DEATH AND DYING

DEATH AND DYING

EMOTIONAL AND PHYSIOLOGIC

ELEMENTS OF DEATH AND
DYING
It's only when we truly know and understand that we have
a limited time on earth -- and that we have no way of
knowing when our time is up, we will then begin to live
each day to the fullest, as if it was the only one we had.

~Dr. Elisabeth Kübler-Ross

 DEFINITION OF TERMS

1. TERMINAL ILLNESS – an illness or condition

which recovery is not expected.

Ex. AIDS, emphysema, dementia and some

types of cancer
 DEFINITION OF TERMS
2. LOSS – is an actual or potential situation that
in which a valued object, person or the like is
inaccessible or changed so that it is no longer
perceived as valuable.

3. BEREAVEMENT - is the subjective response

to a loss through the death of a person with
whom there has been a significant relationship.
 SOURCES OF LOSS
1. Aspect of oneself
2. Loss of an object external to oneself
3. Separation from an accustomed
environment
4. Loss of a loved or valued person
 DEFINITION OF TERMS

4. GRIEF – mental anguish specifically

associated with loss. It is the total response
to the emotional experience of the loss
and is manifested in thoughts, feelings and
behaviors.
 TYPES OF GRIEF RESPONSE
• Abbreviated

• Anticipatory

• Disenfranchised

• Pathologic o r complicated grief

 TYPES OF COMPLICATED GRIEF
• Unresolved or chronic grief

• Inhibited grief

• Delayed grief

• Exaggerated grief
 DEFINITION OF TERMS

5. MOURNING – is the behavioral process

through which grief is eventually resolved
or altered; it is often influenced by culture,
custom and spiritual beliefs.
 DEVELOPMENT CONCEPT OF
DEATH
1. Infancy to 5 - Does not understand the concept of
yrs. death
- Believes death is reversible, a
temporary departure or sleep.
2. 5 – 9 yrs. - Understands that death is final
- Believes own death can be avoided
- Associates death with aggression or
violence.
 DEVELOPMENT CONCEPT OF
DEATH
3. 9 – 12 yrs.old - Understands death as inevitable end of
life
- Begins to understand own mortality

4. 12 – 18 yrs. - Fears of lingering death

- May fantasize that death can be defied,
acting out defiance through reckless
behavior
- Views death in religious and philosophic
 DEVELOPMENT CONCEPT OF
DEATH
5. 18 – 45 yrs. old - Has attitude towards death that is
influenced by religious and cultural
beliefs
6. 45 – 65 yrs.old - Accepts own mortality
- Encounters death of parents and some
peers
- Experiences peak of death anxiety
 DEVELOPMENT CONCEPT OF
DEATH
7. 65 yrs. and - Fears prolonged illness
above - Encounters death of family members
and peers.
- Sees death as having multiple
meanings. E.g. freedom from pain,
reunion with already deceased family
members.
 EMOTIONAL TRANSITIONS AT LIFE’S
END

•Although there are many theories

about the emotional transitions
encountered by dying people, the
best known is. . . . .
 ELISABETH KUBLER-ROSS

Landmark work entitled On Death and

Dying

Identified five emotional stages

experienced by dying individuals
 FIVE EMOTIONAL STAGES

• Denial - or “no not me”

• Anger - or “why me?”
• Bargaining - or “Yes, but. . .”
• Depression - or “It’s me!”
• Acceptance - or “It’s part of life. I have to get
my life in order.”
STAGES OF GRIEVING
DENIAL
- Refuses to believe that loss is
happening.
- Is unready to deal with practical
problems, such as prosthesis after the
loss of a leg
- May assume artificial cheerfulness to
prolong denial
DENIAL
Nursing implications:
- Verbally support client but do
not reinforce denial.
- Examine your own behavior to
ensure that you do not share in
client’s denial.
DENIAL
Effects on the Person’s Behavior
- The person may ask for second
opinion
- The person may act as if nothing is
wrong
- The person may refuse medications
or treatment.
ANGER
- Client or family may
direct anger at nurse or
staff about matters that
normally would not
bother them.
ANGER
Effects on the person’s behavior
- The person may become
moody and withdrawn
- The person may become
uncooperative and hostile
- The person may lose religious
faith.
ANGER
NURSING IMPLICATIONS
- Help client understand that anger is
a normal response to feelings of loss
and powerlessness
- Avoid withdrawal or retaliation; do
not take anger personally.
- Deal with needs underlying any
angry reaction
ANGER
NURSING IMPLICATIONS:
- Provide structure and continuity
to promote feelings of security.
- Allow clients as much control as
possible over their lives.
BARGAINING
seeks to bargain to avoid
loss (e.g., “let me just live
until and then I will be
ready to die.”)
BARGAINING
Effects on Person’s behavior
- The person may speak for
wanting to live long enough to
accomplish a goal or to witness a
specific event (wedding or a
child’s birth)
BARGAINING
Nursing Implications:
- Listen attentively, and
encourage client to talk to
relieve guilt and irrational fear
- - if appropriate, offer spiritual
support.
DEPRESSION
- Grieves over what has
happened and what cannot
be.
- May talk freely, or may
withdraw
DEPRESSION
Nursing implications:
- Allow client to express sadness
- Communicate nonverbally by
sitting quietly without expecting
conversation
- Convey caring by touch
DEPRESSION
Effects on the Person’s Behavior
- The person may be sad or cry a
lot
- The person may withdraw and
say little
- The person may refuse food or
have trouble falling asleep.
ACCEPTANCE
- Comes to term with loss.
- May have decreased
interest in surroundings and
support people
- May wish to begin making
plans
ACCEPTANCE
Effects on Person’s Behavior
- May want to complete
unfinished business
- May want to say goodbye to
friends and loved ones
- May plan his own funeral
service
- May want to talk about his
death with others.
ACCEPTANCE
NURSING IMPLICATIONS
- Help family and friends understand
client’s decreased need to socialize
- Encourage client to participate as
much as possible in the treatment
program.
 MARTOCCHIO’S 5 CLUSTERS OF
GRIEF
1. SHOCK AND DISBELIEF – feeling of numbness
following the death of a loved one.

