1. 1. Define important words in this chapter
anticipatory grief a period of mourning when the dying person or his family is expecting the death. autopsy an examination of a body by a pathologist to try to determine the cause of death. bereavement the period following a loss in which mourning occurs. complicated grief intense, long-lasting grief that does not seem to improve even after time has passed.

2. 1. Define important words in this chapter
cremation the process of burning a dead body until it turns to ash. death the end of life; the cessation of all body functions. grief a deeply emotional process that is a response to loss. grief counseling therapy to try to help a person cope after someone has died. grief process the varying emotional responses to grief.

3. 1. Define important words in this chapter
mourning the period in which people work to adapt to a loss; influenced by culture, tradition, and society. palliative care care that focuses on pain relief, controlling symptoms, preventing side effects and complications, and maintaining quality of life for a person who is very ill and/or is dying. pathologist a doctor with advanced training in the examination of organs and tissues.

4. 1. Define important words in this chapter
postmortem care care of the body after death. rigor mortis the Latin term for the condition after death in which the muscles in the body become stiff and rigid. terminal illness a disease or condition that will eventually cause death.

5. 2. Describe palliative care
Define the following term: palliative care care that focuses on pain relief, controlling symptoms, preventing side effects and complications, and maintaining quality of life for a person who is very ill and/or is dying.

6. 2. Describe palliative care
Understand the goals of palliative care:
Control symptoms
Reduce suffering
Prevent side effects
Maintain quality of life
Emphasize holistic approach

7. 2. Describe palliative care
REMEMBER:
Palliative care works to manage symptoms, not cure the disease.

8. 3. Discuss hospice care
Define the following terms: terminal illness a disease or condition that will eventually cause death. death the end of life; the cessation of all body functions.

9. 3. Discuss hospice care
REMEMBER:
When a serious illness is classified as a terminal illness, or a disease or condition that will eventually cause death, hospice care is often the next step.
This type of care is a compassionate way to care for dying people and their families. Hospice care uses a holistic approach.

10. 3. Discuss hospice care
Remember these points about and goals of hospice care:
Ordered by a doctor for a person who has six months or less to live
Can be given in a hospital, care facility, or in the home
Uses a holistic approach
Focuses on resident and family as a unit
Offers medically-directed, team-managed care
Offers compassionate care

11. 3. Discuss hospice care
Points about and goals of hospice care (cont'd):
Focuses on soothing and comfort care, rather than curative care
Emphasizes pain and symptom management
Provides alternative to traditional care
Helps family obtain financial counseling and legal assistance
Offers assistance for psychosocial needs

12. 3. Discuss hospice care
REMEMBER:
An NA should report complaints of pain or signs of pain immediately.

13. 3. Discuss hospice care
Think about this question: Why is it important that residents who are dying have control over their lives for as long as they are able?

14. 4. Discuss the grief process and related terms
Define the following term: grief a deeply emotional process that is a response to loss.

15. 4. Discuss the grief process and related terms
Understand Dr. Elisabeth Kübler-Ross’s five stages of grief (On Death and Dying):
Denial: refusal to believe they are dying
Anger: “Why me?”
Bargaining: “Yes me, but…”
Depression: need to mourn and review their lives
Acceptance: preparing for death

16. 4. Discuss the grief process and related terms
REMEMBER:
Not every resident goes through all of these stages or goes through them in this order.

17. 4. Discuss the grief process and related terms
Define the following terms: anticipatory grief a period of mourning when the dying person or his family is expecting the death. bereavement the period following a loss in which mourning occurs. complicated grief intense, long-lasting grief that does not seem to improve even after time has passed. grief process the varying emotional responses to grief.

18. 4. Discuss the grief process and related terms
Define the following terms: grief counseling therapy to try to resolve problems due to separation from the deceased. mourning the period in which people work to adapt to a loss; influenced by culture, tradition, and society.

19. 5. Explain legal rights for a resident who is dying
REMEMBER: When a person is dying, there are legal rights that must be respected. Remembering these rights will help you provide proper care, as well as promote the dying person’s dignity.

20. Transparency 27-1: Rights to Remember When Caring for the Terminally Ill
The right to have visitors
The right to privacy
The right to be free from pain
The right to honest and accurate information
The right to refuse treatment

21. 5. Explain legal rights for a resident who is dying
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 don’t seem to be aware of their surroundings.
Only report a visitor if he is disruptive or he becomes a threat.

