NURSING CARE OF DYING AND DEATH PATIENTS

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OBJECTIVES
At the end of this lecture participants will be able to:
1. 2. 3. 4. 5. 6. 7.
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Knows concept of death in our daily life Define death Discuss responses of death and dying patient Enumerate stages of death Explain physical sign of death Illustrate changes in body after death Manage fear of death and death anxiety of patient
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OBJECTIVES
8. Define Hospice and Palliative care 9. Describe goal, purposes and principles of hospice and palliative care. 10. Demonstrate nursing care of death and dying patient. 11. Maintained ethical and legal issues related to death and dying. 12. Understand about concept of cryonics.
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REALITY OF LIFE

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Introduction
Birth and death are two aspects of life, which will happen to everyone.

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Dying and death are painful and personal experiences for those that are dying and their loved ones caring for them.

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Death affects each person involved in multiple ways, including physically, psychologically, emotionally, spiritually, and financially.

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Whether the death is sudden and unexpected, or ongoing and expected, there is information and help available to address the impact of dying and death.

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Definition of death
"cessation of heart- lung function, or of whole brain function, or of higher brain function.

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Definition of death
"either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem

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Responses to dying and death

Although each person reacts to the knowledge of approaching death or to loss in his or her own way, there are similarities in the psychosocial responses to the situation.

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Stages of Dying
According to Kubler- Ross, the five stages of dying are:
1. 2. 3. 4. 5. Denial Anger Bargaining Depression Acceptance

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Denial
On being told that one is dying, there is an initial reaction of shock.

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Denial
The patient may appear confused at first and may then refuse to believe the diagnosis or deny that anything is wrong.

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Denial
Some patients never pass beyond this stage and may go from doctor to doctor until they find one who supports their position.

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Anger
Patients become frustrated, irritable and angry that they are sick. A common response is, Why me?

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Anger
They may become angry at God, their fate, a friend, or a family member. The anger may be displaced onto the hospital staff or the doctors who are blamed for the illness.

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Bargaining
The patient may attempt to negotiate with physicians, friends or even God, that in return for a cure, the person will fulfill one or many promises, such as giving to charity or repeat an earlier faith in God.

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Depression
The patient shows clinical signs of depressionwithdrawal, psychomotor retardation, sleep disturbances, hopelessness and possibly suicidal ideation.

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Depression
The depression may be a reaction to the effects of the illness on his or her life or it may be in anticipation of the approaching death.

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Acceptance
The patient realizes that death is usual and accepts the universality of the experience.

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Acceptance
People with strong religious beliefs and those who are convinced of a life after death can find comfort in these beliefs (Zisook & Downs, 1989).

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PHYSICAL SIGNS OF DYING.

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What are the physical sign of death?

1. 2. 3. 4. 5. 6. 7. 8.
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Confusion Loss of appetite Drowsiness Withdrawal and no socialization Bowel bladder control loss Cool skin Abnormal breathing Involuntary movement
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Confusion about
Time, Place, Identity of loved ones and Visions of people and places that are not present.

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loss of appetite
A decreased need for food and drink, as well as loss of appetite

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Drowsiness
An increased need for sleep and unresponsiveness

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Withdrawal
Withdrawal and decreased socialization

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Loss of bowel or bladder control

Caused by relaxing muscles in the pelvic area

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Cool Skin
Skin becomes cool to the touch

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Abnormal Breathing
Rattling or gurgling sounds while breathing or breathing that is irregular and shallow, decreased number of breaths per minute, or breathing that switches between rapid and slow

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Involuntary movements
Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms also mean that the end of life is near

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CHANGES IN BODY AFTER DEATH

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CHANGES IN BODY AFTER DEATH

1. Rigor Mortis 2. Algor Mortis 3. Livor Mortis

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Rigor Mortis
Body becomes stiff within 4 hours after death as a result of decreased ATP production. ATP keeps muscles soft and flexible.

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Algor Mortis
Temperature decreases by a few degrees each hour. The skin loses its elasticity and will tear easily.

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Livor Mortis
Dependant parts of body become discolored. The patient will likely be lying on their back, their backside being the 'dependant' body part. The discoloration is a result of blood pooling, as the hemoglobin breaks down.
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Hospice and palliative care

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Hospice Care
Specialized program that addresses the needs of the terribly ill and their loved ones.

