DEATH and DYING

Course Objectives:
The student will have a better understanding of death and dying. They
will have the knowledge of the stages and paths offered to all of us. The
student will have the ability to look and death and find a place that they
can put their energy into to avoid nursing burn out.

Learning Objectives:
1. The student will verbalize a knowledge base of death and dying and
their role.
2. The student will verbalize the five stages of death and identify their
role in each stage.
3. The student will verbalize a knowledge of holistic nursing care and
be able to carry it out when needed.
4. The student will be able to demonstrate their knowledge with family
and loved ones in everyone’s role in the process of dying and assist
them in all ways possible.
5. The student will verbalize a knowledge of their role in the care of
themselves in a physical and spiritual way when dealing with death.

INTRODUCTION:
Death is often referred to as “the final stage of growth.” Life is a moving
process, it begins at birth, but when does it end?

Many think death is only the beginning; a step to the next level, the next
realm.

Mosby’s medical, Nursing & Allied Health Dictionary says Death is: The
cessation of life as indicated by the absence of activity in the brain and
central nervous system, the cardiovascular system, and the respiratory
system as observed and declared by a physician.

The style in which a person dies is very individual, just as their life was.

One of the major problems in understanding death in our culture is it is

so unfamiliar, and it causes a great fear in many people. Death is a
strange new experience that usually takes place in a hospital or nursing
home, rather then part of are normal life function.

Death does not effect most people until their adult years, younger people
think of death as an abstract.

For most people the thought of death is frightening. Regardless of

religious beliefs, it is very difficult to imagine oneself not being part of
this world.

Nurses are very committed to life and health. The dying patient is a
contradiction to a nurse's commitment. Occasionally people in the
medical field react to the dying person as if they represent a failure in
their care, or their skills. Although there is really nothing a human being
can do to stop the destiny/ process of another human being. We can help
the dying patient and their families in their final hours with our education
and compassion.

Death is as individual as we are, A sudden death may be harder than a

long term drawn out death. A younger person death might be harder than
an older person's death.

FEARS AND FEELINGS OF DEATH:

The dying patient almost always fears the loss of control. All of a sudden
they cannot control their own fate; there choices to stop a bad habit or to
take care of themselves is now gone. They fear the farther loss of control
as their disease progresses. Having to depend on others and to become a
burden to family and friends is very humiliating.

Fear is something we all face, first we fear our pending death and then
when it comes we even fear it more.

Many of us become angry when someone we love dies or we get angry

when we find out we are dying.

Guilt; if someone we love dies, we can always find something we did or

did not do to them, or for them. (so remember to be kind and always
make up differences. Always say I love you when you can. Many times we
think we could have saved someone; or we find out we are dying from
something that we could have prevented such as lung cancer.
Grief; An over whelming feeling. This feeling is one of immeasurable
heights. There is no emptiness that compares to that of grief from the
loss of someone you love.

CULTURES, REGIONS, AND RITES:

Americans practices and attitudes are very different from other cultures
regarding death.

In some cultures the dying person is kept at home to die and then the
family does the after care. The body is prepared for burial.

Some cultures believe that life after death is a place free of pain and
suffering, a place where there are no hardships. They also believe in a
reunification with loved ones.

Many believe there will be punishment and suffering for sin after death.
Others believe there is no after life, they believe death is the end.

There are also beliefs on the body itself. Some religions believe the body
keeps its physical form and many others believe the sprit and soul leave
the body and go on. Reincarnation is the belief that the sprit and or soul
return in another body, or life form.

Many people strengthen their spiritual beliefs when they are dying, even
people who have had little or no beliefs, find some when the end is near.
Many religions have rites and rituals that are practiced during the dying
process and at the time of death. Prayers, blessings, and scriptures that
are read.

In Vietnam, quality of life is more important then quantity; this is true

because of their belief in reincarnation. Death is at home and upon death
the body is washed and wrapped in clean white sheets, coins or jewelry
are placed in the deceased mouth; this is believed to help the soul with
their encounters with God and the devil. Their burial is in a coffin in the
ground.

The Chinese have an aversion to death; autopsy and burial are up to

each individual. Euthanasia is allowed…. Donation of body parts is
encouraged. The eldest son is responsible for all arrangements of the
deceased, after 7 years the body is resumed and then it is cremated, the
urn is then reburied in the tomb, White clothes are worn for mourning.
In India their need for a clear head needs to be respected when they are
dying. They believe in Gods will, and are unsure of this will if they are
under the influence of medications that alter their minds. Providing a time
and place for the family to pray is necessary, this helps them deal with
stress and conflict. After death the Hindu priest pours water into the
deceased mouth. Hindus may prefer only family members touch the body
and do the entire postmortem themselves. Blood transfusions, organ
transplants, and autopsies are all allowed. Cremation is preferred;
reincarnation is a Hindu belief.