22. 5. Explain legal rights for a resident who is dying
The right to privacy
Privacy is a basic right, but why may privacy for visiting be even more important now?
The right to be free from pain
It is very important to monitor dying residents for signs that they are in pain. If they can no longer speak, how else can you tell if a resident may be in pain?

23. 5. Explain legal rights for a resident who is dying
The right to honest and accurate information
Residents have the right to honest information about what is happening and what their diagnosis is. Refer medical questions that are outside your scope of practice to the nurse.

24. 5. Explain legal rights for a resident who is dying
The right to refuse treatment
Have you ever cared for someone who did not want more treatment? How did you feel about that?
We need to remember that whether we agree or disagree with the decisions, the choice is not ours, but belongs to the person involved.
Sometimes, when residents are not capable of making a decision, they have told their family how they wish things to be done. Be supportive of family members; do not judge them. They are probably following the person’s wishes.

25. Handout 27-1: The Dying Person’s Bill of Rights
I have the right to:
be treated as a living human being until I die.
maintain a sense of hopefulness, however changing its focus may be.
be cared for by those who can maintain a sense of hopefulness, however changing this may be.
express my feelings and emotions about my approaching death in my own way.
participate in decisions concerning my care.
expect continuing medical and nursing attentions even though “cure” goals must be changed to “comfort” goals.
not die alone.
be free from pain.
have my questions answered honestly.
not be deceived.

26. Handout 27-1: The Dying Person’s Bill of Rights (cont'd)
I have the right to:
have help from and for my family in accepting my death.
die in peace and dignity.
retain my individuality and not be judged for my decisions which may be contrary to beliefs of others.
discuss and enlarge my religious and/or spiritual experiences, whatever these may mean to others.
expect that the sanctity of the human body will be respected after death.
be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death.
(This was created at a workshop on The Terminally Ill Patient and the Helping Person, sponsored by  Southwestern Michigan In-service Education Council, and appeared in the American Journal of Nursing, Vol. 75, January, 1975, p. 99.)

27. 5. Explain legal rights for a resident who is dying
Think about this question: Why are these rights important for the dying person?

28. 6. Explain how to care for a resident who is dying
Remember these guidelines for care of the dying resident:
Skin, Nose and Mouth care
Give frequent skin care.
Bathe often.
Change gowns and sheets often.
Give incontinence care promptly.
Turn and reposition often.
Give oral care frequently.
Offer ice chips.
Use lubricant on nose and mouth.

29. 6. Explain how to care for a resident who is dying
Guidelines for care of the dying resident (cont'd):
Breathing Problems
Report gurgling or rattling.
Elevate the head of the bed and change positions as ordered.

30. 6. Explain how to care for a resident who is dying
Guidelines for care of the dying resident (cont'd):
Food and Fluid Issues
Feed residents slowly.
Encourage fluids.
Do not force residents to eat or drink.
Report nausea, vomiting and diarrhea.
Elevate head of bed.

31. 6. Explain how to care for a resident who is dying
Guidelines for care of the dying resident (cont'd):
Pain Control and Comfort
Pain relief is critical.
Observe and report signs of pain.
Adjust blankets for temperature changes.

32. 6. Explain how to care for a resident who is dying
Guidelines for care of the dying resident (cont'd):
Diminished Senses
Keep room softly lit.
Use alternate forms of communication.
Speak normally and describe care that is being performed.

33. 7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs
Define the following term: cremation the process of burning a dead body until it turns to ash.

34. 7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs
Know the factors that influence feelings and attitudes about death:
Experience with death
Personality type
Religious beliefs
Cultural background

35. 7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs
REMEMBER: It is important to honor individual practices and traditions without judging them.

36. 7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs
Think about this question: Are there practices or traditions regarding death that are different from your own that bother you? Think about why this may be and what you can do to address this.

37. 7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs
Remember these guidelines for understanding the psychosocial and spiritual needs of dying residents:
Listen more; talk less.
Provide privacy for visits.
Notify the nurse if resident requests visit from spiritual leader.
Do not discuss personal religious beliefs or try to change resident’s beliefs.
Do not judge.
Never share anything private with others, except for the nurse.
Inform the nurse if resident has expressed fear of dying.

