College of Medicine and Health Sciences

School of Nursing
Department of Comprehensive Nursing
Care of Terminally Ill Patient and Post-mortem
Care
(Loss And Grieving)
 Learning outcomes

On completing this lesson, you will be able to:

 Define care of terminal ill patient
 Discuss principles of humane approach to care of the
dying
 Describe stages of death
 Describe the physiological changes which occur after
death
 Discuss about post-mortem care
 List the purpose of post-mortem care

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 Care of terminally ill patient
 Terminal illness: progressive, irreversible illness that despite
cure-focused medical treatment will result in the patient‟s death

 One of the most difficult realities that nurses face is that, despite
our very best efforts, some patients will die

 Although we cannot change this fact, we can have a significant

and lasting effect on the way in which:

 Patients live until they die, the manner in which the death
occurs, and the enduring memories of that death for the families

 Nursing has a long history of holistic, person- and family-

centered care

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 Terminal illness
 Terminal illness is a medical term that describe a disease that
cannot be cured or adequately treated and that is reasonably
expected to result in the death of the patient within a short
period of time
 This term is more commonly used for progressive diseases
such as cancer or advanced heart disease than for trauma
 In popular use, it indicates a disease that eventually ends the
life of the sufferer

 Terminal patient, terminally ill or simply terminal: A patient

who has such an illness
 Often, a patient is considered terminally ill when their
estimated life expectancy is six months or less
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 Management
 No cure or adequate treatment for terminal illnesses

 However, some kinds of medical treatments may be

appropriate anyway, such as treatment to reduce pain or
ease breathing

 Palliative care is normally offered to terminally ill

patients, regardless of their overall disease

 Complementary medicine approaches, such as relaxation

therapy, and massage, may relieve some symptoms and
other causes of suffering

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Principles underlying a more comprehensive and humane
approach to care of the dying:

Respecting patients‟ goals, preferences, and choices

Attending to the medical, emotional, social, and spiritual

needs of the dying person

Building mechanisms and systems of support

Death must be accepted

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 Cont……..
The patient‟s total care is best managed by an
interdisciplinary team whose members communicate
regularly with each other

Pain and other symptoms of terminal illness must be

managed

The patient and family should be viewed as a single unit

of care

Bereavement care must be provided to family members

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 DEATH
It is a permanent cessation of all vital functions

The classic indicators of death are the permanent

cessation of heart and lung function, and, in almost all
cases, these remain the criteria by which death is certified

The diagnosis of death under normal circumstances, when

the individual is not on a ventilator, is

Based on the absence of breathing, absence of heartbeat,

and on the pupils being fixed wide open and unresponsive
to light
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 Stages of Death and Dying
 In 1969, Elisabeth Kübler-Ross described five stages of death,
popularly referred to as DABDA

 These are stages a person may go through after he is told he

has a terminal illness and that, in all likelihood, death is just
around the corner
 Not all terminal patients go through all five stages
sequentially

 The client may express anger and, a few minutes later, express
acceptance of the inevitable, then express anger again

 These stages are experienced in varying degrees and for

varying lengths of time among clients
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 1. Denial
o Avoidance, Confusion,…
o Denial, which is an immediate response to loss experienced
by most people, is a useful tool for coping

o If you were diagnosed with a deadly disease, you might

believe the news is incorrect–a mistake must have occurred
somewhere in the lab–they mixed up your blood work with
someone else

o If you receive news on the death of a loved one, perhaps you

cling to a false hope that they identified the wrong person

o In the denial stage, you are not living in „actual reality,‟ rather,
you are living in a „preferable‟ reality
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 2. Anger
 Frustration, Irritation,…
 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, God, and others

 Often the nurse is the recipient of the anger when the client
lashes out
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 Anger Cont’d…
 This is a common stage to think “why me?” and “life‟s
not fair!” You might look to blame others for the cause of
your grief and also may redirect your anger to close
friends and family

 If you are strong in faith, you might start to question your

belief in God. “Where is God? Why didn‟t he protect
me?”

 Researchers and mental health professionals agree that

this anger is a necessary stage of grief
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 3. Bargaining
• Struggling to find meaning, telling one‟s history…
• 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

• When something bad happens, have you ever caught yourself

making a deal with God? “Please God, if you heal my
husband, I will strive to be the best wife I can ever be–and
never complain again.” This is bargaining.

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 Bargaining Cont’d…

• In a way, this stage is false hope

• You might falsely make yourself believe that you can
avoid the grief through a type of negotiation

• If you change this, I‟ll change that

• You are so desperate to get your life back to how it was
before the grief event, you are willing to make a major
life change in an attempt toward normality

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 Bargaining Cont’d…

• Guilt is a common wing man of bargaining. This is when

you endure the endless “what if” statements

• What if I had left the house 5 minutes sooner – the

accident would have never happened

• What if I encouraged him to go to the doctor six months

ago like I first thought – the cancer could have been
found sooner and he could have been saved

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 4. Depression
 Helplessness,…
 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

 In fact, most people associate depression immediately with

grief–as it is a “present” emotion

 It represents the emptiness we feel when we are living in

reality and realize the person or situation is gone or over
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 Depression Cont’d…

In this stage, you might withdraw from life, feel numb,
live in a fog, and not want to get out of bed

The world might seem too much and too overwhelming

for you to face

You don‟t want to be around others, don‟t feel like

talking, and experience feelings of hopelessness

You might even experience suicidal thoughts – thinking

“what‟s the point of going on?”

