Section 28 mandates that all government agencies and instrumentalities should allocate
one percent of their total agency budget to programs and projects for older persons and
persons with disability

Republic Act No. 10645, An Act Providing For the Mandatory Philhealth Coverage
for All Senior Citizens”, Amending for the purpose, Republic act No. 7432, as
amended by Republic Act No. 9994 by removing the qualification that a senior citizen
has to be indigent before being covered by PhilHealth

Republic Act No. 10868, “Centenarians Act of 2016”, An Act Honoring and
Granting Additional Benefits and Privileges to a FILIPINO CENTENARIANS. All
Filipinos who have turned centenarian in the current fiscal year shall be awarded a
plaque of recognition and a cash incentive by their respective city or municipal
governments in appropriate ceremonies in addition to the LETTER of FELICITATION
and centenarian gift of P 100,000.00. Aside from DSWD, other agencies involved in the
implementation of the law’s provisions are Department of the Interior and Local
Government (DILG), Department of Health (DOH), and Commission on Filipinos
Overseas (CFO).

Presidential Proclamation No. 470, Series of 1994, declares the first week of
OCTOCER of every year as “ Elderly Filipino Week.”

Presidential Proclamation No. 1048, Series of 1999,declaring a “Nationwide

Observance in the Philippines of the International Year of Older Persons”.

Executive Order No. 105, series of 2003, approved and directed the implementation
of the program providing for group homes and foster homes for neglected, abandoned,
abused, detached, and poor older persons and persons with disabilities.

The Philippine Plan of Action for senior Citizens (2011-2016). This plan aims to
ensure giving priority to community-based approaches which are gender-responsive,
with effective leadership and meaningful participation of senior citizens in decision-
making processes, both in the context of family and community.

ETHICS OF CARE include compassion, equity, fairness, dignity, confidentiality, and

mindfulness of a person’s autonomy within the realm of the person’s abilities and mental
capacity.

ETHICAL PRINCIPLES

1. ADVOCACY – refers to loyalty and a championing of the needs and interest of

others, to educate and informed the patients about their rights and access benefits
entitled for them.

2. AUTONOMY- is the concept that each person has a right to make independent
choices and decisions.

3. BENEFICENCE / NONMALEFICENCE- These concepts of do good (beneficence)

and do no harm (nonmaleficence) are integral to health care.

4. CONFIDENTIALITY – emphasizes respect for human dignity that is demonstrated in

daily work.

5. FIDELITY – refers to keeping promises or being true to another, being faithful to

commitments and responsibilities.

6. FIDUCIARY RESPONSIBILITY – refers to using both fiscal reserves and caregiving

resources wisely,potentially requiring a cost-benefit analysis to facilitate decision
making.
7. JUSTICE – refers to fairness of an act situation

8. QUALITY AND SANCTITY OF LIFE – quality of life is a perception based on

personal values and beliefs, sanctity of life referring to the value of life and the right to
live.

9. RECIPPROCITY – is a feature of integrity concerned with the ability to be true to

one’s self while respecting and supporting the values and views of another.

10. VERACITY – means truthfulness and refers to telling the truth, or at the least, not
misleading or deceiving patients or their families.

ISSUES TO BE CONSIDERED

These are:

 Issues on Conflict of interest

 Issues on Confidentiality
 Issues on decision-making capacity

Issues on Conflict of Interest

1. Actual Conflict of Interest issues- between family members and caregivers

represent the elderly or assist them in decision-making.

These include conflicts:

 Between spouses and the elder’s wishes and interest;

 Between family members and the elder’s wishes and interest;
 Between a guardian, conservator or other lawfully designated agent and the
elder’s wishes and interests;
 Between a caregiver’s business interests and the elder’s interests. Well-being
and quality of life.

2. Perceived Conflicts of Interest – which include those which are not actual conflicts
in the course of care but may later become conflicts when the elder patient’s interest
diverge from those who provide the care.

Issues on Confidentiality- in caring for an elderly patient, invariably, there is

disclosure made by the family and relatives regarding information that may otherwise be
personal and confidentiality to the patient alone.

Issues on Decision- Making Capacity – Many times, the older patient’s decision-
making capacity ( also referred to as “ competence”) may be required for certain
decisions.
DEATH AND DYING

Loss

 An actual or potential situation in which something that is valued is changed, no longer

available or gone.
 Parting with an object, person, belief or relationship that one values.
 Loss of body image, significant other, a sense of well-being, a job, personal
possessions, beliefs, a sense of self. etc.

