End of Life Care

Benedict John R. Bacena

Responses to dying and death The reaction of any person to another persons impending or real death, or to the potential reality of his or her own death, depends on all the factors regarding loss and the development of the concept of death. Development of the Concept of death AGE Infancy to 5 years BELIEFS/ ATTITUDES Does not understand concept of death Infants sense of separation forms basis for later understanding of loss and death Believe death is reversible, a temporary departure, or sleep Emphasizes immobility and inactivity as attributes of death Understands the death is final Believes own death can be avoided Associates death with aggression or violence Begins to understand own mortality, expressed as interest in afterlife or as fear of death May fantasize that death can be defied, acting out defiance through reckless behaviours ( dangerous driving, Substance abuse) Has attitude toward death influenced by religious and cultural beliefs Experiences peaks of death Death anxiety diminishes with emotional well being Sees death as having multiple meanings ( freedom from pain, reunion with already deceased family members)

5 to 9 years

9 to 12 years 12 to 18 years

18 to 45 years 45 to 65 years

65+ years

Reference: Chapter 43/loss Grieveing and Death/pg 1090

Cultural and Religious Practices at End of life Religion

Buddhism

During sickness
Important to die in positive state of organ permitted

Dying/death
Help die peacefully by encouraging forgiveness, position on right side, left hand on left thigh, legs stretched out, no special body preparations Terminal diagnosis dying information given to family, not the patient; family decides how much info to share with the patient Body on its side, facing mecca, friends and loved ones pray for mercy forgiveness and blessing of Allah

After death
Leave body alone as long as possible to avoid disturbing the consciousness during transition from death to new life

Hinduism

Family does daily care; father. Oldest son makes health decisions; same sex caregiver due to modesty

Body washed usually by eldest son, then cremated

Islam/ Muslim

Prayer 5x day; clean area of any body waste, including person and sheets; can use pitcher and basin provided; use clean sheet to cover patient during prayer. Best efforts provided to maintain life; hardship is a test from Allah can remove life support; natural death will allow person to accept the will of Allah No blood transfusion;; organ transplant per individual conscience

Person of same gender prepares body for burial; same day as death if possible; cremation Forbidden.

Jehovahs Witness

Respectful care for dying person and family respond to their individual needs

Generally follow traditional state mandates for burial or cremation

Judaism

In serious illness, patient is not to be left alone to be attended by family; doctors duty to prolong life unless death is imminent and certain; cannot hasten death Respect and dignity for body; organ donation and autopsy allowed if treatment is of no benefit or unreasonable burden, may forgo and allow natural death; decision up to patient family If possible, fast 1 hour before receiving Eucharist; moral obligation to use ordinary or proportionate means preserving life

Autopsy not permitted unless required by law; organ donation only after person declared dead Open to pastoral care; some have a rite of anointing by a priest; some have service of commendation of dying

Cremation forbidden; focus on decreased and funeral; mourning occurs in the home for 7 days after the funeral.

Christianity(general )

Practices may vary by denomination, but commonly include a gathering with family and friends after the funeral or memorial service

Roman Catholicism

Sacrament of anointing of the sick before surgery, for elderly in weakened condition by a priest

May be cremated; cremains may be brought to funeral mass.

Reference: Gerontological Nursing/ 2nd edition/pg 775-776

Definitions and Signs of Death

The traditional clinical signs of death were cessation of the apical pulse, respiration and blood pressure. Also referred to as heart lung death, however, since the advent of artificial means as maintain respiration and blood circulation, identifying death is more difficult. In 1968, the World Medical Assembly adopted the following guidelines for physicians as indication of death: Total lack of response to external stimuli No muscular movement, espeacilly breathing No reflexes Flat encephalogram ( brain waves) In instances of artificial support, absence of brain waves for at least 24 hours is an indication of death. Only then can a physician pronounce death, and only after this pronouncement can life support system be shut off.
IMPENDING CLINICAL DEATH LOSS OF MUSCLE TONE Relaxation of facial muscle Difficulty speaking Difficulty swallowing and gradual loss of gag reflex Decreased activity of the gastrointestinal tract Possible urinary and rectal incontinence due to decreased sphincter control Diminished body movement

SLOWING OF THE CIRCULATION Mottling and cyanosis of the extremities Cold skin (first in the feet and latter hands, ear, nose) Slower and weaker pulse Decreased blood pressure

RESPIRATION Rapid, shallow, irregular or abnormally slow

1Closer the drapes and/or door.Allow the family to stay in the room if desired
2Notify the physician in charge when death hasoccurred.Have the physician or other qualifiedperson pronounce the clients death. 3. Notify the nursing supervisor, admittingdepartment and any other departments thatneed to know of the clients death. 4. Wash your hands and apply gloves and other protective equipment. 5. Bathe the body, removing all tubes (or leavestubes in place for autopsy according to theinstitutions policy).Put a gown on the client ifthe family will view the body.Also, clean theimmediate environment as indicated. 6. Follow the institutions policy about removing orinserting dentures, dental plates, artificial eyes,limbs and hair and removing contact lenses. 7. Gently close the clients eyes if open.Do not usetape. 8. Allow family and friends of the deceased time to view the deceased if desired.Be available to answer questions and provide support.Besensitive to different cultural beliefs surrounding the deceased immediately after death.The family should be informed when the body will besent to the mortuary.The family needs to be aware of hospital or institution resources such as a chaplain or priest or facilities such as chapels. 9. Inventory the clients belongings if this are notalready been done. 10. Send all the clients belongings, jewelry andpersonal effects home with the family if possible.Document the name of the person who receivedthe items.If the family is not available, followthe institutions policy regarding disposition ofbelongings. 11. Place identifying tags on the decreasedaccording to the institution of belongings 12. Wrap the body in a sheet or shroud. 13. Transfer the body to the stretcher or morgue. 14. Arrange for transportation to the morgue. 15. Leave the morgue cart in the room until ready totransport. 16. Document in the progress notes the time thepulse and respiration ceased; the time thephysician was notified; the time the family wasnotified, absence or presence of the family; anddisposition of jewelry, personal effects and the body

TEST YOUR KNOWLEDGE 1. Which of the following may be considered normal or healthy types of grief? Select all that apply. a. b. c. d. e. f. Abbreviated grief Anticipatory grief Disenfranchised grief Complicated grief Unresolved grief Inhibited grief

2. A clients family tells the nurse that their culture does not permit a dead person to be left alone before burial, hospital policy states that after 6:00 pm when mortuaries are closed, bodies are be stored in the hospital morgue refrigerator until the next day. How would the nurse best manage this situation? a. b. c. d. Gently explain the policy to the family and then implement it. Inquire of the nursing supervisor how an exception to the policy could be made Call the clients primary care provider for advice Move the deceased to an empty room and assign an aide to stay with the body

3. The shift changed while the nursing staff was waiting for adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following greetings is most appropriate? a. b. c. d. Im very sorry for your loss Ill take you in to view the body I dont know your father but I am sure he was a wonderful person how long will you want to stay with your father?

4. At which age does a child begin to accept that he or she will someday die? a. b. c. d. Less than 5 years old 5-9 years old 9-12 years old 12-18 years old

5. In your own words what is the meaning of End Life