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 5. Acceptance
 Exploring options, new plan in place moving on,…
 The last stage of grief identified by Kübler-Ross is acceptance

 Not in the sense that “it‟s okay my husband died” rather, “my
husband died, but I‟m going to be okay.”

 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
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 Acceptance Cont’d…

 Verbalization of emotions facilitates acceptance

 With acceptance comes growing awareness of peace and

contentment

 In this stage, your emotions may begin to stabilize

 You re-enter reality. You come to terms with the fact that the
“new” reality is that your partner is never coming back–or
that you are going to succumb to your illness and die soon-
and you‟re okay with that

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 Acceptance Cont’d…

 It‟s not a “good” thing – but it‟s something you can live
with

 It is definitely a time of adjustment and readjustment.

There are good days, there are bad days, and then there
are good days again

 In this stage, you may lift from your fog, you start to
engage with friends again, and might even make new
relationships as time goes on

 You understand your loved one can never be replaced,

but you move, grow, and evolve into your new reality
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 After-death Care
Caring for the deceased body and meeting the needs of
the grieving family are nursing responsibilities
This section discusses care of the body and responding to
the needs of families of the dead

Care of the Body

The body of the deceased needs to be treated in a way
that respects the holiness of the human body
Nursing care includes maintaining privacy and
preventing damage to the body

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 After-death Care: Physiological changes Cont’d…

Physiological Changes to be considered includes:

Several physiological changes occur after death

Pallor mortis: as the heart stops beating, the circulation

blood through out the body decreases, decreased blood
received, pale lifeless appearance

The body temperature decreases with a resultant lack of

skin elasticity (algor mortis)

Therefore, the nurse must use caution when removing

tape from the body to avoid skin breakdown
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 After-death Care: Physiological changes Cont’d…

Another physiological change, liver mortis(hypostasis),

is the bluish purple discoloration that is a byproduct of
red blood cell destruction

It is the stage where the heart stops pumping blood

through the system

As a result, blood starts to leave the extremities and pools

at the lowest point of the body. Another name for this is
post-mortem stain

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 After-death care: Physiological changes Cont’d…
 Approximately 2 to 4 hours after death, rigor mortis
occurs; this is stiffening of the body caused by
contraction of skeletal and smooth muscles

 Its biochemical basis is the deprivation of the energy

source that is require for movement

 To prevent disfiguring effects of rigor mortis, as soon as

possible after death the nurse should close the eyelids,
close the mouth, and position the body in a natural
position

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 After-death Care: Physiological Changes Cont’d…
• In preparing the body for family viewing, the nurse seeks to
make the body look comfortable and natural
• After the family has viewed the body, the nurse places
identification tags on the body‟s toe and wrist

• The body is then placed in a plastic or fabric shroud and the

shroud is tagged
• Then the body is transported to the morgue according to the
agency‟s policy

• The nurse is also responsible for returning the deceased‟s

possessions to the family
• Jewelry, eyeglasses, clothing, and all other personal items are
returned to the family
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 After-death Care: Cont’d…

Legal Aspects

• In most states, the physician is legally responsible for

determining the cause of death and signing the death
certificate

• The nurse may, in certain situations, be the person

responsible for certifying the death

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 After-death Care: Cont’d…

Autopsy

• An autopsy (postmortem examination to determine the

cause of death) is mandated in situations in which an
unusual death has occurred

• For example, an unexpected death and a violent death are

circumstances that would necessitate an autopsy

• Families must give consent for an autopsy to be

performed

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 After-death Care: Cont’d…
Organ Donation
• The donation of organs for transplantation is a matter that
requires compassion and sensitivity

• It is important that families of the deceased know the

importance of and process for organ donation

• At the time the family gives consent for donation, the

nurse notifies the team an organ is available for transplant

• Time is of the essence because the organ or tissue must

be harvested and transplanted quickly to maintain
viability
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 After-death care (post-mortem care)

It is the care given to the body after death

Purpose –
 To show respect for the dead
 To prepare the body for burial
 To prevent spread of infection
 To show kinds of the family, etc.

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 Equipment
 Basin of water
 Cotton
 Gauze
 Dressing and tape
 Clean sheet
 Stretcher
 Forceps
 Name tag
 Glove
 Charting material, etc.
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 Procedure
 Note the exact time of death and chart it

 Call doctor to pronounce death

 If family members are not present send for them

 Close the eyes and mouth

 Place the body flat on back with arms and legs straight

 Remove blanket from the bed and cover with sheet

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 Procedure Cont’d…

 Ask the family to wait outside while you prepare the

body

 Change any soiled dressing with clean ones

 Remove the gown and wash the body

 Pack all orifice with cotton to prevent soiling from stool,

urine, vaginal discharge, and nasal discharge

 Tie limb loosely together, using padding and gauze roll

 Tie thigh, lower leg, ankle and toe together

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 Procedure Cont’d…

 Place sheet over the body

 Move the body to the morgue on the stretcher

 Be sure family receives all articles and closes that

belongs to death

 If the deceased was in isolation continue isolation

technique through out this procedure

 Document

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 THANK YOU In ADVANCE!

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