American Indians, believe that the sprit does not leave the body for at
least 72 hours, they will many times place the body above the ground in
the air and allow the sprit time to leave the deceased, at which time the
body is disposed of.

The Catholic Religion believes in last rights, it is very important to assist a

dying person who feels a need for last rights to have a priest there ASAP.
The Catholic religion feels the need to repent all of their sins through the
priest before they can enter into heaven.

Whatever the culture or religious beliefs your dying patient may have it is
a very big part of the nurse’s role to provide this care.

Again each person’s death is very individual, and we owe it to our patient
to give him or her what it is they need to leave this world in whatever
manor they choose. If a request does not interfere with the health or
safety of anyone else grant a dying patient their last wishes. This can be
as simply as seeing a long lost son or a dog or even visiting a place, if it
is possible, we must do the best we can to get it to happen.

THE STAGES OF LOSS:

Dr. Elisabeth Kubler- Ross described five stages of dying/ Loss.

Denial- this is usually the first stage, it may be revisited many times in
the future, but denial is our bodies’ first defense mechanism to death.
People refuse to believe they are dying, “No not me” is a very common
response. There must be a mistake. This also happens when we lose
someone we love, “No not them," it is easier to deny it, then to feel the
extreme pain of loss. This person can not deal with any problems or
decision making at this time! This stage can last for hours, days, or much
longer.
Anger - This is usually the second stage but as with all the stages, there
is NO set path to follow when one is going though these stages. The
person thinks “Why Me” This happens as the patient accepts the fact it is
happening, they are dying. This goes true also when we love some we
love, “Why them."

Anger Cont. People going through this stage may begin to resent those
who have life. Family, friends and health care workers are usually the
targets of this patient's anger. It may be hard for everyone involved to
deal with this stage of dying. Try very hard not to take it personal. Avoid
any urge to attack back.

Bargaining- this is the third stage. Anger has passed (or it has left for a
minute) and then it is “OK it’s me but," or “if you let her live, I will”

Often the bargain is with God for more time. , Just one more Christmas.
This stage may go unnoticed; it is many times done in private.

Depression- this is the fourth stage. “Yes Me,” or “Yes them," This is a
very sad time. This is a mourning stage, things that will be lost. There
may be a lot of crying or no words at all.

Acceptance- person is calm, almost a sudden transformation may occur.

There is a peace. The words have been spoken; all that had to be done is
done. The person is ready to accept death. This doesn’t always mean
they die soon after they enter this stage… With the loss of someone else,
acceptance is a hard place to get to, the person might accept the loss of
their loved one and then a trigger occurs and they go right back into
anger, or depression, or even denial.

People do not follow a given or set path, they go in and out of the
different stages, and this is OK. People do not always go through all five
stages, and they may never get beyond a certain stage. Each person is
an individual. Each individual need us to recognize there need to go
through what ever they need to go through for them….

NURSES ROLE and INTERVENTIONS:

To give the best care a nurse can give, they must have an understanding
and spiritual belief system within them selves about death. Death does
matter, weather it be a patient of one day or a patient of one year, their
death causes an effect. It is when we try to be that super nurse, and
pretend nothing bothers us, we get in trouble. You must deal with the
deaths in your life, or they will deal with you.

A very important principal of nursing is all patients are equal and

individual, who deserve the best possible care we can give. Regardless of
a person’s background or illness. Unfortunately studies show that social
values determine the way a dying person is treated. Such as age,
attractiveness, socioeconomic status, and former accomplishments. Many
times he nurse becomes the most important link with life for the dying
person. Again this will become a problem for the nurse if they do not deal
with each and every loss as they come, and to issue their own belief
system.

PSYCHOLOGICAL, SOCIAL, AND SPIRITUAL NEEDS

The dying patient continues to have psychological, social, and spiritual
needs. They may want their family and friends present. They may want
or need to talk out their fears, worries, and desires. Some people might
want to be alone, or they act as if they do, out of fear. Many patients
need to talk during the night; fears may increase at this time.

One of the most important and most rewarding skills a nurse can give to
the dying patient is to LISTEN. Just LISTEN. The dying person is the one
who needs to talk, to express their feelings, and share their worries and
concerns. Just to be there to listen, nothing really needs to be said, and
never worry about saying the wrong thing, just talk from your heart.

