End-of-Life Care

Causes of Death in Adults Ages 65 and Older

Diseases of the heart
•
Malignant neoplasms
•
• Cardiovascular diseases
• Chronic obstructive pulmonary
disease
• Pneumonia and influenza
• Diabetes mellitus
• Alzheimer disease
• Nephritis, nephrotic syndrome,
nephrosis
• Accidents
• Septicemia
ATTITUDES TOWARD DEATH AND END-OF-LIFE PLANNING
 The role of health professionals has shifted from that of a decision maker
to that of a service provider whose primary responsibility is to help
consumers make informed decisions. Consequently, the approach to
end-of-life care has shifted from a purely medical focus to a more holistic
approach that takes into con- sideration consumers’ personal values,
cultural and spiritual beliefs, and life experiences.
ADVANCE DIRECTIVES
 Specific end-of-life decisions can be expressed in advance directives and
physicians orders for life sustaining treatment.
 These documents specify the type and amount of intervention desired by
someone. Once initiated, they remain in effect until changed.
 Health care consumers should provide copies of their advance directives
to their primary care providers, the person holding durable power of
attorney, and any other person or health care agency who might be
involved in their care.
 The decisions about end-of-life care are not set in stone and can be
changed as the situation changes. To make an informed decision about a
specific interven- tion or treatment, a patient must have enough informa-
tion including (1) the amount of time a treatment will add to life; (2) the
quality of life with this treatment; (3) the amount of pain, disability, or
risk involved with the treatment; (4) the amount of time involved in the
treatment; (5) the cost of treatment and whether it is covered by
insurance; (6) the need for and availability of caregivers; and (7) the
availability, benefits, and risks of other treatment options.
VALUES CLARIFICATION RELATED TO DEATH AND END-OF-LIFE CARE
 Individuals’ responses are influenced by their age, gender, culture, religious
background, and life experiences.
 Caregivers should reflect on their personal values related to the end of life to
identify those values that are likely to influence their decision-making processes
and behavior when caring for dying patients.
 Ethical dilemmas relating to end-of-life care are more likely to occur when the
value systems of the patient and of the care- giver differ significantly.
Understanding the value systems of others can help the nurse provide quality
end-of-life care, even when the nurse does not share the same values.
WHAT IS A “GOOD” DEATH?
Summary of Patients’ Wishes Related to End of Life
Most dying patients desire to:
• Be able to issue advance directives to ensure their wishes are respected
• Be afforded dignity, respect, and privacy
• Know when death is coming and what to expect
• Have access to information and options related to care
• Retain control of decision making regarding care
• Have control over symptom and pain relief
• Have access to emotional, cultural, and spiritual support
• Retain control regarding who may be present at the end of life
• Know possible options (e.g., hospital, home care, and hospice) and have a choice regarding where and how death will occur
• Have time to say goodbye to significant others
• Leave life when ready to go without unnecessary or pointless interventions

PALLIATIVE CARE
 According to World Health Organization, palliative care focuses on reducing or relieving the
symptoms of a disease without attempting to provide a cure; it neither hastens nor postpones
death.
 Palliative care affirms life while accepting death as its normal conclusion. Interventions are
designed to optimize the patient’s ability to live as active and complete a life as possible until
death comes.
 Competent adults, regard- less of age, who are suffering from life-threatening diseases such as
cancer or advanced chronic conditions, such as emphysema or end-stage renal disease, can, and
often do, make the decision that they no longer desire aggressive treatment, such as chemo-
therapy, assisted ventilation, or dialysis. This does not mean that these patients forego all medical
intervention. They will still receive treatments that support the goal of optimizing their ability to
live as active and complete a life as possible until death comes.
 Individuals who choose palliative care typically choose to decline other procedures such as
cardiopulmonary resuscitation (CPR), artificial ventilation, and artificial feeding, which may prolong
the dying process. Medical treatment and nursing care focus on actions that enable the dying person
to have the highest quality of life for whatever time remains.
COLLABORATIVE ASSESSMENT AND INTERVENTIONS FOR END-OF-LIFE CARE
I. COMMUNICATION AT THE END OF LIFE
 To establish rapport and maintain therapeutic relationship with the recipients of care, the nurse
needs to know as much as possible about the dying person and his or her loved ones including
personal and spiritual beliefs, cultural background, values, and personal experiences that may
influence decision making and the content of the advance directives for health care.
 Nurses must demonstrate verbally and nonverbally that they are approachable and are neither
detached nor indifferent. A good way to start is by consistently addressing or referring to the
dying person by his or her name. This shows respect and helps the dying person maintain a sense
of self-worth and dignity.
 An empathetic word and gentle touch can demonstrate caring. Holding a hand, gentle
repositioning, providing good basic hygiene, and maintaining an aesthetically pleasing
environment free from odors, clutter, and unnecessary medical equipment communicate that the
dying person is respected and valued.
 Answer all questions honestly and directly. If the information is not readily available or cannot
be disclosed, make sure that the dying person and his or her loved ones receive the necessary
information in a timely manner. Discussions regarding end-of-life experiences and care should be
clear and truthful.
 Avoid using complicated technical terms and whenever possible, provide explanations using
plain language and simple statements.
 Try to prevent or correct any mis- understandings or mistaken perceptions by
summarizing, clarifying, and restating what the patient said. Allow time for
 response and further clarification if necessary.
 Use reflective and open-ended statements such as: “There seem to be things that are worrying
you,” “If you want to talk, I’ll listen,” or “It must be hard. Do you want me to sit with you for a
while?” as ways to encourage a conversation. Start communication from where the patient is,
then go where they wish to go.
 Ensure that the communication is focused on the patient rather than the caregiver.
The dying person and his or her loved ones should be free to discuss the things that
concern them the most, not the topics concerning the caregivers.

