Learning Objectives

• Apply knowledge of the physiology of dying in supporting the person, family or carer as they
experience the person’s dying process.
• Identify signs of respiratory and swallowing difficulties and implement management strategies in
accordance with ACP or ACD.
• Address malignant wound management in accordance with the unique needs of non-healing wounds
of a deteriorating person.
• Identify and report signs of the person’s deterioration or imminent death in accordance with ACP or
ACD.
• Support the dignity of the person when undertaking all care activities in their end-of-life stages as well
as after their death.
• Identify and reflect on any ethical issues or concerns about the person, and discuss with an
appropriate person according to organisation procedures.

End of Life Care

• The final phase of palliative care is end of life or terminal care.
• Known as care of the dying person.
• Provided during the final weeks or days of a person’s life.
• Focus is on the psychological and physiological issues.
• Family is supported in dealing with the rapidly changing condition.

End of Life Care Strategies

• Maintain Patient Centred Care with short term goals related to:
o Comfort
o Support
o Alleviation of symptoms
• Regularly check for any changes to the care plan that indicate if decisions made by the person has
been reviewed.
• Provide a supportive environment for the person and their carers, family and/or significant other.
• Respect and support the person’s end-of-life care.
• Maintain dignity.
• Recognise signs of imminent death.

Holistic Palliative Care and Discussion

• It is essential palliative care remains holistic.
• Nursing care that is too task orientated may devalue and lessen the dying persons individual needs.
• In what way does the culture in a busy acute care hospital impact on the experience of clients who
are dying?

Death and Dying

• Death is defined as the cessation of all vital functions of the body including the heartbeat, brain
activity (including the brain stem), and breathing.
• Under Australian law, death is generally defined as:
either irreversible cessation of circulation of blood in the body of the person or irreversible cessation
of all function of the brain of the person.
• National Health and Medical Research Council: This definition applies to all states except Western
Australia, which has no statutory definition of death.

Legal definition of dying

The last stage of life; a process that from a medical point of view begins when a person has a disorder that is
untreatable and inevitably ends in death, or the final stages of a fatal disease.
Issues to consider: Technology and artificial life saving equipment…….
Dying
Dying is a process, it is not the final act. Very simply, the process of dying begins when there is a reduction in
oxygen to vital organs and there is limited chance to survive. It is therefore the process of systems shutting
down. The time taken for death to occur varies, and depends on the individual’s physiological, psychological
and spiritual state.

Physiology of dying and death

As bodies move towards death, there is less desire for food and fluids. The swallowing reflex can be impaired,
increasing the risk of choking. Saliva that the patient is unable to swallow may collect in the back of the throat
causing a sound sometimes called a “death rattle”. Patients developed fear of choking and may hold their
mouth tightly closed when food or fluids are offered. This may result in dehydration which increases
production ketone levels. Most patients have dyspnoea at the end of life. They may have tachypnoea, facial
grimacing and use of accessory muscles to breath. Some patients will have episodes of apnoea in the days or
hours before they die. As the body loses its ability to control temperature, the patient may become diaphoretic
or feel cold all the time. As death approaches, the feet and legs may become cool, cyanotic and mottled. Most
patients will become incontinent of bowel and bladder during the course of dying process.
Urine output declines due to dehydration; it will darken in colour and have a strong odour. In the final weeks
of life, patients may be sleeping for most of the day due to a change in metabolism. They start emotionally
detaching from families as part of their preparation to leave. Most patients are unconscious for hours or days
and their ability to see may be diminished before they die. Hearing is the final sense to be lost. The skin
becomes pale, waxen. Death has occurred when there is absence of heartbeat and respirations. The eyes
remain open and pupils are fixed.