Types of Loss:

1. Personal loss
 Any significant loss of someone or something that can no longer be seen or felt,
heard, known or experienced & that requires individual adaptation through the
grieving process.

2. Perceived loss
 Loss that is less tangible & uniquely defined by the grieving client (loss of
confidence, prestige)
 Experienced by one person but cannot be verified by others.

3. Maturational loss
 Change in developmental process that is normally expected during a lifetime.
 Loss that occur on the process of normal development.

4. Situational loss
 Loss of a person, thing or quality resulting from a change in a life situation, including
changes related to illness, body image, environment and death.
 Any sudden, unexpected and definable event that is not predictable.

5. Actual loss
 Can be identified by others & can arise either in response to or in anticipation of a
situation.
 Any loss of a person or object that can no longer be felt, heard, known, or
experienced by the individual.

Grief

 The total response to the emotional experience related to loss which is usually resolved
within 6 months to 2 years.
 Sorrow manifested in thoughts, feelings, & behaviors occurring as a response to an
actual or perceived loss.
 Permits individual to cope with the loss gradually & to accept it as part of reality; a social
process best shared & carried out with assistance of others.
 May be experienced as a mental (anger, guilt, anxiety, sadness & despair); physical
(sleeping problems, difficulties in swallowing, vomiting, fatigue, headaches, dizziness,
 fainting, blurred vision, skin rashes, excessive sweating, menstrual disturbance,
palpitations, chest pain, dyspnea, changes in appetite, physical problems, weight loss, or
illness); social (feelings about taking care of others in the family, seeing family or friends,
or returning to work, or emotional reaction (depression, etc.)

Types of Grief:

1. Abbreviated grief
 Grief which is brief but genuinely felt; lost may not have been sufficiently important to
the grieving person or may have been replaced immediately by another, equally
esteemed object.

2. Anticipatory grief
 Process of accomplishing part of the grief work before an actual loss; grief response
in which the person begins grieving process before an actual loss.

3. Dysfunctional grief
 Occurs when there is prolonged emotional instability, withdrawal from usual task or
activities that previously gave pleasure & lack of progression from one level to
successful coping with the loss.
 Extended grief, unsuccessful use of intellectual and emotional responses by which
individuals attempt to work through the process of modification.
 Dysfunctional Grief may be: (1) Unresolved Grief - extended in length and severity,
bereaved may also have difficulty expressing the grief, may deny the loss or may
grief beyond expected time; severe chronic grief reaction in which the person does
not complete the resolution stage of the grieving process within a reasonable time.
(2) Inhibited Grief – many of normal symptoms of grief are suppressed and other
effects, including somatic are experienced instead.

Grieving process

 Sequence of affective, cognitive & physiological states through which the person
responds to and finally accepts an irretrievable loss.

Bereavement

 The subjective response experienced by the surviving loved ones after the death of a
person with whom they have shared a significant relationship.
 Experience alterations in libido, concentration, patterns of eating, sleeping, activity and
communication.

Concepts which help the Nurse to Plan for Interventions:

1. Mourning
  The behavioral process through which grief is eventually resolved or altered.
 Process by which people adapt to a loss which is influenced by cultural, customs,
rituals, and society’s rules for coping with loss.

2. Hope
 Characterized by a confident, yet uncertain expectation of achieving a goal.

3. Closure
 The point at which the loss has been resolved and the grieving individual can
move on with life without focusing on the loss.

Sources of Loss
1. Loss of Aspect of Self
 Any change the person perceives as negative in the way the person relates to
the environment is loss of self.

2. External Object
 Loss of inanimate object that has importance to the person (ex. Jewelry, money,
etc…)
2. Accustomed Environment
 Separation from an environment and people who provide security.

3. Loved Ones
 Loss of valued person or loved ones through illness, separation, divorce, broken
relationship, moving, running away, promotion at work, or death.

4. Loss of Life
 Physical death, brain death, ability to reason.
 Concern is not about death itself but about pain and loss of control, fear of
separation, abandonment, loneliness or mutilation.

