THE DYING THE DYING PERSONPERSON

CHAPTER 41CHAPTER 41

INTRODUCTIOINTRODUCTIONN† Some deaths are sudden, others expected

† Accepting one’s own mortality is a developmental stage of life

† Your feelings about death affect the care you give

† Must understand the dying process to meet dying person’s physical, psychological, social, & spiritual needs

TERMINAL TERMINAL ILLNESSILLNESS

† Illness or injury for which no reasonable expectation of recovery exists

† Doctors can’t predict time of death

† Hope and the will to live strongly influence living and dying

ATTITUDES ABOUT ATTITUDES ABOUT DEATHDEATH

† Experiences, culture, religion, and age influence attitudes

† Attitudes change as age & circumstances change

† Dying people often need hospital, nursing center, hospice, or home care

† Family often involved in process

ATTITUDES ABOUT ATTITUDES ABOUT DEATHDEATH

† When death occurs funeral director called to take body

† Many adults & children have never had contact with dying person or at time of death

† Practices & attitudes differ among cultures

† Attitudes influenced greatly by religion

RELIGION’S AFFECT ON RELIGION’S AFFECT ON DYINGDYING† Beliefs about life after death influence

attitude toward death (ex: reincarnation is belief that spirit or soul is reborn into another human body or into another form of life)

† Rites & rituals during dying process or at death influenced by religion

† Religion offers comfort to some people as they or loved one are dying

AGE’S AFFECT ON DYINGAGE’S AFFECT ON DYING† Adults:

† Fear pain & suffering, dying alone, invasion of privacy, loneliness, and separation from loved ones

† Worry about loved ones left behind

† Resent death ability to keep from dreams

† Age 3-5 think death is temporary† Blame themselves

† See death as punishment for being bad

AGE’S AFFECT ON DYINGAGE’S AFFECT ON DYING† Age 5-7

† Know death is final† Think death only happens to others† Relate death to punishment & body

mutilation (ideas from TV, cartoons, video games, movies, fairy tales)

† Older persons† Fewer fears than younger persons, but may

fear dying alone† Know it will come, may welcome it (free of

pain & suffering) or think of as reunion with loved one

STAGES OF DEATH & DYING STAGES OF DEATH & DYING DESCRIBED BY ELISABETH DESCRIBED BY ELISABETH

KUBLER-ROSSKUBLER-ROSS Denial: “No, not me!” Anger: “Why me?” May be

outraged & jealous of healthy Bargaining: make promises to bargain for more

time – may be on spiritual level Depression: mourn things lost & that will be lost Acceptance: calm & at peace NOTE: may not go through stages in order, may

go back & forth, may never get to last stage

PSYCHOLOGICAL, PSYCHOLOGICAL, SOCIAL, AND SPIRITUAL SOCIAL, AND SPIRITUAL

NEEDSNEEDS Dying person may want: Family & friend’s present To talk about fears & anxieties To be alone

Listen and let them express feeling in own way

Use touch to show caring (along with silence)

May want to see spiritual leader Provide privacy Be courteous to leader Handle spiritual objects with respect

PHYSICAL NEEDSPHYSICAL NEEDS Dying may take minutes, hours, weeks:

Body processes slow Person is weak LOC change Keep comfortable and maintain dignity

Vision blurs: Explain what doing May turn toward light, avoid bright lights Dark room may frighten Eyes may be ½ open with secretions in

corners – good eye care essential

PHYSICAL NEEDSPHYSICAL NEEDS Hearing one of last functions lost

Assume they can hear you – provide reassurance & explanations

Speak in normal voice Speech become difficult

Anticipate needs Don’t ask questions that require long

answers Continue to talk to person

PHYSICAL NEEDSPHYSICAL NEEDS Mouth Oral hygiene promotes comfort As death nears & unable to take frequent

oral fluids, frequent oral care important (esp. if can’t swallow)

