1. Define the following term:
Terminal illness
a disease or condition that will eventually cause death.

2. 1. Discuss the stages of grief
REMEMBER:
Not every resident goes through all of the stages of grief, nor do they necessarily go through them in this order.

3. Transparency 23-1: Stages of Grief
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

4. 2. Describe the grief process
These are seven common reactions to the death of a loved one.
Shock: especially at our own feelings
Denial: usually lasts a short time
Anger: at God, the doctors, even at the person who died
Guilt: that we are still alive
Regret: for what we did or did not do
Sadness: depression, headaches, or insomnia
Loneliness: missing the person and painful memories

5. 3. Discuss how feelings and attitudes about death differ
The following factors may 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 have your background and experiences affected your attitudes about death?

7. 4. Discuss how to care for a dying resident
Remember these guidelines when caring for a dying resident:
Be aware of diminished senses and help keep resident comfortable
Provide attentive care of mouth and nose
Provide good skin care
Physical comfort is very important - observe carefully for signs of pain
Help make the environment soothing and pleasant
Remember that emotional and spiritual support are essential at this time

8. 4. Discuss how to care for a dying resident
Think about these questions:
How can you treat residents with dignity when they are approaching death?
Which of the residents’ rights may apply when a resident is close to death?

9. 4. Discuss how to care for a dying resident
REMEMBER:
Advance directives must be honored and the residents’ decisions regarding advance directives must be respected.

10. 5. Describe ways to treat dying residents and their families with dignity and honor their rights
REMEMBER:
You can treat residents with dignity as they are approaching death by respecting their rights and their preferences (see Handout 23-1, “The Dying Person’s Bill of Rights”).

11. Transparency 23-2: Rights to Remember When Caring for the Terminally Ill
The right to refuse treatment.
The right to have visitors.
The right to privacy.

12. 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 be especially cheerful or sad.
Keep the resident comfortable.
Assure privacy when they want it.
Respect the privacy of the family and other visitors.
Help with the family’s physical comfort.

13. Define the following term:
Palliative care
care that focuses on the comfort and dignity of the person rather than on curing him or her.

14. 6. Define the goals of a hospice program
Hospice care and palliative care have the following goals:
Comfort of resident
Dignity of resident

15. 6. Define the goals of a hospice program
Think about this question:
Hospice works to meet the resident’s physical, emotional, social, and spiritual needs. Why is the focus not on wellness or recovery?

16. 6. Define the goals of a hospice program
The following skills and attitudes are useful in a hospice setting:
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.

17. 6. Define the goals of a hospice program
Think about these questions:
Are the skills and attitudes listed on the previous slide any different than those required when caring for other residents?
How can NAs deal with their own feelings when doing hospice work? Would a hospice NA support group be a good idea?

18. Define the following term:
Cheyne-Stokes respirations
slow, irregular respirations or rapid, shallow respirations.

19. 7. Explain common signs of approaching death
REMEMBER:
Death can be sudden or gradual, but physical signs often occur that can indicate approaching death.

20. Transparency 23-4: Signs of Approaching Death
Blurred vision that gradually fails
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
Slow, irregular respirations or rapid, shallow respirations
“Rattling” or “gurgling” sound when breathing
Cold, pale skin
Mottling, spotting, or blotching of skin caused by poor circulation
Perspiration
Incontinence
Disorientation or confusion

21. 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.

22. 8. List changes that may occur in the human body after death
The following changes occur in the body after death:
No heartbeat, pulse, respiration, or blood pressure
Rigor mortis
Eyelids partially open; eyes in fixed stare
Mouth may remain open
Incontinence

23. 8. List changes that may occur in the human body after death
REMEMBER:
Although these changes are a normal part of death, it is also normal to find them frightening. Tell the nurse immediately to help confirm the death.

24. Define the following term:
Postmortem care
care of the body after death.

25. 9. Describe postmortem care
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.
Place drainage pads.
Do not remove tubes or other equipment.
Put in dentures if instructed by the nurse.

26. 9. Describe postmortem care
Postmortem care guidelines (cont’d.):
Close eyes.
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.

27. 9. Describe postmortem care
REMEMBER:
Facilities may have special policies on postmortem care. Know and follow your facility’s policy.

28. 9. Describe postmortem care
Think about these questions:
How do you think you will feel about providing postmortem care? Do you think you find it difficult to touch a dead body?
How can they show emotional support to the resident who is dying? To family members after the death?

29. 9. Describe postmortem care
REMEMBER:
In home care it is important to ask the family members of a client who has died what you can to do help. You may answer the phone, make coffee or a meal, supervise children or keep family members company.

30. Chapter Exam
1. Which of the following is part of “The Dying Person’s Bill of Rights?” I have the right to
(A) Be told what to believe about life after death
(B) Be cared for by someone who will always tell me what she thinks I want to hear
(C) Have my questions answered honestly
(D) Be treated with forced cheerfulness
2. 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 dying is Mrs. Levine going through?
(A) Denial
(B) Anger
(C) Bargaining
(D) Acceptance

31. Chapter Exam (cont’d.)
3. 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 dying.
(A) Denial
(B) Anger
(C) Bargaining
(D) Acceptance
4. Which of the following statements is true of the grief process?
(A) All family members and friends grieve in the same way.
(B) A person may be angry after a loved one dies.
(C) Everyone will go through every stage of the grief process.
(D) A person is rarely depressed after a loved one dies.

32. Chapter Exam (cont’d.)
5. A factor that influences attitudes about death is
(A) A person’s dietary habits
(B) Whether a person has had the measles
(C) How often a person reads the newspaper
(D) A person’s religious beliefs
6. 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

33. Chapter Exam (cont’d.)
7. When caring for a dying resident’s diminished senses a nursing assistant should
(A) Turn the lights up
(B) Try not to speak to the resident
(C) Turn up the radio or television
(D) Observe body language
8. To treat dying residents and their families with dignity a nursing assistant should
(A) Make promises
(B) Listen if they want to talk
(C) Babble
(D) Isolate the dying resident

34. Chapter Exam (cont’d.) 9. Postmortem care includes
(A) Placing drainage pads where needed
(B) Removing tubes
(C) Removing equipment
(D) Leaving the eyes open
10. _______ is the special care that focuses on the dignity and comfort of a dying person.
(A) Postmortem
(B) Cheyne-Stokes
(C) Hospice
(D) Terminal

35. Chapter Exam (cont’d.) 11. 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
12. An attitude that is helpful in hospice work is
(A) Do everything you can to help cure the resident
(B) Help the resident embrace your faith before death
(C) Make the resident and his family cheerful all the time
(D) Respect privacy and independence