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Team involve in hospice..?

Physicians Nurses Social workers Clergy (religious leaders) home health aids Volunteers Therapists family caregivers.
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Purpose of Hospice care

Help a dying person Manage pain Provide medical services Offer family support

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What is palliative Care

Palliative care is the active total care of patients whose disease is not responsive to curative treatment (World Health Organization).

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Principle of Palliative care

1. Respects the goals, likes and choices of the dying person. 2. Looks after the medical emotional, social and spiritual needs of the dying person. 3. Supports the needs of the family members. 4. Helps gain access to needed health care providers and appropriate care settings. 5. Builds ways to provide excellent care at the end of life (Foley and Carver, 2001)
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Goals of palliative care

The relief of suffering Control of pain Control of other symptoms Control of psychological, social and spiritual problems
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MANAGING DEATH ANXIETY

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Spirituality

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TECHNIQUES TO DEAL WITH DEATH ANXIETY.

1. 2. 3. 4. 5. 6. 7. Concern Competence Communication Children Cohesion Cheerfulness Consistency

Seven Cs
Cassen (1991)

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Concern
Empathy, compassion, and involvement are essential.

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Competence
Skill and knowledge can be as reassuring as warmth and concern.

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Communication
Allow patients to speak their minds and get to know them.

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Children
If children want to visit the dying, it is generally advisable; they bring comfort to dying patients.

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Cohesion
Family cohesion reassures both the patient and family.

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Cheerfulness
A gentle, appropriate sense of humor can be palliative; a somber (serious) or anxious demeanor(appearance) should be avoided.

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Consistency
Continuing, persistent attention is highly valued by patients who often fear that they are a burden and will be abandoned (avoided); consistent physician involvement mitigates (lessen) these fears.

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Nursing care of a dying individual

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Nursing care of a dying individual

1. 2. 3. 4. 5. 6. 7. Decrease fear of Death Listen more Self evaluation Self control Family Involvement Resource management Pain and communication
(Schwartz and Karasu, 1997)
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Death fear
Deal with mental anguish and fear of death,

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Listen more
Try to respond appropriately to patients needs by listening carefully to the complaints

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Self evaluation
Be fully prepared to accept their own counter transferences, as doubts, guilt and damage to their selfimportance are encountered.

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Self evaluation
Management of the dying patient often elicits anxiety in nursing staff.

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Self evaluation
Education and role playing can improve perspective taking and empathetic skills, respect each others point of view as well as appreciate the situation of patient and their families.
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Self control

Developing a sense of control and efficacy.

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Family Involvement
Encouraging peer groups for families coping with bereavement.

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Resource management
Developing increased resourcefulness in dealing with death related situations.

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Pain and communication

Improving our understanding of pain and suffering will also improve communication and effective interactions.

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Ethical and Legal Issues

Patients have a right to refuse Life-sustaining treatment, even if they die as a consequence (Stanley, 1992).

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Ethical and Legal Issues

Informed consent and refusal to lifesustaining treatment has three elements:
1. adequate information must be conveyed to the patient, 2. the patient must be able to decide, and 3. the patient must have freedom from coercion (force).

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CRYONICS
Cryonics is the preservation of the dead body to be revived, till the time, medical technology advances to do so.

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Arguments against cryonics

1. There is no way to preserve bodies so that their organ will resume functioning when they are thaw (Darwin and Wowk, 1992). 2. Immortality does not yet fall within the province of technology (Shermer, 1992).
Currently, these efforts are simply wastage of resources.
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REFERENCES
Robbins J, Moscrop J. caring for the dying & family. 3rd ed. London: Chapman&Hall;1995 Craven R F, Hirnle C J. Fundamentals of Nursing. 5th ed. Philadelphia: Lippincott Williams & Wilkins Publishers;2006 Feinberg A. W. The care of dying patients. Annals of internal medicine. 2007 Jan 17; 126 (2): 164-65. Meyers T. a turn towards dying: presence, signature, and the social course of chronic illness in urban America. Med Anthropol(PMID 17654261). 2007 JulySept;26(3):205-27.
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THANK YOU
Nomi Waqas Gul Asst. Clinical Instructor Continuing Nursing education (CNE) Pakistan Institute of Medical Sciences, Islamabad, Pakistan

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