On Death And Dying

Emotional and Physiologic Elements of Death and Dying

David Plaut

Teresa Rogers

July, 2013

Contents

Physiology of Dying

Stages of Death and Dying

Right to Life Issues

– Advance Directives

– Living Will

– Medical Power of Attorney

Terminal Illness

• Any disease that cannot be cured and will result in death.

• Everyone reacts differently to news of a terminal illness.

• Some react with fear and anxiety.• Many fear pain, abandonment, loneliness, and

the unknown.

• They may become anxious about their loved ones, unfinished work, or dreams.

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

Emotional and Physical Reasons People May Fear Death.

• Helplessness

• Dependence on others

• Physical faculties

• Mutilation by surgery or disease

• Uncontrollable pain

• Being unprepared for 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

FAILING METABOLISM

• Metabolic rate decreases, almost stopping

• Feces might be retained or incontinence might be present

FAILING URINARY SYSTEM• Urinary output

decreases

• Blood pressure too low for kidney filtration

• Further load on cardiovascular system due to increase circulating volume

FAILING NERVOUS SYSTEM

• Decrease oxygen to the brain, means decreasing brain function

• Sensation and power lost in legs, first, then arms

• May remain conscious, semi-conscious, or comatose

1.Unable to oxygenate the body enough for adequate gas diffusion

2.Respirations become stridorous or noisy, leading

to “death rattle”

3. Cheyne-Stokes respiration sign of pulmonary system failure a. Consists of alternate hyperpneic and apneic

phases

Respiratory System

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

Other Changes

• Metabolism rates decrease.• The person might retain feces or become

incontinent. • Urinary output decreases. • Dying person may turn toward light as sight

diminishes. • Dying person may hear only what is distinctly

spoken.• Dying person may remain consciousness or

become unconscious/comatose

Other Changes

• Some dying people rally in clarity and consciousness just prior to their death

• A person’s eyes might be open even if unconscious

• Dying people might turn toward or speak to someone who is not visible to anyone else in room

• Pain might be present • Pain medication should not be withheld as person

nears death.

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

Social Reasons People May Fear Death

• Fear of separation from family or home

• Fear of leaving behind unfinished tasks or responsibilities

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

• Her landmark work is On Death and Dying

Dr. Elizabeth Kubler-Russ

• Identified five stages of grieving that dying patients and their families and friends may experience: denial, anger, bargaining, depression, and acceptance

• They may not be in order and may overlap or repeat a stage at times.

• Others may not experience all stages.

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.”

Denial

• Usually occurs when the person is first told of the illness.

• Individual’s may say,– “The tests are wrong.”– “This can’t be happening to me.”– “I don’t believe it.”

• Others don’t talk about it.• Health care workers should listen

without confirming or denying it.

Anger

• This stage occurs when the patient can no longer deny death.

• The patient may blame themselves, their loved ones, or health care workers for their illness.

• Health care workers must understand this is not a personal attack.

Bargaining• Usually occurs when patient accepts

death but wants more time to live.• Patients turn to religion and spiritual

beliefs during this period.• They want to see their child graduate,

get married, or hold a grandchild.• Making promises to God to try and

obtain more time sometimes occurs.

Depression

• This stage occurs when the patient realizes that death will come soon and they won’t be with their families any longer.

• They realize that some goals they set will not be met.

• Health care workers need to let the patient know that depression is “OK”.

Acceptance

• This is normally the final stage.

• The patient understands that they are going to die.

• May complete unfinished business and try to help those around them deal with death.

• Patients will slowly get farther away from the world and other people.

• They need emotional support during this stage.

Interventions for Health Care Professionals

• Talk as needed • Avoid superficial answers, i.e. “It’s God’s will.” or “It will be OK.”• Provide religious support as appropriate • Stay with the patient as needed • Work with the family so they might be strong enough to offer support to the dying

person.

Right to Die

• Most people with terminal illness believe that someone with a terminal illness should be allowed to refuse measures that would prolong their life.

• This is the right to die.

• Respirators, pacemakers, and other medical devices can be withheld and the person can die with dignity.

• DNR – Do Not Resuscitate Order

DNR

• Do Not Resuscitate Order

Hospice Care

• This philosophy is to allow the patient to die with dignity and comfort.

• Pain is controlled so that the patient can remain active as long as possible.

• Specially trained volunteers are an important part of many hospice programs.

Advance Directives

• A general term that describes two types of legal documents.

• Living Will

• Healthcare (Medical) Power of Attorney

Living Will

• Allows a person their wishes about medical treatments for the end of life in writing in the event that they cannot communicate those wishes directly.

• Different states may use different names.

Healthcare Power of Attorney• Also know as a “healthcare proxy,”

“ appointment of a healthcare agent,” or “durable power of attorney for healthcare.”

• The person you appoint will be authorized to deal with all medical situations when you cannot speak for yourself.