Touch is also important; touch can convey caring and concern when
words can not. Sometimes a person does not want to talk or they are
afraid to share their fears, so just be near for them. Silence, along with
touch, is a very powerful nursing skill…

Spiritual needs are important. The dying person may wish to see a priest,
rabbi, minister, or other clergy. The person may also want to take part in
some sort of religious practice. Privacy is necessary during prayer time
and spiritual moments. The dying person should be allowed to have
religious items around them, you need to respect their value to the
patient. Many times I have had patients who want the bible read to them.
Please feel free to do this. I do not say you must practice or believe in
their faith, I merely ask you assist them in whatever way you can in their
needs for a spiritual exit.
THE FAMILY, is a very important part of this dying patient. Families
consist of a lot of different people, and the nurse is not the one to decide
who is and is not family. Blood does not always have to flow in a person’s
vein to make them family. The patients' wishes must be honored. We do
not ask the family questions for a patient if the patient is able to answer
for them selves, this is even true of the patient's spouse.

The family is going through a very hard time and should be recognized as
such. Normal visiting hours does not apply; family and friends are
encouraged to spend as much time as they need with the dying person. If
the family want to help give care, this is OK if the patient agrees first.
The family needs to feel they are helping in some way. The family may be
very tired and upset, they to need support and understanding. Watching
a loved one die is very painful. So is dealing with the eventual loss of that
person. They might find some peace in meeting with clergy also. Always
listen to all the people involved and do the best you can in fulfilling their
needs.

PHYSICAL NEEDS OF THE DYING PATIENT:

Dying may take a few minutes, days or weeks. There is a general slowing
down of the bodies' processes as a person is dying. They become weak;
levels of consciousness may change. It is very important to allow the
patient as much independence as possible. As they become weaker or
less responsive the nursing team will need to help with basic needs. As
the death nears the patient might become totally dependent on the
nursing staff for all of their ADL’s.

Every effort is given to provide the best care, physically and psychological
to a dying patient. This person needs be allowed to die in comfort and
with DIGNITY…

VISION, HEARING and SPEECH- Vision may become blurred and

gradually fail, this person will automatically turn towards the light, a very
dark room may frighten them. Keeping some light in the room is
important, but not real bright lights. The eyes may stay half-open, this
will cause dryness and accumulation of secretions in the corners, and
frequent eye care is necessary. Always talk to the patient and let them
know you are there and keep some light in the room. Hearing is the last
sense to go, ALWAYS remember the patient can hear you even when you
think there is no way they could, they can! So talk to them, continue to
explain what you are doing and why, keep your normal tone of voice,
offer words of reassurance and comfort. Remember to never offer false
promises.

MOUTH, NOSE and SKIN- oral hygiene is a must! A dying person’s mouth
many times become very dry and their lips crack. Mouth care is important
and needs to be done frequently with glycerin swabs, or toothettes. You
do not want to put a lot of water, or fluids in the dying person's mouth.
Many times they are unable to swallow and too much fluid can cause
them to aspirate. When giving mouth care always have the head of the
bed up and their heads turned to the side. Part of mouth care is applying
lubricant to the patients' lips. The nostrils may become dry or crusted
from drainage or oxygen, assess these areas frequently.

CIRCULATION decreases and then fails. Body temperature may increase

as death approaches. Even though the body temperature goes up the
skin becomes cool, pale, and mottled. Perspiration increases, many times
profusely. Good skin care, bathing, and prevention of decubitis ulcers are
very important nursing measures.

Positioning the patient frequently and keeping them comfortable as

possible, you may use pillows to help with positioning and to avoid skin to
skin contact.

ELIMINATION- the dying person may become incontinent of bowel and

bladder. Remember DIGNITY. Bed protectors or attends may be needed.
Perineal care is very important.

THE RIGHT TO DIE:

There are legal issues involved in dying. The right to die. Many people do
not want to be kept alive by machines or other measures. Consent must
be given to do any treatment on a patient. If the patient is not able to do
so, the nearest living relative will be asked. People need to make their
own decisions while they are able..

The self-determination Act and Obra give a person the right to accept or
refuse medical treatment. They also have a right to make advance
directives (a written document stating a person’s wishes about health
care when the stated person is unable to do so for themselves). Living
will (a person’s written statement about the use of life-sustaining
measures, feeding tubes, ventilators, and CPR are a few). Durable power
of attorney (the power to make decision about health care is given to
another person, family or friend, or sometimes a lawyer) These are
common forms of advance directives.

All health care agencies must inform patients of their right for advance
directives on admission. This information must be in writing. The patient’s
medical record must have documentation of their advance directives.

Do Not Resuscitate Orders… When death is sudden and unexpected,

every effort to save life is given. CPR and any and all emergency
treatment is given to sustain a person life.

