1. Death and Dying

2. Objectives The student will:
Explain the stages of death and dying including the philosophy of hospice care

3. Contents Stages of Death and Dying Right to Life Issues
Advance Directives
Living Will
Medical Power of Attorney

4. Terminal Illness
Any disease that cannot be cured and will result in death.
Everyone reacts differently to news of a terminal illness.
Some react with fear and anxiety.
Many fear pain, abandonment, loneliness, and the unknown.
They may become anxious about their loved ones, unfinished work, or dreams.

5. Emotional and Physical Reasons People May Fear Death.
Helplessness
Dependence on others
Physical faculties
Mutilation by surgery or disease
Uncontrollable pain
Being unprepared for death

6. Social Reasons People May Fear Death
Fear of separation from family or home
Fear of leaving behind unfinished tasks or responsibilities

7. Dr. Elizabeth Kubler-Ross
Identified five stages of grieving that dying patients and their families and friends may experience.
They may not be in order and may overlap or repeat a stage at times.
Others may not experience all stages.
Stages include denial, anger, bargaining, depression, and acceptance.

8. Denial Usually occurs when the person is first told of the illness.
Individual’s may say,
“The tests are wrong.”
“This can’t be happening to me.”
“I don’t believe it.”
Others don’t talk about it.
Health care workers should listen without confirming or denying it.

9. Anger This stage occurs when the patient can no longer deny death.
The patient may blame themselves, their loved ones, or health care workers for their illness.
Health care workers must understand this is not a personal attack.

10. Bargaining
Usually occurs when patient accepts death but wants more time to live.
Patients turn to religion and spiritual beliefs during this period.
They want to see their child gradate, get married, or hold a grandchild.
Making promises to God to try and obtain more time sometimes occurs.

11. Depression
This stage occurs when the patient realizes that death will come soon and they won’t be with their families any longer.
They realize that some goals they set will not be met.
Health care workers need to let the patient know that depression is “OK”.

12. Acceptance This is normally the final stage.
The patient understands that they are going to die.
May complete unfinished business and try to help those around them deal with death.
Patients will slowly get farther away from the world and other people.
They need emotional support during this stage.

13. Interventions for Health Care Professionals
Talk as needed
Avoid superficial answers, i.e. “It’s God’s
will.” or “It will be OK.”
Provide religious support as appropriate
Stay with the patient as needed
Work with the family so they might be
strong enough to offer support to the dying person.

14. Physical Changes Of Death

15. Respiratory System
1.Unable to oxygenate the body enough for adequate gas diffusion
2.Respirations become stridorous or noisy, leading to “death rattle”
3. Cheyne-Stokes respiration sign of pulmonary system failure
a. Consists of alternate hyperpneic and apneic phases

16. Cardiovascular System
Heart unable to pump strongly enough to keep blood moving
Decreased blood causes decreased circulation to the body
Skin becomes cool to the touch, pale
Person appears cyanotic, possibly mottled
Failure of peripheral circulation frequently results in a drenching
sweat cooling the body surface.
Pulse becomes weak and thready, ultimately irregular
A stronger pulse typically means death is hours away
A weak, irregular pulse typically means that death is imminent in the next couple of hours.
An apical pulse might be required.

17. Other Changes Metabolism rates decrease.
The person might retain feces or become incontinent.
Urinary output decreases.
Dying person may turn toward light as sight diminishes.
Dying person may hear only what is distinctly spoken.
Dying person may remain consciousness or become unconscious/comatose

18. Other Changes
Some dying people rally in clarity and consciousness just prior to their death
A person’s eyes might be open even if unconscious
Dying people might turn toward or speak to someone who is not visible to anyone else in room
Pain might be present
Pain medication should not be withheld as person nears death.

19. Right to Die
Most people with terminal illness believe that someone with a terminal illness should be allowed to refuse measures that would prolong their life.
This is the right to die.
Respirators, pacemakers, and other medical devices can be withheld and the person can die with dignity.
DNR – Do Not Resuscitate Order

20. DNR
Do Not Resuscitate Order

21. Hospice Care
This philosophy is to allow the patient to die with dignity and comfort.
Pain is controlled so that the patient can remain active as long as possible.
Specially trained volunteers are an important part of many hospice programs.

22. Advance Directives
A general term that describes two types of legal documents.
Living Will
Healthcare (Medical) Power of Attorney

23. Living Will
Allows a person their wishes about medical treatments for the end of life in writing in the event that they cannot communicate those wishes directly.
Different states may use different names.

24. Healthcare Power of Attorney
Also know as a “healthcare proxy,” “ appointment of a healthcare agent,” or “durable power of attorney for healthcare.”
The person you appoint will be authorized to deal with all medical situations when you cannot speak for yourself.