2. YEARNING AND PROTEST – the anger that the

bereaved feel may be directed at the
deceased for having died, at GOD, at others
whose love ones are still alive or at the
caregivers.
 MARTOCCHIO’S 5 CLUSTERS OF
GRIEF
• 3. ANGUISH, DISORIENTATION AND
DESPAIR - when the reality of the loss is
genuinely admitted, depression can set in.
Weeping is common. The bereaved lose
interest and motivation in pursuing the
future and lack of confidence and
purpose.
 MARTOCCHIO’S 5 CLUSTERS OF
GRIEF
• 4. IDENTIFICATION IN BEREAVEMENT – the
bereaved may take on the behavior,
personal traits, habits and ambitions of
the deceased. Sometimes they may also
experience the same symptoms of
physical illness.
 MARTOCCHIO’S 5 CLUSTERS OF
GRIEF
•5. REORGANIZATION AND RESTITUTION
– achieving stability and sense of
reintegration can take a period of
time that ranges widely, from less than
a year to several years.
 ENGEL’S STAGES OF
GRIEVING
•1. SHOCK AND DISBELIEF – refusal
to accept loss, stunned feelings
and intellectual acceptance but
emotional denial
 ENGEL’S STAGES OF
GRIEVING
2. DEVELOPING AWARENESS –
reality of loss begins to penetrate
awareness; anger may be directed
at hospital, nurses, etc and crying
and self – blame.
 ENGEL’S STAGES OF
GRIEVING
3. RESTITUTION – rituals of mourning.

4. RESOLVING THE LOSS – attempts to deal

with painful void; still unable to accept
new love object to replace the loss
person; may accept more dependent
relationship with support; thinks over and
talks about memories of the dead person.
 ENGEL’S STAGES OF
GRIEVING
5. IDEALIZATION – produces image of
dead persons that is almost devoid of
undesirable features; represses all
negative and hostile feelings toward
the deceased; unconsciously
internalizes admired qualities of the
deceased; reinvest feelings in others.
 ENGEL’S STAGES OF
GRIEVING
6. OUTCOME
Behavior influenced by several others:
- Importance of the lost object as source of support
- Degree pf ambivalence toward deceased
- Number and nature of other relationship
- Number and nature of previous grief experiences
 SYMPTOMS OF GRIEF
• Repeated somatic distress
• Tightness in chest
• Choking or shortness of breath
• Sighing
• Empty feeling in the abdomen
• Loss of muscular power
• Intensive subjective distress
 ASSISTING CLIENTS WITH THEIR GRIEF
• Provide opportunity for the person to tell their
story.
• Recognize and accept the varied emotions
that people express in relation to a significant
loss.
• Provide support for the expression of difficult
feelings such as anger and sadness
 ASSISTING CLIENTS WITH THEIR GRIEF
4. Include children in their grieving process
5. Encourage the bereaved to maintain
established relationships.
6. Acknowledge the usefulness of mutual – help
group.
7. Encourage self – care by family members
particularly, the primary caregivers
8. Acknowledge the usefulness of counseling for
specially difficult problems.
DEATH CAN INVOLVE FEARS THAT ARE
PHYSICAL, SOCIAL, AND EMOTIONAL

• PHYSICAL - Helplessness,
dependence, loss of physical faculties,
mutilation, pain

• SOCIAL - Separation from family,

leaving behind unfinished business

• EMOTIONAL - Being unprepared for

death and what happens after death
 INTERVENTIONS FOR FEARS

• Talk as needed
• Avoid superficial answers, i.e.
“It’s God’s will
• Provide religious support as
appropriate
• Stay with the patient as needed
• Work with families to strengthen
and support
 PHYSIOLOGY OF DYING