Things are different with a long term or chronic illness, the patient has a
right to have their doctor write a “No Code," or Do Not Resuscitate DNR
order. This means that no attempts will be made to resuscitate a
terminally ill person. The person is allowed to die in peace and with
dignity. The orders should only be written after the MD speaks with the
patient and then with the family, significant others.

THE DYING PERSONS BILL OF RIGHTS:

I have a right to- be treated as a living human being until I die

I have a right to- maintain a sense of hopefulness, however changing its

focus may be.

To be cared for by those who can maintain a sense of hopefulness,

however changing that may be.

To express my feelings and emotions about my approaching death, in my

own way.

To participate in decisions concerning my care.

To expect continuing medical and nursing attention even though I have

comfort only goals.

Not to die alone.

To Be free from pain!

To have my questions answered honestly.

Not to be deceived.
Have help from my family accepting my death.

To die in peace and DIGNITY.

To retain my individuality and not be judged for my decisions.

To discuss and enlarge my religious and spiritual beliefs.

To expect the sanctity of my human body will be respected after death.

To be cared for by caring, sensitive, knowledgeable people who will

attempt to understand my wants and needs, and will gain some sort of
satisfaction in helping me face my death.

SIGNS OF DEATH:
There are many times when we think it is time for someone to die. If you
feel it in your gut, even it there are some of the signs of death or not,
you may want to notify the family. You do not have to call and startle
them. You can call and tell them it might be a good time to come in and
see their loved one. If a family member wants to run out and get
something to eat, you might suggest they get something bring it back to
the room. If you as the medical professional have an intuition, a feeling,
you might tell the family member they might not want to leave at this
time… You might get them a recliner, or something to make them more
comfortable. Some family members want to be there when the last
breath is taken, others do not. These are questions that need to be
discussed. Signs of death may happen suddenly or they may happen
slowly.

Movement, sensation and muscle tone are lost. This most often starts in
the feet and legs and then spreads all over the body. The mouth muscles
relax, the jaw may drop, and the mouth may stay open.

Peristalsis and other GI functions slow down; there may be distention of

the abdomen, fecal incontinence, impaction, and nausea, vomiting (many
times bile, stomach acid).

Circulation fails, body temperature rises. The person may feel cool or
even cold, they may be very pale or gray in color, and perspiration
increases. The distal extremities become cyanotic, this gradually grows
up from the toes and fingers. The lips may also become blue in color. The
pulse becomes very fast, weak and irregular. Sometimes you may find it
hard to even find a pulse.

The respiratory system fails. Cheyne stokes, slow, or rapid and shallow
respiration’s are observed. Fluids back up and they become very wet, this
causes the “the death rattle."

Pain decreases as the person loses consciousness and or dehydrated.

Death-- No Pulse, No Respiration’s, No Blood Pressure. Fixed and dilated

pupils.

POST MORTEM CARE:

The nursing staff gives post mortem care, if it is you first time, do not do
this alone.

This care begins when the person has been pronounced dead. PLEASE
ALWAYS REMEMBER TO USE UNIVERSAL PRECAUTIONS WHENEVER
DEALING WITH BODY FLUIDS.

Post mortem care is done to clean the patient's body and maintain their
appearance. Remember to always give dignity to the patient. Keep them
covered as you would if they were still alive, talk t them as you complete
your work, many times this helps the nurse release some of her tensions.
You need to get the body ready and looking as nicely as you can before
the family comes to see them. Remember death is a very difficult time for
all involved, be kind and compassionate.

Within 2-4 hours after death rigor mortis (stiffness or rigidity) sets in on
the skeletal muscles. Post mortem care includes positioning the patient in
a normal position as soon as possible. Many times movement of the body
can cause air that is trapped within the body to be expelled, through the
mouth or anus, do not let these sounds scare you, they are normal and
happen frequently. Post mortem care also involves gathering all personal
items for the family and or the mortuary, (the mortuary might want the
dentures and anything else that may be needed for the body). Make sure
any and all things that are taken are signed off the property sheet.

Once all is said and done, Breath and walk away, take care of you. Death
becomes part of our lives in the medical field, and we need to establish a
line for our selves. A line that keeps us close yet not too close.
Please do not let yourself become the cold and callused health
professional, that turns your patients into just another bed number.

* You are so important and can make such a difference in the life and
death of a person, take your time, go slow, it will benefit your patient and
yourself.

*You’re a wonderful being and we need you in the medical profession!

Please take care of yourself. Allow yourself time to grieve each and every
time a death occurs. People touch our lives and you have touched theirs,
be grateful they have walked through your life, think about what lessons
they may have been hear to teach you.

They are at peace, please allow yourself to be at peace too.

*Always remember a persons body (their form) leaves this earth when
they die (ashes to ashes) but no one can take away their essence, we are
but a thought and thought never dies..

God Bless You..