1. Chapter 23: Dying, Death, and hospice

2. Learning objectives Discuss the stages of grief
Describe the grief process
Discuss how feelings and attitudes about death differ
Discuss how to care for a dying resident
Describe ways to treat dying residents and their families with dignity and how to honor their rights
Define the goals of a hospice program
Explain common signs of approaching death
List changes that may occur in the human body after death
Describe postmortem care
Understand and respect different postmortem practices

3. Stages of grief Stages of grief: Denial Anger Bargaining Depression
Acceptance
A terminal illness is a disease or condition that will eventually cause death. This will inevitably cause grief – deep distress or sorrow over a loss – for the resident and his or her family. When faced by death, a resident (and his or her family) will likely go through the five stages of grief.
Denial: “No, not me”
Anger: “Why me?”
Bargaining: “Yes me, but…”
Depression: need to mourn and review their lives
Acceptance: preparing for death
Remember: Not every person goes through every one of these stages, and not every person goes through them in this order.

4. The grief process Common reactions to the death of a loved one
The following are common reactions to the death of a loved one:
Shock: especially at one’s own feelings
Denial: usually lasts a short time
Anger: at themselves, God, the doctors, even at the person who died
Guilt: wishing they had done more, guilty because they are still living
Regret: for what they did or did not do
Sadness: depression, headaches, or insomnia
Loneliness: missing the person and having painful memories

5. Feelings and attitudes about death differ
Factors that influence feelings and attitudes about death
It is likely that everyone in this course has differing views about death.
These factors can influence feelings and attitudes about death:
Experience with death
Personality type
Religious beliefs
Cultural background

6. How to care for a dying resident
Important points to remember
When caring for dying residents, an NA must take special notice of these issues:
Diminished senses
Care of mouth and nose
Skin care
Comfort
Environment
Emotional and spiritual support
Remember: Advance directives must be honored. The care team’s personal feelings about them are not relevant. Advanced directives are legal documents that allow people to choose what medical care they wish to have if they are unable to make those decisions themselves.

7. Ways to treat dying residents and their families with dignity
Resident’s rights
Rights to remember when caring for the terminally ill:
The right to refuse treatment
The right to have visitors of their own choosing
The right to privacy
NAs should remember these points about the right to refuse treatment:
Caregivers need to remember that whether they agree or disagree with the decisions, the choice is not theirs, but belongs to the person involved.
Sometimes, when residents are not capable of making a decision, they have told their families how they wish things to be done. Caregivers should be supportive of family members and not judge them. They are probably following the person’s wishes.
NAs should remember these points about the right to have visitors:
It may be inconvenient to have visitors coming and going at odd hours, but when death is close, it is an emotional time for all those involved.
Saying goodbye can be a very important part of dealing with a loved one’s death.
It may also be very reassuring to the dying person to have someone in the room, even if they do not seem to be aware of their surroundings.
Respect their wishes in all ways possible.
Do not isolate or avoid a resident who is dying.
Do not make promises that cannot or should not be kept.
Continue to involve the dying person in facility activities.
Listen if they want to talk.
Do not babble or act especially cheerful or sad.
Keep the resident comfortable.
Assure privacy when it is desired.
Respect the privacy of the family and other visitors.
Help with the family’s physical comfort.

8. Goals of a hospice program
Hospice care
Palliative care
Guidelines for hospice care
Hospice care is holistic, compassionate care given to dying people and their families. Palliative care is often part of hospice care. Palliative care is care that focuses on the comfort and dignity of a person who is very sick and/or dying, rather than on curing him or her.
NAs should remember these guidelines for hospice care:
Be a good listener.
Respect privacy and independence.
Be sensitive to individual needs.
Be aware of your own feelings.
Recognize the stress.
Take good care of yourself.
Take a break when you need to.
Remember: It is very important that NAs find a productive way to deal with their own feelings when doing hospice work.

9. Common signs of approaching death
Blurred and failing vision
Unfocused eyes
Impaired speech
Diminished sense of touch
Loss of movement, muscle tone, and feeling
Rising body temperature or below-normal temperature
Decreasing blood pressure
Weak pulse that is abnormally slow or rapid
Alternating periods of slow, irregular respirations and rapid, shallow respirations (Cheyne-Stokes)
Rattling or gurgling sound when breathing
Cold, pale skin
Mottling, spotting, or blotching of skin
Perspiration
Incontinence
Disorientation or confusion
These signs may be present for hours or days before death.

10. Changes that may occur in the human body after death
Changes that occur after death
The following changes occur after death:
No heartbeat, pulse, respiration, or blood pressure
Rigor mortis
Eyelids partially open; eyes in fixed stare
Mouth may remain open
Incontinence

11. Postmortem care Postmortem care Postmortem care guidelines
Postmortem care is care of the body after death.
NAs should remember these postmortem care guidelines:
Rigor mortis may make body difficult to move. Talk to the nurse if you need assistance.
Bathe the body gently and place drainage pads where needed.
Do not remove tubes or other equipment.
Put in dentures if instructed by the nurse.
Close eyes.
Position body. Put a small pillow under head.
Follow facility policy on personal items.
Strip the bed after body is gone.
Open windows to air the room. Straighten room.
Respect wishes of family and friends.
Document procedure.
Remember: Facilities may have special policies on postmortem care. NAs must always follow facility policies.

12. Understand different postmortem practices
Common postmortem practices
There is no right way to grieve. NAs and HHAs will see many different responses to a loved one’s death, and their job is to respond professionally. Postmortem practices that the family and/or others perform must be respected.
You may find yourself grieving the loss of a resident. Remember: It is important to check with a supervisor before attending a resident’s or client’s funeral.
Postmortem practices may include the following, depending on the cultural background, religion, and personal preferences of the resident and the resident’s family:
Wake
Viewing
Open casket funeral
Closed casket funeral
Cremation
Burial ceremony
Whether a resident was religious or non-religious, the NA’s job is to respect the family’s customs and choices.

13. Review Discuss the stages of grief Describe the grief process
Discuss how feelings and attitudes about death differ
Discuss how to care for a dying resident
Describe ways to treat dying residents and their families with dignity and how to honor their rights
Define the goals of a hospice program
Explain common signs of approaching death
List changes that may occur in the human body after death
Describe postmortem care
Understand and respect different postmortem practices
In this chapter we discussed the stages of grief and the grieving process. Everyone’s feelings and attitudes may differ about death and therefore grieving will look different from person to person. We discussed how to care for a dying resident and ways to promote dignity and honor for residents and their families throughout the dying process. Goals of hospice care were outlined and common signs of approaching death were explained. Changes that may occur after death and postmortem care were discussed.