1 Dying and death HAIVN Havard Medical School AIDS Initiative in Vietnam

2 By the end of this session, participants should be able to : Review the five (5) emotional stages of death and dying Discuss five (5) things that can help ease the dying process Describe the course of physical death Provide physical care for dying patients Support patient’s family members and others to complete 4 specific tasks at the funeral Learning objectives

3 The stages might not occur in exact order Patients can move back and forth between stages Patient’s family might experience similar stages Patient and his/her family members may be in different stages, which can make interactions difficult 5 stages of dying

4 Patients: DON’T believe that they are dying DON’T want to hear the prognosis about their remaining time For Example: “Not me” “Not now” Denial stage

5 Patients will be very angry and feel that it’s not fair for them to die before other people It’s very difficulte to communicate with patients at this stage For example: “Why me?” “I am not ready for this yet” Anger stage

6 Patients will try their best to bargain For example: “I will be nice, very nice if you let me live until my son grows up” “I will never use drugs again if you give me a chance to fix this” Bargaining stage

7 Sense death is impending Think about everyone and everything that will happen after: Loss of control: cannot take care of themselves Loss of mental competency: cannot work much longer Loss of family and friends Might isolate themselves and avoid seeing people Feel hopeless / depressed Depression stage

8 Not all patients go through this stage Patients are sad but accept that their life will end Sort out assets and clarify remaining tasks for the person who will accepted fiscal responsibility Say “goodbye” to their family and close friends Acceptance stage

9 Avoid mentioning death when communicating with patients and their families Don’t make patient’s family upset Prepare to answer patient’s questions: What will happen to my body when I die? What are some signs of dying? Will it hurt? Taking care of dying patients (1)

10 Support patients and their families: Comfort, encourage them to reduce / alleviate their concerns Patients might be concerned about what will happen to their families after they die Help patients select desired / appropriate setting: At home or at hospital Determine who will be at patient’s bedside during dying process Taking care of dying patients (2)

11 Patients often desire to: 1. Apologize for what they have done wrong in their lives 2. Ask for forgiveness from their family & friends 3. Forgive other people for what those people have done wrong to patient 4. Thank their family and friends 5. Say their goodbyes Resting in peace: 5 things that help patients reconcile and obtain closure

12 Nurses need to be aware that it’s not easy for patients to complete the 5 tasks listed previously Nurses can help them to have a peaceful death by: Encouraging them to think about life Helping them communicate with their family and friends: Directly Via mail / Via videos Support from nurses to help patients have a peaceful death

13 Death due to illness is a process, in which physical changes will happen over a period of time Usually, the body will become weaker and weaker and then stop functioning Process of physical death of patients (1)

14 Reduce their food and drink intake Don’t feel hungry or thirsty much Become weaker and reduce their physical movement Might not be able to voluntarily control urination and defecation Experience changes in resting and sleeping habits Wake up at midnight and sleep during the day Process of physical death of patients (2)

15 Pay less attention to surrounding, environment May describe odd feelings / sensations / visions Visits from relative(s) who are deceased May experience alterations in senses: Reduced vision, sensation in feet Retained sounds in ears for longer periods May experience changes in breathing: Breathing might become more rapid and shallow Occurrence of cessations during breathing (apneas) increases Process of physical death of patients (3)

16 More difficult to arouse/ wake patient up Might need a few seconds When awakened, patient might not talk Patients “stare blankly into space” Patients experience visual hallucinations Signs that death is near…(1)

17 Hands & feet are cold to touch and become pale in color Eyes and mouth remain ajar Heart rate can be rapid and peripheral veins are weak Lower jaw drops down Increased frequency of apneas Signs that death is near…(2)

18 Dying cannot be stopped Goal of care during this time is to help patients and their families feel more comfortable and at ease with process Treatment process during dying stage is not acute treatment but more palliative in nature Discuss with family what will occur Physical care for dying patients (1)

19 Do not try to force food or drink on the patient Losing appetite is common for dying patients Keep mouth wet / moist Evaluate frequency of pain and provide pain medications regularly Physical care for dying patients (2)

20 Continue taking good care: Keep patients clean and dry Change bed sheets regularly Change posture for patients regularly Oral care Keep eyes wet Create personal space for patients and their families Physical care for dying patients (3)

21 Taking care of dying patients and their families is an emotional challenge: Nurses can feel loss and sadness when patients die Expressing feelings is important, therefore it is necessary to provide: Support for nurses and have group discussion(s) Personal counseling When taking care of dying patients…

22 Completion of 4 missions of the farewell is a part of caring These missions: Need to happen in order Can be applied for any loss or grief Four missions of the “farewell” (1)

Accept loss Mission 1 Overcome feelings relating to loss (sadness, depression, anger, etc.) Mission 2 Make necessary changes to move on Mission 3 Establish new relationships Mission 4 Four missions of the “farewell” (2)

24 Taking good care of dying patients physically and mentally is very helpful for patients and their families Nurses, when taking care of dying patients and suffering from loss, need to have emotional support Providers can assist patients’ families to complete 4 missions of the farewell Key points

25 Thank you! Questions?