• Somatic death or death of the body

• Series of irreversible events leading to cell death

• Causes of death varies

• However, there are basic body changes leading to

all deaths
THESE BASIC BODY CHANGES RESULT IN
THE DEATH OF ALL VITAL BODY SYSTEMS

• PULMONARY:
• Unable to oxygenate the
body
• Assess for poor
oxygenation-skin pale,
cyanotic, mottled, cool
• in dark skinned - assess
mucous membranes, palms
of hands, soles of feet
 CARDIOVASCULAR

Large load on heart when lungs fail

Heart not getting needed oxygen
Pumping heart not strong enough
to circulate blood
Blood backs up causing failure
Leads to pulmonary and liver
congestion
 BLOOD CIRCULATION
•Decreased, as heart less able to pump
•May have a “drenching sweat” as death
approaches
•Pulse becomes weak and irregular
•If pulse relatively strong, death is hours
away
•If pulse is weak and irregular, death is
imminent
 COMBINATION OF THESE EVENTS LEADS TO
CELL DEATH, AND DEATH OF THE
ORGANISM (HUMAN)

As pulmonary and cardiovascular

systems fail, other body systems
begin to fail, also
 FAILING METABOLISM

Physical change Care measures

• Metabolic rate - Offer ice chips and
decreases, provide frequent oral
almost stopping care to keep the
mouth moist and
• Feces might be promote comfort.
retained or Enemas may be
incontinence necessary to assist
might be with bowel
present elimination
 FAILING URINARY SYSTEM
Care Measures
Physical Change Check person
regularly for
Urinary output incontinence.
decreases
Clean the skin
Blood pressure too gently and change
low for kidney soiled or wet
filtration clothing and bed
Further load on linens.
cardiovascular Bed protectors or
system due to indwelling urinary
increase circulating catheters may be
volume needed
 FAILING NERVOUS SYSTEM
Physical change
Care measures
- Some people lose the - Ask questions that can be
ability to speak answered by a nod or a shake of
the head
- Vision may become - Keep the room well lit and make
sure you introduce yourself when
blurred entering the room.

- Pain is usually diminished - Observe the person for pain and

report findings to the nurse so that
the person can receive
- Hearing usually remains medication to remain
sharp comfortable
- Always talk to the person as if he
- Consciousness may be or she is able to ehar you, even if
he or she cannot respond.
altered Encourage family members to talk
to the dying person also.
 SPECIFIC SENSORY DECLINE

• Dying person turns toward light - sees only what is

near
• Can only hear what is distinctly spoken
• Touch is diminished - response to pressure last to
leave
• Dying person might turn toward or speak to
someone not visible to anyone else
• Eyes may remain open even if unconscious
• Person might rally just before dying
 FURTHER NEUROLOGIC DECLINE AT DEATH

•Pupils might react sluggishly or not at all to

light
•Pain might be significant
•Assess for pain if person unable to talk:
restlessness, tight muscles, facial
expressions, frowns
•Provide pain medication as needed
 NEVER LOSE SIGHT. . .
Death is the end, as we know it, for that person
We can only support, listen therapeutically, and
Make the person as physically comfortable as
possible
We can also use our knowledge and expertise
to strengthen, support, and prepare the family
INDICATIONS OF DEATH
 INDICATIONS OF DEATH
1. Total lack of response to external stimuli.

2. No muscular movement

3. No reflexes

4. F l a t E C G . T h i s i s t h e m o s t a c c u r a t e
indicator of death.
 POST MORTEM CARE
The care of a person’s body after the person’s death.

Body changes :

Rigor mortis – the stiffening of the muscles that usually develops within 2 to 4 hrs
of death.
- Results from lack of adenosine triphosphate (ATP) which is not synthesized
due to lack of oxygen in the body
- Position the body, place dentures in the mouth and close eyes and mouth
before rigor mortis sets in.
ALGOR MORTIS – is the 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 celcius (1.8 °F) per hour
until it reaches room temperature.

LIVOR MORTIS – discoloration of the skin after circulation has ceased. The RBC
break down, releasing hemoglobin which discolors the surrounding tissues.
 NURSING INTERVENTIONS FOR THE
BODY AFTER DEATH
1. Make the environment as clean and as pleasant as possible
2. Make the body appear natural and comfortable
3. Remove all equipment and supplies from the bedside
4. Remove soiled linens, so the room is free from odors
5. Place the body in supine position, the arms at the sides, palms down
6. Place one pillow under the head and shoulders to prevent blood from
discoloring the face
7. Close the eyelids, insert dentures and close the mouth
8. Wash soiled areas of the body.
 CONT.
9. Place absorbent pads under the buttocks to take up any feces and urine
released because of relaxation of the sphincter muscles.
10. Provide clean gown, brush/comb the hair
11. Remove all jewelry. All the client’s valuables are listed and placed in a safe
storage area for family to take away.
12. Allow family to view the patient’s body
13. Apply identification tags, one to the ankle and one to the wrist.
14. Wrap the body in shroud. Apply another identification tag to the outside of
the shroud.
15. Bring the body to the morgue for cooling (cyanosis).
 THE END
thank you, see you in level IV