38. Transparency 27-2: Signs of Approaching Death
Cyanotic, pale, or darkening skin or mucous membranes
Cold skin
Skin that looks bruised (mottling)
Heavy perspiration
Fever
Low blood pressure
Increased pulse
Cheyne-Stokes breathing
Gurgling and rattling sound when breathing
Difficulty swallowing
Decreased appetite and sense of thirst
Dry mouth
Nausea, vomiting, and diarrhea
Decreased sense of touch

39. Transparency 27-2: Signs of Approaching Death (cont'd)
Loss of feeling, beginning in the legs and feet
Extreme weakness and exhaustion
Loss of muscle tone
Fallen jaw, causing the mouth to stay open
Inability to speak
Loss of vision
Dilated pupils and staring eyes
Urinary and fecal incontinence
Decreased urinary output
Hallucinations
Extreme drowsiness
Disorientation or confusion
Loss of hearing

40. 9. List changes that may occur in the human body after death
Remember these points about the body after death:
No pulse, respiration, or blood pressure
Eyelids partially open
Fixed and dilated pupils
Jaw drops
Urinary and fecal incontinence

41. 9. List changes that may occur in the human body after death
Define the following term: rigor mortis the Latin term for the condition after death in which the muscles in the body become stiff and rigid.

42. 9. List changes that may occur in the human body after death
These Latin terms describe changes in the body after death:
Algor mortis is the cooling of the body after death and the decrease in elasticity of the skin.
Livor mortis is skin discoloration after death in the dependent areas of the body, such as the feet and legs.
Rigor mortis is the stiffness that occurs after death due to a biochemical change that causes muscles to become rigid.

43. 10. Describe ways to help family and friends deal with a resident’s death
Understand some of the feelings that family and friends may experience after a loved one dies:
Feeling numb or being in shock
Disbelief or denial of the death
Intense sadness and crying
Anxiety or fear
Anger

44. 10. Describe ways to help family and friends deal with a resident’s death
Feelings that family and friends may experience after a loved one dies (cont'd):
Physical reactions or symptoms, such as pain, especially chest pain, nausea, or difficulty breathing
Feelings of guilt, especially if there were any unresolved problems or issues with the relationship
Feelings of relief

45. 10. Describe ways to help family and friends deal with a resident’s death
REMEMBER: Family may direct anger at staff members. They may just be reacting to the loss of a loved one. They may blame staff for a problem that they feel was not addressed. Whatever the reason, refer any family complaints to the nurse. Do not try to calm a family member or friend who is upset with staff.

46. 10. Describe ways to help family and friends deal with a resident’s death
Think about this question: Why is it important to allow the family and friends of someone who has died to express their feelings?

47. 10. Describe ways to help family and friends deal with a resident’s death
Remember these guidelines for helping families and friends:
Allow the family to show their feelings.
Be available. Listen when they want to talk.
Do not be afraid to show your feelings.
Do not make inappropriate comments or use clichés.
Report requests for spiritual leaders to the nurse.

48. 11. Describe ways to help staff members cope with a resident’s death
REMEMBER: You have a right to experience strong feelings when a resident dies. Being able to grieve is important. Do not underestimate your own feelings, and do not hesitate to seek out counseling or bereavement therapy if needed.

49. 11. Describe ways to help staff members cope with a resident’s death
Understand the ways that staff can cope with a resident’s death:
Express your feelings—they are normal.
Getting enough sleep, eating nutritious meals, drinking only in moderation, and not smoking
Participating in enjoyable activities and exercising regularly
Spending quality time with people they love
Sharing memories
Joining a support group
Talking to a counselor

50. 12. Describe postmortem care
Define the following terms: postmortem care care of the body after death. autopsy an examination of a body by a pathologist to try to determine the cause of death. pathologist a doctor with advanced training in the examination of organs and tissues.

51. 12. Describe postmortem care
REMEMBER: Before performing postmortem care, be sensitive to the needs of family and friends after death occurs. They may wish to stay with the body for a while. Allow them time to do so. If an autopsy is going to be performed by a pathologist to determine the cause of death, the person may need to be transferred to another facility.

52. 12. Describe postmortem care
REMEMBER: Be aware of religious or cultural practices that the family wants to observe.

53. Provide for privacy with a curtain, screen, or door.
Postmortem care
Equipment: two pairs of gloves, drainage pads, shroud kit or sheets, clean gown, washcloth or wipes, wash basin of warm water, mils soap, towel
Identify the resident.
Wash your hands
Explain procedure to resident’s family and ask them to step outside. Be courteous, respectful, and compassionate at all times.
Provide for privacy with a curtain, screen, or door.
5. Adjust bed to safe working level, usually waist high. Lock bed wheels.
6. Avoid trauma to the resident’s body throughout the procedure. Treat the body with the utmost respect.
7. Put on gloves.