Systemic Physiology
Integumentary system:
• Decrease mobility-pressure sores
• Changes in colour-mottled
Circulatory system:
• Changes in vital signs -↓BP
• Weak and irregular pulse rate
• Destruction of red blood cells
Respiratory system:
• Regular - rapid, slow or shallow
• Breathing rates may vary from rapid to long gaps between breaths (Cheyne-Stokes Respiration)
• Decrease of cardio pulmonary circulation and build-up of waste products
Muscular-skeletal:
• Loss of muscle tone - drop in facial muscles
Gastrointestinal tract:
• Decreased peristalsis
• Incontinence of faecal matter
• Coughing and swallowing decrease and may collect in the back of the throat
Urinary tract:
• Decreased urine output- incontinence
Neurological:
• Changes in sensory perception
• Blurred vision
• Hearing remains intact
• Impaired sense of taste and smell

Signs of imminent death and/or deterioration

• Appetite and thirst decrease.
• Sleep/alert patterns alter severely.
• More time sleeping and difficult to rouse.
• Changes in body temperature.
• May alter from extreme hot/cold.
• Skin may appear blotchy and darker as circulation decreases (mottling).
• Decline in urine production – incontinent.
Nursing interventions
• Appetite changes:
o Sips of water
o Ice to suck
o Moisten the mouth
o Not forced to eat.
• Talk to client when they seem alert.
• Allow them to sleep as they desire.
• Extra bedding when cold.
• Fans, cold, damp towels when hot.
• Incontinence:
o Utilise pads and absorbent sheets to help with hygiene.
• Medications may slow down the production of mucous, turning the patient also helps drainage. Assist
by gently elevating the head and turning to one side.
• Comfort is of importance and provision of an egg shell mattress/air bed is an advantage.
• Decrease in swallowing and coughing; avoid the giving of food and drink to a patient with decreased
swallowing and coughing reflexes.

Care after death

• Meeting the needs of the grieving family and carers for the deceased body are nursing
responsibilities.
• Treat the body with utmost respect by maintaining privacy and preventing damage to the body.
Post mortem care is given immediately after death before the body is moved to the mortuary.
Algormortis:
Change in body temperature - decreases loss of skin elasticity.
Livormortis:
20 minutes post death.
Blue/purple discoloration of the skin; by-product of RBC destruction (elevate head)
Rigor mortis:
Begins 2- 6 hours post death
Natural stiffening of muscles of the body

Care of the body after death (Last Offices)

1. Place the body in the supine position with arms on the side, palms down or across the abdomen.
2. Place a small pillow under the head, to prevent discoloration from blood pooling.
3. Hold the eyelids down for a few seconds so they remain closed.
4. Insert dentures, for normal facial features.
5. Wash soiled body parts, place absorbent pads under the body and dress the body.
6. Remove any tubes. Always follow policy and procedures with removal of tubes. (Different for
Coroner’s case).
7. Family may stay with the body as long as they want.
8. When the family leaves, tag the body on the toe.
9. All belongings are returned to the family.
10. Document.

Autopsy
An examination of the body after death to determine the cause of death.
Mandated in situations where a reportable death has occurred:
1. Violent death.
2. Unexpected death.
3. Cause of death is unknown.
4. If the doctor is unable to sign the death certificate.
5. If death occurred during an anaesthetic.
6. Death occurring within 24 hours of hospital admission.
Ethical issues and issues to consider
• Autonomy, self-determination, decision making.
• Informed consent.
• Competence, substitute decision makers, conflicts in stakeholders.
• Advance care planning, statements, health care directives.
• Selection of proxies.
• Refusal of treatment.
• Ambiguity/ ambivalence.
• Euthanasia, (Physician) assisted suicide, voluntary euthanasia.
• Withholding/withdrawal of treatment.
• Extraordinary measures.
• Medical futility, powerlessness.
• Acceptable treatments and the questions related to suffering.
• Pain and other symptom management.
• Palliative sedation.
• Nutrition & hydration issues.
• Spiritual care access, adequacy, guilt.
• Psychosocial care, especially relational issues.
• Surgery and palliative treatment, and goal delineation for outcomes.
• Diversional activities and quality of life issues.
• Tragedy: does living a good life include dying a good death?
• Research participation and need for expanding knowledge about living with the awareness of death
(mortal time).
• Truth telling: how?, where?, when?, by whom