Carefully clean nose (crusting) & apply lubricant prn

Circulation fails & body temp rises as death nears: Skin cool & mottled Diaphoretic – have increased need for skin

care & changing gown/ linens, use light covers

PHYSICAL NEEDSPHYSICAL NEEDS• Appetite slowly decreases to point

of no intake– Meat, first to avoid, followed by

breads/fruits/vegetables; then sweets only then liquids onto sips

water only

– Assist family to accept this

loss of appetite

PHYSICAL NEEDSPHYSICAL NEEDS Elimination

Incontinence may occur – pericare needed Constipation & urinary retention may

necessitate enemas & catheters

Comfort and positioning Good alignment & changing positions Analgesics prn May need Semi-Fowlers

position to make breathing easier

PHYSICAL NEEDSPHYSICAL NEEDS Person’s room should be comfortable &

pleasant: Well lit & ventilated Remove unnecessary equipment Keep upsetting equipment out of site Arrange mementos, religious items, flowers,

or significant items in view Family members may

be present all the time Room may be near

nurses’ station

FAMILYFAMILY† Hard time for family – show

feelings by being available & courteous† Stay as long as they wish - respect the

right to privacy, but don’t ignore care of patient

† Family members need support, understanding, courtesy, and respect – go thru same stages as patient

† Family may desire spiritual leader also

HOSPICE CAREHOSPICE CARE† Focuses on the physical, emotional,

social, and spiritual needs of dying† May be part of hospital or nursing

center or separate agency – many offer home care

† Not concerned with cure or life-saving measures, but comfort & preserving quality of life

† Provides follow-up care and support groups for survivors

LEGAL ISSUESLEGAL ISSUES† Much attention given to right to die† Consent is needed for any treatment.† The Patient Self-Determination Act and

OBRA (right to accept or refuse medical treatments) – Advance Directives:†Living wills: document with wishes†Durable power of attorney

† “Do not resuscitate” orders written by MD after consulting with patient & family

QUALITY OF LIFEQUALITY OF LIFE† Person has right to die in peace & with dignity

† Dying person’s bill of rights (see p. 810)† Right to privacy before & after death – drape &

screen

† Right to visit with others in privacy – family able to come & go freely, private room if possible

† Right to confidentiality (diagnosis & condition)

† Free from mistreatment or restraints

† Right to safe & home-like setting – protect property, keep odor-free, neat & clean

† Right to personal choice – advance directives – staff must respect choices

SIGNS OF DEATHSIGNS OF DEATH† Signs may occur rapidly or slowly:

† Movement, muscle tone, sensation lost – mouth may stay open

† Peristalsis slows – distention, fecal incontinence or impaction common

† Body temperature rises – feels cold, looks pale, & perspires heavily

† Circulation fails – pulse fast, weak, irregular & BP falls

† Respiratory system fails – Cheyne-Stokes or slow respirations & mucous collects (death rattle)

† Pain decreases as loses consciousness† At time of death: no pulse, respirations, or blood

pressure & pupils are fixed and dilated† Doctor must pronounce dead (coroner or medical

examiner may pronounce or be notified)

CARE OF THE BODY AFTER CARE OF THE BODY AFTER DEATH – POSTMORTEM DEATH – POSTMORTEM

CARECARE The right to privacy and the right to be treated with dignity and respect apply after death (close drapes, curtains, doors)

Care begins after pronounced dead Goal is to maintain good appearance of

body - discoloration & skin damage prevented, handle gently

Valuables gathered to give to family

Other patients may need support

CARE OF THE BODY AFTER CARE OF THE BODY AFTER DEATH – POSTMORTEM DEATH – POSTMORTEM

CARECARE Rigor mortis (rigidity of skeletal muscles) develops 2-4 hours after death Body positioned in normal body alignment

before rigor mortis sets in Body should appear in comfortable

position for viewing by family Moving body may cause expulsion of air

from lungs or intestines, normal sounds produced

Standard Precautions

CARE OF THE BODY AFTER CARE OF THE BODY AFTER DEATH – POSTMORTEM DEATH – POSTMORTEM

CARECARE Raise bed to comfortable level Place pillow under head & shoulders Close eyelids gently by pulling lashes down Close mouth using rolled washcloth under

chin to support closed position prn Follow facility policy for dentures (in mouth

or in cup to be sent to mortuary) Remove tubes, replace

dressings, inventory valuables

CARE OF THE BODY AFTER CARE OF THE BODY AFTER DEATH – POSTMORTEM DEATH – POSTMORTEM

CARECARE Bathe soiled areas & comb hair If family coming to view:

Apply clean gown & bed linen Cover body to shoulders Arrange room neatly Provide for privacy

Identify & assemble belongings - place in labeled bags for family – document

After body is removed, strip unit Follow instructions per charge nurse

CARE OF THE BODY AFTER CARE OF THE BODY AFTER DEATH – POSTMORTEM DEATH – POSTMORTEM

CARECARE Observe & report: What was done with belongings Unusual occurrences related to care Unusual responses of family or

residents Any other significant

observations Remove & discard

gloves, wash hands