54. 9. Gently close resident’s eyes without pressure.
Postmortem care
8. Turn off any oxygen, suction, or other equipment if directed by the nurse. Do not remove any tubes or other equipment. A nurse or the funeral home will perform these tasks.
9. Gently close resident’s eyes without pressure.
10. Position the body in good alignment, on the back with legs straight. Fold arms across the abdomen. It is important to position the body before rigor mortis occurs, as it will make positioning difficult. The period from two to four hours after death is most common for the development of rigor mortis.
Close the mouth. Place a rolled towel under the chin.
12. Gently bathe the body using mild soap (or solution as directed). Be careful to avoid bruising. Replace any dressings only if directed to do so.

55. 13. Comb or brush hair gently without tugging.
Postmortem care
13. Comb or brush hair gently without tugging.
14. Place drainage pads where needed. Most often this is under the head and/or under the perineal area and buttocks.
Put a clean gown on the body.
16. Cover the body to just over the shoulders with sheet. Do not cover face or head.
17. Tidy the room so family may visit.
18. Remove all used supplies and linen.
Follow your facility’s policy for handling or removing personal items.
Remove and discard gloves.
Wash your hands.
22. Return bed to low position if raised. Turn lights down and allow family to enter and spend private time with resident.

56. 23. Return after family departs and put on clean gloves.
Postmortem care
23. Return after family departs and put on clean gloves.
24. Place shroud on resident and follow instructions on completing ID tags.
Remove and discard gloves.
26. Wash your hands.
27. Report and record observations. Document procedure using facility guidelines.

57. 12. Describe postmortem care
Think about these questions: What feelings do you have about providing postmortem care? Do you think you would have trouble touching a dead body?

58. Exam 1
Multiple Choice. Choose the correct answer. 1. What does palliative care involve? (A) The resident’s recovery (B) Comfort and managing symptoms (C) Teaching the resident to care for himself (D) Curing the resident’s illness 2. When is hospice care usually ordered by a doctor? (A) When a diagnosis of a terminal illness is made (B) When the long-term care facility can no longer care for the resident (C) When the resident requests it (D) When a person has six months or less to live

59. Exam 1 (cont'd)
3. Ms. Fleming, a resident who has recently been diagnosed with terminal cancer, has accused the nursing assistants in her unit of taking poor care of her and causing her disease. I what stage of grief is Ms. Fleming? (A) Denial (B) Anger (C) Bargaining (D) Depression 4. Mr. Parker has always been cheerful and optimistic, but since his diagnosis of Alzheimer’s disease, he has been quiet and withdrawn. He does not seem to enjoy any of his favorite activities and rarely talks to anyone. Which stage of grief is Mr. Parker in? (A) Depression (B) Bargaining (C) Denial (D) Acceptance

60. Exam 1 (cont'd)
5. Mrs. Levine, a resident, prays about her terminal illness. She promises God that she will make peace with her sister, whom she has not seen in 20 years, if she is allowed to live. Which stage of grief is Mrs. Levine going through? (A) Denial (B) Anger (C) Bargaining (D) Acceptance 6. A terminally ill resident, John Castillo, visits with his family. He discusses his funeral arrangements with them. He lets them know that he is concerned about their well-being after he is gone. He says he wants to spend as much time as possible with them before he dies. Mr. Castillo is going through the ________ stage of grief.

61. Exam 1 (cont'd)
7. Which of the following is part of The Dying Person’s Bill of Rights? (A) I have the right to be told what to believe about life after death. (B) I have the right to be cared for by someone who will always tell me what she thinks I want to hear. (C) I have the right to have my questions answered honestly. (D) I have the right to be treated with forced cheerfulness. 8. Which of the following is true of a resident who is dying? (A) Residents will always be able to tell you when they are in pain. (B) The room of a dying resident should be brightly lit. (C) Residents should lie flat on their backs to ease problems with breathing. (D) Residents should be fed slowly to help prevent choking and aspiration.