Signs of Impending Death

1. Loss of Muscle Tone

a. Relaxation of the facial muscles (jaw may sag)
b. Difficulty speaking
c. Difficulty swallowing & gradual loss of the gag reflex.
d. Decreased activity of the GIT, with subsequent nausea, accumulation of flatus,
abdominal distention & retention of feces.
e. Possible urinary & rectal incontinence due to decreased sphincter control
f. Diminished body movement

2. Slowing of the Circulation

a. Diminished sensation
b. Mottling & cyanosis of the extremities
c. Cold skin, first in the feet and later in the hands, ears and nose (however the
client may feel warn due to elevated temperature)
3. Changes in Vital Signs
 a. Decelerated and weaker pulse
b. Decreased BP
c. Rapid shallow, irregular, or abnormally slow respirations; Cheyne strokes
respirations; noisy breathing, referred to as death rattle due to collecting of
mucus in the throat; mouth breathing, which leads to dry oral mucus membranes.

4. Sensory Impairment
a. Blurred vision
b. Impaired sense of taste & smell (hearing is the last sense to disappear)

Clinical Signs of Death

 Cessation of the apical pulse, respirations and blood pressure.

1. Total lack of response to external stimuli.
2. No muscular movement, especially breathing.
3. No reflexes.
4. Flat encephalogram for 24 hours.

Cerebral Death

 Occurs when the higher brain center, the cerebral cortex, is irreversibly destroyed.
 It is believed that the cerebral cortex, which holds the capacity for thought, voluntary
action & movement, is the individual.

Body Changes
1. Rigor Mortis
 Stiffening of the body that occurs about 2 to 4 hours after death due to lack of
Adenosine Triphosphate (ATP),which is not synthesized because of a lack of glycogen
in the body.
 Starts in the involuntary muscles (heart,bladder, etc.) then progresses to head, neck,
trunk and finally reaches the extremities.
 Leaves the body about 96 hours after death.

2. Algor Mortis
 Gradual decrease of the body’s temperature after death.
 When blood circulation terminates and the hypothalamus ceases to function, body
temperature falls about 1 degree Celsius per hour until it reaches room temperature.

3. Livor Mortis
 Bluish discoloration of the skin after death.
 After blood circulation has ceased, skin becomes discolored.
 The RBC breakdown, releasing hemoglobin, which discolors the surrounding tissues.

4. Embalming
 Injection of chemicals in the body to destroy the bacteria.
 Tissues after death become soft & eventually liquefied by bacterial fermentation.
  The hotter the temperature, the more rapid the change, therefore, bodies are often
stored in cool places to delay the process.

Stages of Death and Dying

(Elizabeth Kubler-Ross, 1969, 1974)

Denial

 It is the immediate response to loss experienced by most people and it is a useful tool
for coping.

Anger

 The client has no control over the situation and thus becomes angry in response to this
powerlessness.
 The angry may be directed at self, God, and others.

Bargaining

 The anticipation of the loss through death brings about bargaining through which the
client attempts to postpone or reverse the inevitable.

Depression

 When the realization comes that the loss can no longer be delayed, the client moves to
the stage of depression.
 It helps the client detach from life to be able to accept death.

Acceptance

 The final stage of acceptance 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.

Promotion of Comfort

1. Relief of pain is critically important, the sooner the dying client obtains pain relief, the
more energy the client can direct toward maintaining quality in the remainder of his life.
2. Provide personal hygiene measures, control pain, relief respiratory difficulties, assists
with movements, nutrition, hydration and elimination, provide measures related to
sensory changes.

Promotion of Spiritual Comfort

 1. Support client in his expression of the philosophy he has chosen for his life.
2. Attentive listening encourages client to express feelings, clarify them, and accept his
fate.
3. Praying silently with the client.
4. Make referral for spiritual counseling.
5. Facilitate expression of feeling, prayer, meditation, reading, and discussion with
appropriate clergy/spiritual advisor.

Care of the Body

1. Placed in supine position with arms at the side, palms down, or across the abdomen
(to make the body look as natural and comfortable as possible).
2. Place a small pillow or folded towel under the heads (to prevent discoloration from
blood pooling).
3. Gently hold eyelids close for a few seconds to make it remain close.
4. Insert client’s dentures to maintain the normal facial features.
5. Place a rolled-up towel under the chin to keep mouth closed.
6. Wash any soiled body parts, dress the body in a clean gown, and cover the body up to
the shoulders with clean linen.
7. Place absorbent pads under the perineal and rectal area to collect any oozing feces or
urine.
8. Remove all jewelries and present it and any valuables to the family.
9. If the weeding band is left in place, tape it securely to the finger.
10. Allow family members to enter the room when body is prepared never allow a single
family member to enter the room alone (for emotional support).
11. Special tags containing the deceased’s name, hospital number, and name of the
attending physician are placed on the wrist and ankles and on the outside of the
shroud.
12. In the morgue, body is placed in a special cooling unit to slow decomposition.

