9/29/2011

Death and Dying Assisting the patient to…

What do we do?
• Nurses interact with dying patients and their families or caregivers in variety of setting. • Nurses must recognize the various influences on the dying process – legal, ethical, religious, spiritual, personal and be prepared to provide sensitive, skilled and supportive care to all those affected.

―Live well‖

and
―Die well‖

Common Fears Of The Dying Patient
• Fear of Loneliness or Fear of Sorrow • Fear of the unknown • Loss of self concept and body integrity • Fear of Regression or Fear of Loss of Self Control • Fear of Suffering and Pain Kübler-Ross Stages of Grieving
• Denial, Anger, Bargaining, Depression, Acceptance

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
• 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. • Perceived loss – loss that is less tangible & uniquely defined by the grieving client (loss of confidence, prestige)

• Maturational loss – change in developmental process that is normally expected during a lifetime. • 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. • Actual loss – can be identified by others & can arise either in response to or in anticipation of a situation.

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.

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family will chant (mantra) and pray. lost may not have been sufficiently important to the grieving person or may have been replaced immediately by another. • Dysfunctional grief – occurs when there is prolonged emotional instability. considered bad luck and evil • Muslim—illness is a result of sin and death is part of life as destined by God • Orthodox Jews—do not leave the dying person alone. decrease BP • Respirations-strenuous. have ―minyan‖ praying at the bedside • Hindu—may refuse food and pain medication because of belief in transmigration. Avoid giving advice • Allow patient to talk or express signs of hope • Support hope by helping focus Assist Family to Grieve • • • • • • • Explain procedures and equipment Prepare them about the dying process Involve family and arrange for visitors Encourage communication Provide daily updates Resources Do not deliver bad news when only one family member is present Cultural Considerations Related to End-ofLife Issues • Chinese—to discuss death is taboo. equally esteemed object. head will face east with a lamp near the head. and rapid. cold clammy skin • Pulse-irregular.9/29/2011 TYPES OF GRIEF • Abbreviated grief – grief which is brief but genuinely felt. Nursing Strategies Appropriate For Grieving Persons • Anticipatory grief – process of accomplishing part of the grief work before an actual loss. ―Death rattle‖ • Jaw and Facial muscles relax • Most positive sign of death=absence of brain waves World Medical Assembly Guidelines for Death • No response to external stimuli • No muscular movement. esp during breathing • No reflexes • Flat encephalogram • In instances of artificial support. absence of brain waves for at least 24 hours 2 . withdrawal from usual task or activities that previously gave pleasure & lack of progression from one level to successful coping with the loss. Cheyne stokes. grief response in which the person begins grieving process before an actual loss. you may be target of anger • Remove barriers. they may spread incense and apply ash to the client’s forehead • Catholic—priest will anoint the client and give Holy Communion Communicating Truthfully about Terminal Illness • Patient has a right to know and the time frame • The physician will tell the client first • Nurse assesses what the patient/family have been told • Choices of Care Setting • Patient or family have the right to choose where to care is to be provided • Hospital. • Open ended statements and let Pt sets the pace • Accept any grief reaction. irregular. Home/Hospice Helping Clients Die with Dignity • Thorough pain control • Maintain independence • Prevent isolation • Spiritual comfort • Support the family Signs/Symptoms of Approaching Death • Motion and sensation is gradually lost • Increase in temp.

with small pillow under head • Insert dentures • Remove valuables and give to family • Stay with family. connective tissue – Bone marrow Organ donation does not affect the appearance of the body. lung. although family makes the final decision Care of the Body After Death • • • • • Check orders for special requests Remove equipment and supplies Change soiled linens and cleanse patient Use room deodorizer Place patient in supine position. pancreas – Non-vital organs are: eye corneas. and skin 3 . Client must be on life-support to support vital organs 2. patient decision before death • Legally person is dead when brain waves cease – This definition allows for harvesting of organs and tissue for donation – Vital organs are: heart. middle ear bones. heart valves. skin. coroners case • For tissue and organ removal: – Keep CV system going. cephalic reflexes. No age limit although parents must consent when client is under 18 years old 4.9/29/2011 Cerebral Death • Cerebral cortex is irreversibly destroyed • Permanent loss of cerebral and brainstem function – Absence of responsiveness to external stimuli. Indicate on drivers license request to be organ donor. kidneys. including the brainstem‖ • Post-mortem care – must be done soon after death because of the changes the body undergoes – DNR—do not resuscitate – Omnibus Budget Reconciliation Act (OBRA) of 1986 – Autopsy—postmortem exam to determine the exact cause of death – Cultural considerations Organ Donation 1. kidney. liver. liver. Call donor bank representative – Must be agreed on by all family members. intestines – Tissue—cornea. if requested Continued… • What can be donated? – Organs—heart. lungs. long bones. Apnea • Isoelectric EEG for at least 30 minutes in the absence of hypothermia and poisoning by CNS depressants • Physical Changes of Death Rigor mortis—stiffening of the body Algor mortis— decrease of body temperature after death Livor mortis – yellowish discoloration of skin Post-mortem—after death • The Uniform Determination of Death Act (UDDA)— defines death as ―irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the brain. Family must understand that client is braindead 3. an open casket is still possible After Client Dies • Encourage the family to view the body • May wish to clip a lock of hair as a remembrance • Children should be included in the events surrounding the death if they wish Nursing Interventions • Provide private place for family discussion • Be sure that the decision is made by the appropriate person • Contact local donor registry • Inform family that body will be cared for • Be sure family understands that there is no cost for organ donation • • • • • • After The Family Leaves Leave wrist ID tag on Apply additional identification tags Wrap the body in a shroud Apply ID to the outside of the shroud Take the body to the morgue Or arrange to have a mortician pick it up from the client’s room • Handle the deceased with dignity Autopsy or Organ Donation • Autopsy . pancreas.to determine cause of death.

avoid placing one hand over the other • Place small pillow under head and elevate the head of the bed 10-15 degrees • Close eyes. If not. unless contraindicated by client’s religious preference • Shave men unless family requests otherwise 4 . ET tubes.9/29/2011 Post-Mortem Care • Always follow agency policy and procedure • Ensure that correct identification is on the body • Remove foley catheters. place them in cup to stay with body Continued… • Position body in natural position. oxygen. and peripheral IV’s • Reinsert dentures if possible.

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