1. DEATH AND DYING Emotional and Physiologic Elements of Death and Dying

2. EMOTIONAL TRANSITIONS AT LIFE’S END Although there are many theories about the emotional transitions encountered by dying people, the best known is.....

3. ELISABETH KUBLER-ROSS Landmark work entitled On Death and Dying Identified five emotional stages experienced by dying individuals

4. FIVE EMOTIONAL STAGES Denial - or “no not me” Anger - or “why me?” Bargaining - or “Yes, but...” Depression - or “It’s me!” Acceptance - or “It’s part of life. I have to get my life in order.”

5. DEATH CAN INVOLVE FEARS THAT ARE PHYSICAL, SOCIAL, AND EMOTIONAL PHYSICAL - Helplessness, dependence, loss of physical faculties, mutilation, pain SOCIAL - Separation from family, leaving behind unfinished business EMOTIONAL - Being unprepared for death and what happens after death

6. INTERVENTIONS FOR FEARS Talk as needed Avoid superficial answers, i.e. “It’s God’s will Provide religious support as appropriate Stay with the patient as needed Work with families to strengthen and support

7. PHYSIOLOGY OF DYING Somatic death or death of the body Series of irreversible events leading to cell death Causes of death varies However, there are basic body changes leading to all deaths

8. THESE BASIC BODY CHANGES RESULT IN THE DEATH OF ALL VITAL BODY SYSTEMS PULMONARY: Unable to oxygenate the body Assess for poor oxygenation-skin pale, cyanotic, mottled, cool in dark skinned - assess mucous membranes, palms of hands, soles of feet

9. CARDIOVASCULAR Large load on heart when lungs fail Heart not getting needed oxygen Pumping heart not strong enough to circulate blood Blood backs up causing failure Leads to pulmonary and liver congestion

10. BLOOD CIRCULATION Decreased, as heart less able to pump May have a “drenching sweat” as death approaches Radial Pulse becomes weak and irregular. (demonstrate palpation) It may become necessary to check apical pulse. If pulse relatively strong, death is hours away If pulse is weak and irregular, death is imminent

11. Respiratory Failure As the heart begins to fail, levels of CO2 begin to build up in the body The body attempts to expel the excess CO2 by a pattern of breathing known as Cheyne Stokes respirations This pattern consists of cycle of progressive hyperventilation, followed by periods of apnea ( demonstrate) The carbon dioxide levels fluctuate.

12. COMBINATION OF THESE EVENTS LEADS TO CELL DEATH, AND DEATH OF THE ORGANISM (HUMAN) As pulmonary and cardiovascular systems fail, other body systems begin to fail, also

13. FAILING METABOLISM Metabolic rate decreases, almost stopping Feces might be retained or incontinence might be present

14. FAILING URINARY SYSTEM Urinary output decreases Blood pressure too low for kidney filtration Further load on cardiovascular system due to increase circulating volume

15. FAILING NERVOUS SYSTEM Decrease oxygen to the brain, means decreasing brain function Sensation and power lost in legs, first, then arms May remain conscious, semi- conscious, or comatose

16. SPECIFIC SENSORY DECLINE Dying person turns toward light - sees only what is near Can only hear what is distinctly spoken Touch is diminished - response to pressure last to leave Dying person might turn toward or speak to someone not visible to anyone else Eyes may remain open even if unconscious Person might rally just before dying

17. FURTHER NEUROLOGIC DECLINE AT DEATH Pupils might react sluggishly or not at all to light Pain might be significant Assess for pain if person unable to talk: restlessness, tight muscles, facial expressions, frowns Provide pain medication as needed

18. NEVER LOSE SIGHT... Death is the end, as we know it, for that person We can only support, listen therapeutically, and Make the person as physically comfortable as possible We can also use our knowledge and expertise to strengthen, support, and prepare the family

19. Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 19 Caring for the Dying Patient Very challenging, but rewarding work Supportive care Health care worker must have self- awareness Common to want to avoid feelings by avoiding dying patient

20. Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 20 Hospice Care Palliative care only Often in patient’s home Philosophy: allow patient to die with dignity and comfort Personal care Volunteers After death contact and services

21. Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 21 Right to Die Ethical issues must be addressed by the health care worker Laws allowing “right to die” Under these laws specific actions to end life cannot be taken Hospice encourages LIVE promise Dying Person’s Bill of Rights

22. Copyright © 2004 by Thomson Delmar Learning. ALL RIGHTS RESERVED. 22 Summary Death is a part of life Health care workers must understand death and dying process and think about needs of dying patients Then health care workers will be able to provide the special care these individuals need