1. CHAPTER 41
THE DYING PERSON

2. INTRODUCTION 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

3. TERMINAL ILLNESS
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

4. ATTITUDES ABOUT DEATH
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

5. ATTITUDES ABOUT DEATH
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

6. RELIGION’S AFFECT ON DYING
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

7. AGE’S AFFECT ON DYING Adults: Age 3-5 think death is temporary
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

8. AGE’S AFFECT ON DYING Age 5-7 Older persons 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

9. STAGES OF DEATH & DYING DESCRIBED BY ELISABETH KUBLER-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

10. PSYCHOLOGICAL, SOCIAL, AND SPIRITUAL NEEDS
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

11. PHYSICAL NEEDS Dying may take minutes, hours, weeks: Vision blurs:
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

12. PHYSICAL 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

13. PHYSICAL 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

14. PHYSICAL 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

15. PHYSICAL NEEDS Elimination Comfort and positioning
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

16. PHYSICAL 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

17. FAMILY
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

18. HOSPICE 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

19. LEGAL 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

20. QUALITY 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

21. SIGNS 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)

22. CARE OF THE BODY AFTER DEATH – POSTMORTEM CARE
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

23. CARE OF THE BODY AFTER DEATH – POSTMORTEM CARE
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

24. CARE OF THE BODY AFTER DEATH – POSTMORTEM CARE
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

25. CARE OF THE BODY AFTER DEATH – POSTMORTEM CARE
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

26. CARE OF THE BODY AFTER DEATH – POSTMORTEM CARE
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