62. Exam 1 (cont'd)
9. Which is the last sense to leave a person? (A) Sight (B) Hearing (C) Touch (D) Smell 10. One way for nursing assistants to help meet the psychosocial and spiritual needs of a dying resident is to (A) Leave the resident alone as much as possible (B) Listen more, talk less (C) Share their religious beliefs with the resident (D) Tell the resident’s family things that the resident has told her about them

63. Exam 1 (cont'd)
11. Which of the following is a sign of approaching death? (A) Low blood pressure (B) Sharper vision (C) Warm, dry skin (D) Heightened sense of touch 12. One change that might occur in the body after death is (A) The mouth closes (B) The body will not have a pulse, respiration, or blood pressure (C) The eyes close (D) The pupils constrict

64. Exam 1 (cont'd)
13. Nursing assistants can help a resident’s family and friends deal with the resident’s death by: (A) Trying to calm any family members or friends who are upset with staff (B) Asking them not to cry and reassuring them that they will get over it (C) Listening to them if they want to talk (D) Not showing any feelings for the resident who has died 14. Postmortem care is (A) Examination of a body by a pathologist to try to determine the cause of death (B) Meeting the emotional needs of the resident’s family and friends (C) Grief counseling for staff after a resident’s death (D) Care of the body after death

65. Exam 1 (cont'd)
13. Nursing assistants can help a resident’s family and friends deal with the resident’s death by: (A) Trying to calm any family members or friends who are upset with staff (B) Asking them not to cry and reassuring them that they will get over it (C) Listening to them if they want to talk (D) Not showing any feelings for the resident who has died 14. Postmortem care is (A) Examination of a body by a pathologist to try to determine the cause of death (B) Meeting the emotional needs of the resident’s family and friends (C) Grief counseling for staff after a resident’s death (D) Care of the body after death

66. Exam 2
Multiple Choice. Choose the correct answer. 1. The term _______________ means an examination by a pathologist to determine cause of death. (A) Atrophy (B) Anatomy (C) Autopsy (D) Avulsion 2. What is the period of time following a loss in which mourning occurs? (A) Breakthrough (B) Burnout (C) Bereavement (D) Blackout

67. Exam 2 (cont’d)
3. A guideline for skin, nose, and mouth care that the nursing assistant should provide for a dying resident is (A) Change the resident’s gown weekly (B) Offer ice chips to keep the mouth moist (C) Avoid using room humidifiers (D) Pour mouthwash into the resident’s mouth 4. A period of mourning in which the dying person or the family is expecting death is called (A) Reactive grief (B) Emotional grief (C) Anticipatory grief (D) Actualized grief

68. Exam 2 (cont’d)
5. The stage of dying in which the person feels “no, not me” is the __________ stage. (A) Anger (B) Bargaining (C) Depression (D) Denial 6. What is one thing that a caregiver may see happen to the body following death? (A) Low blood pressure (B) High fever (C) Jaw dropping (D) Perspiration

69. Exam 2 (cont’d)
7. Postmortem care includes (A) Covering the body completely (B) Propping the eyes open (C) Positioning the body in proper alignment (D) Leaving on the oxygen 8. The Latin term for the cooling of the body after death is (A) Rigor mortis (B) Algor mortis (C) Livor mortis (D) Algae mortis

70. Exam 2 (cont’d)
9. The stage of dying in which a person prepares for death is identified as (A) Bargaining (B) Depression (C) Denial (D) Acceptance 10. The process of burning a dead body until it turns to ash is (A) Cremation (B) Libation (C) Pronation (D) Expiration

71. Exam 2 (cont’d)
11. What is one way a nursing assistant can help a family respond to the death of a loved one? (A) Influencing the family with the NA’s religion (B) Promptly reporting a request for a clergy visit (C) Isolating the family and friends (D) Judging past behavior to make the family feel better 12. The dying person’s right to be free from pain includes (A) Being given pain medication when needed (B) Ignoring a request from the family for pain pills (C) Advising the person that pain medication is not needed (D) Telling the person they are asking for pain medication too often

72. Exam 2 (cont’d)
13. The stage of dying in which a person believes “yes me, but…..” is called (A) Depression (B) Denial (C) Acceptance (D) Bargaining 14. A type of illness that will eventually cause death is known as a (A) Marginal illness (B) Palliative illness (C) Terminal illness (D) Complicated illness

73. Exam 2 (cont’d)
15. When caring for a dying resident, the nursing assistant should (A) Keep the room light, bright, and sunny (B) Be aware that the sense of hearing is the last to leave (C) Speak loudly so the resident can hear her (D) Press the resident for answers to her questions 16. Signs of approaching death include (A) Dry, rashy skin (B) High blood pressure (C) Increased urinary output (D) Dilated pupils