1. 1. Discuss the stages of grief
Define the following terms: terminal illness a disease or condition that will eventually cause death. grief deep distress or sorrow over a loss.

2. Transparency 23-1: Stages of Dying
Denial: “No, not me”
Anger: “Why me?”
Bargaining: “Yes me, but…”
Depression: need to mourn and review their lives
Acceptance: preparing for death

3. 1. Discuss the stages of grief
REMEMBER: Not every person goes through every one of these stages, and not every person goes through them in this order.

4. 2. Describe the grief process
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. 3. Discuss how feelings and attitudes about death differ
These factors can influence feelings and attitudes about death:
Experience with death
Personality type
Religious beliefs
Cultural background

6. 3. Discuss how feelings and attitudes about death differ
Think about this question: How do your own experiences and your cultural background influence your feelings about death?

7. 4. Discuss how to care for a dying resident
Define the following term: advance directives legal documents that allow people to choose what medical care they wish to have if they are unable to make those decisions themselves.

8. 4. Discuss how to care for a dying resident
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

9. 4. Discuss how to care for a dying resident
REMEMBER: Advance directives must be honored. The care team’s personal feelings about them are not relevant.

10. 5. Describe ways to treat dying residents and their families with dignity and how to honor their rights
Think about these questions: How can an NA treat residents with dignity when they are approaching death? Which of the Residents’ Rights may apply when a resident is close to death?

11. Transparency 23-2: 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

12. 5. Describe ways to treat dying residents and their families with dignity and how to honor their rights
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.

13. 5. Describe ways to treat dying residents and their families with dignity and how to honor their rights
Think about these questions: Have you ever cared for someone who did not want more treatment? How did you feel about that?

14. 5. Describe ways to treat dying residents and their families with dignity and how to honor their rights
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.

15. 5. Describe ways to treat dying residents and their families with dignity and how to honor their rights
Think about this question related to a dying resident’s right to privacy: Privacy is a basic right, but why may privacy for visiting be even more important now?

16. Handout 23-1: 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.

17. Handout 23-1: 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. 911.)

18. 5. Describe ways to treat dying residents and their families with dignity and how to honor their rights
Think about this question: Why do you think the rights outlined in The Dying Person’s Bill of Rights are important for a dying person?

19. Transparency 23-3: Ways to Treat Dying People and Their Families with Dignity
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.

20. 6. Define the goals of a hospice program
Define the following terms: hospice care holistic, compassionate care given to dying people and their families. palliative care 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.

21. 6. Define the goals of a hospice program
Think about this question: Why does hospice care focus on meeting physical, emotional, social and spiritual needs rather than on wellness or recovery?

22. 6. Define the goals of a hospice program
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.

23. 6. Define the goals of a hospice program
Think about this question: Are the skills and attitudes needed in providing hospice care any different from those required when caring for other residents?

24. 6. Define the goals of a hospice program
REMEMBER: It is very important that NAs find a productive way to deal with their own feelings when doing hospice work.

25. 7. Explain common signs of approaching death
Define the following term: Cheyne-Stokes respirations alternating periods of slow, irregular breathing and rapid, shallow breathing.

26. Transparency 23-4: 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

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

28. 8. List changes that may occur in the human body 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

29. 9. Describe postmortem care
Define the following term: postmortem care care of the body after death.

30. 9. Describe postmortem care
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.

31. 9. Describe postmortem care
Postmortem care guidelines (cont’d):
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.

32. 9. Describe postmortem care
REMEMBER:
Facilities may have special policies on postmortem care. NAs must always follow facility policies.

33. 9. Describe postmortem care
Think about these questions:
Do you think you would have difficulty touching a dead body?
How can an NA show emotional support to family members after a death?

34. 9. Describe postmortem care
Home Care Focus
REMEMBER:
It is important for an HHA to ask family members of the deceased client what the HHA can do to help. She may answer the phone, make coffee or a meal, supervise children, or keep family members company.

35. 10. Understand and respect different postmortem practices
REMEMBER:
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.

36. 10. Understand and respect different postmortem practices
REMEMBER:
It is important to check with a supervisor before attending a resident’s or client’s funeral.

37. 10. Understand and respect different postmortem practices
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

38. 10. Understand and respect different postmortem practices
REMEMBER:
Whether a resident was religious or non-religious, the NA’s job is to respect the family’s customs and choices.

39. 10. Understand and respect different postmortem practices
Think about this question:
What different postmortem practices (funerals, etc.) have you seen? What is common in your family or culture?