Death Certificate

 Made out when a person dies, usually signed by the attending physician and filled with a
local health or other government office.
 Family is given a copy to use for legal matters.

Labeling of the Deceased

 If appropriately identified and prepared incorrectly can create legal problems.

 Placed on the wrist, ankle, and on the shroud.
 Contains name of deceased, Hospital number and name of attending physician.

Autopsy or Postmortem Examination

 An examination of the body after death and is performed only in certain cases:
a. When death is sudden or occurs within 48 hours of admission to a hospital, the
organs and tissues of the body are examined to establish the exact cause of death.
 b. To learn more about the disease.
c. To assist in the accumulation of statistical data.
 Consent should be obtained by the physician from the decent (before death) or by the
next of kin (surviving spouse, adult children, parents, siblings)
 Hospitals cannot retain any tissues or organs without the permission of the person who
consented to the autopsy

Terminal illness is a disease that will result in the death of the patient regardless of any
treatment intervention. A patient is considered terminally ill when their estimated life
expectancy is six months or less, under the assumption that the disease will run its
normal course.

When Symptoms May Be Normal Sadness

Grief is a normal part of the dying process. Feelings that are common among terminally
ill patients may include:

-deep sadness and regret (this may include crying or sobbing)

-anger

-difficulty sleeping or changes in appetite

-fatigue

-restlessness

-disbelief

-disengagement or apathy

(When normal feelings of grief become excessive and start to interfere with every
aspect of a person’s life, they may indicate a more serious problem.)

When Symptoms May Be Depression

The symptoms of depression in terminally ill patients often correspond with symptoms of
their disease, making it all the more difficult to diagnose. Symptoms to watch for
include:
 severe mood swings or other mood disturbances           
 prolonged difficulty sleeping
 prolonged difficulty eating
  loss of interest in once pleasurable activities or hobbies
 feelings of helplessness
 feelings of guilt
 persistent worrying
 suicidal ideation

When Symptoms May Be Side Effects of Medication

Many medications may cause symptoms that might be mistaken for depression. They
include:

 changes in appetite and weight gain or loss

 dry mouth (“cotton mouth”)
 disturbance in sleep patterns
 fatigue or a decrease in energy

Risk Factors for Depression in the Elderly

Risk factors include: 

 a history of chronic illness

 a personal or family history of depression
 substance abuse
 poorly controlled pain
 lack of social support system
 recent bereavement
 difficulty adjusting to stressful situations
 brain disease
 decreased mobility
 certain medications
 physical and cognitive decline 

CARING FOR TERMINALLY ILL PATIENT

1. Offer to listen and hear what the patient has to say. Avoid being judgmental, and
prepare to hear a variety of emotions, including anger and frustration.

2.Ask the patient what he needs or what would make him more comfortable. Perhaps
this is music, special books or a visit from a certain person. Try to meet any requests the
patient has. If a request is not possible to fill, ask the patient if there is anything else you
can do as a substitute.

3. Arrange to help the immediate family. Perhaps the spouse could benefit from having
meals prepared and brought to him so he can be at his wife's bedside. Child care might be
needed. Reducing stress from the patient's loved ones can also reduce the cancer victim's
stress.

4. Offer to record messages for the patient. Some patients might wish to leave a video
message for young children, unborn grandchildren or others, which could be nothing more
than a legacy of who he is.

5. Be present. If your friend or loved one is afraid to die, be there for her. If you can't be
present, arrange for others to sit with her through her fear. You can only do so much and
be there so much, but your presence or the presence of another person can be very
comforting to a terminally ill cancer patient.

6. Incorporate things the patient likes into visits. If the patient loves flowers, bring in
fresh flowers for a visit. If the patient loves a certain cookie, bring this if it's allowed. If the
patient loves to read but no longer can, bring a book on CD for her to listen to.

7. Offer comfort and as much understanding as possible. Don't pretend to understand

what the patient is going through. You haven't died, and left loved ones so you don't know
what it is like to face certain death. Hugs and even holding a hand might bring the patient
much comfort.