40. Exam Multiple Choice. Choose the correct answer.
Which of the following is an example of a resident who is going through the bargaining stage of the grief process, according to Dr. Kubler-Ross?
(A) The resident makes a new will and tells her family about funeral arrangements.
(B) The resident insists that a mistake was made on her blood tests.
(C) The resident tells her sister that if she lives, she will start volunteering every day at the senior center.
The resident feels sad most of the time and does not want to see anyone.

41. Exam
A terminally ill resident discussed his funeral arrangements with his family. 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. Which stage of dying is this resident in?
(A) Denial
(B) Anger
(C) Bargaining
(D) Acceptance

42. Exam Which of the following statements is true of the grief process?
(A) A family member may be shocked after the death of a loved one, even if she was aware that the person was dying.
(B) All people grieve in the same way, following the same process.
(C) Missing a person who has died is an uncommon response to death.
(D) Feeling angry after a person has died is unhealthy and unnatural.
One factor that influences personal attitudes about death is
(A) A person’s diet
(B) A person’s culture
(C) A person’s weight
(D) A person’s height

43. Exam
When caring for a dying resident’s diminished senses, a nursing assistant should
(A) Ask many questions to see what is comfortable for the resident
(B) Turn on as many lights as possible
(C) Observe body language
(D) Encourage all visitors to remain silent
The last sense to leave the body is usually the sense of
(A) Hearing
(B) Sight
(C) Taste
(D) Touch

44. Exam How can NAs give emotional support to residents who are dying?
(A) By leaving dying residents alone as much as possible
(B) By listening more
(C) By sharing their religious beliefs with residents
(D) By letting residents know that it will all be over soon
One way that NAs can respect the rights of residents who are dying is to
(A) Keep visitors away from residents
(B) Let the family know if the NA does not agree with residents’ medical decisions
(C) Promise residents that they will get better
(D) Promote privacy for residents

45. Exam
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.
Which of the following is true of advance directives?
(A) Advance directives must be honored as long as family members agree with the resident’s decisions.
(B) Advance directives must be honored unless NAs do not agree with the diagnosis.
(C) Advance directives must be honored.
(D) Advance directives should be changed when the resident’s spiritual leader does not agree with the resident’s decision.

46. Exam What does palliative care involve? (A) The resident’s recovery
(B) Pain relief and comfort
(C) Teaching the resident to care for himself
(D) Curing the resident’s illness
An attitude that is helpful in hospice work is
(A) Being sensitive to individual needs
(B) Pushing residents to talk about their feelings
(C) Joining in the conversation during personal visits
(D) Helping the resident embrace the NA’s faith before death

47. Exam Which of the following is a sign of approaching death?
(A) Decreasing blood pressure
(B) Sharper vision
(C) Warm, dry skin
(D) Heightened sense of touch
The NA’s responsibilities regarding postmortem care include
(A) Placing drainage pads where needed
(B) Removing tubes from the dead resident
(C) Removing equipment from the room
(D) Examining the body to help determine the cause of death

48. Exam
_______ is the special care that focuses on the dignity and comfort of a dying person.
(A) Postmortem
(B) Cheyne-Stokes
(C) Hospice
(D) Terminal
Which of the following statements is true?
(A) Most people respond in a vocal and emotional way after a loved one has died.
(B) Dealing with the death of a loved one will take approximately two months.
(C) NAs may grieve for residents after they die.
(D) NAs will be expected to attend residents’ funerals.

49. Exam Burning of a body until it is reduced to ashes is called
(A) Burial
(B) Cremation
(C) Memorial
(D) Eulogy
When a dead person’s body is displayed at a funeral service, it is called a(n) ___________ funeral.
(A) Closed casket
(B) Visible body
(C) Open casket
(D) Urn displayed

50. Exam
A watch over a dead body before burial that often involves singing, eating, drinking, and storytelling is called a
(A) Viewing
(B) Wake
(C) Burial
(D) Eulogy

51. CHAPTER 23 PRACTICE
1. The last sense to leave the body is usually the sense of
(A) Hearing
(B) Sight
(C) Taste
Touch
2. 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.
3. A watch over a dead body before burial that often involves singing, eating, drinking, and storytelling is called a
(A) Viewing
(B) Wake
(C) Burial
(D) Eulogy

52. CHAPTER 23 PRACTICE ANSWERS
A-HEARING
C-I HAVE THE RIGHT TO MY QUESTIONS ANSWERED HONESTLY
B- WAKE