PSYCHOSOCIAL PERSPECTIVES, ASSESSMENTS, AND INTERVENTIONS

CULTURAL PERSPECTIVES
 When nurses and patients come from different cultural and religious backgrounds, nurses must
be careful not to impose their beliefs and should work to under- stand the perspectives of others.
The four areas that need a particularly careful cultural assessment are: (1) communication
about death; (2) the decision- making process; (3) amount and type of intervention that will be
accepted; and (4) the significance of pain and suffering.
Religious Practices Regarding End of Life
• Buddhism A person’s state of mind at the time of death is of great importance. A peaceful state may be
achieved by listening to friends, family, or monks; reading scriptures; and chanting mantras. Buddhists
view death not as a continuation of the soul but as an awakening. Funeral rites last 49 days ending in the
rebirth of the individual. Cremation is common.
• Christianity Christians believe in a union with Christ, necessary for the full enjoyment of God and the
happiness of heaven. If possible, a special anointing (sacrament of the sick) is performed, and the dying
person is given a chance to confess his or her sins. Depending on the branch of Christianity, cremation
and organ donation may be prohibited.
• Judaism Anything that may hasten death is forbidden. Death is viewed as a natural process in movement
to a more rewarding afterlife. Extensive rituals are used to show respect for the dead and to comfort the
living. After death, the body is not left alone until burial. Special washing and wrapping in a simple
shroud with religious symbols are typically done by special religious volunteers. There is no viewing of the
remains; a simple casket is used, and the body is always buried, never cremated.
In general, autopsies are discouraged unless required by law.
• American Indian (Lakota) Death is a part of life and after death; people enter a neutral spirit land.
The spirit is believed to reside in the body and should not be disturbed, so burial is preferred over
cremation. A religious celebration of the person’s spirit is held a year after death.
• Islam Muslims believe that life on earth is a trial to prepare for the next realm of existence. When death
is imminent, the patient must face Mecca and confess sins and beg forgiveness in the presence of the
family or a practicing Muslim. After death, the body is washed and wrapped in a clean white cloth and
positioned facing Mecca. Burial is performed as soon as possible, after a special prayer. Cremation is
forbidden; autopsy is prohibited except for legal reasons.
• Hinduism Hindus believe in the reincarnation and rebirth of the soul leading to a higher state of
completeness. Death is viewed as the temporary stopping of physical activity. The fate of one’s soul after
death is determined by the person’s previous actions, the state of mind, the time and circumstances of the
death, the activities of his or her children, and the grace of God. After death, the body is given a final bath
and cremated, and the ashes are scattered in various places to allow the body to mingle with earth, air, and
water and return to the elements.

SPIRITUAL CONSIDERATIONS
Nurses play an important role in helping dying persons meet their spiritual needs. The
following are some guidelines to remember when attempting to meet the spiritual
needs of the dying person:
1. Determine whether or not any specific religious beliefs or practices are important to
the patient or his or her family members.
2. Assess whether or not the patient has a preferred spiritual counselor. When no
particular individual is identified, ask the patient whether he or she wishes to
receive counsel from anyone else. Spiritual counseling is very personal, and the
dying person should have the right to select whomever he or she wishes.
3. Offer choices when available. Most hospitals or extended-care facilities maintain a
list of ministers who will visit the dying without concern to denomination or church
affiliation. Not all spiritual counselors are equally sensitive to the needs of the
dying. If one spiritual counselor does not meet the patient’s needs, make the patient
aware that there are others available.
4. Determine whether or not the person wishes any spiritual counselor to be
notified. Respect the wishes of people who do not wish spiritual counsel. Spiritual
counseling can be very beneficial when desired. When it is not desired, intervention
can cause more problems than it solves.
5. Demonstrate respect for the patient’s religious and spiritual views. Provide the
dying person time for private thought, prayer, or meditation when desired.
 Incorporate important activities and items into the care plan. The religious rituals
related to dying can differ widely among cultures, and the nurse should help the
family whenever possible to facilitate their practices even if this involves moving
furniture to face a specific sacred direction, opening windows, or providing space
for a large group of family members.
6. Do not impose your own beliefs on the patient. The nurse should keep the focus of
spiritual discus- sions on the patient and his or her beliefs, not on the nurse’s beliefs.
7. Be present, be available, and listen. The nurse cannot and should not attempt to
solve the patient’s problems, but empathy demonstrates acceptance and caring. This
allows the patient to feel less alone and often decreases spiritual distress.
8. Keep the patient’s relevant religious symbols readily available and treat them
with respect.
9. Avoid moving beyond role and level of expertise unless you have specific
ministerial or pastoral training in death and dying.
PHYSIOLOGIC CHANGES, ASSESSMENTS, AND INTERVENTIONS
 Typical physiologic changes observed as death nears include fatigue, dyspnea,
gastrointestinal changes (dry mouth, anorexia, nausea and vomiting,
constipation), anxiety, and delirium.
 Pain is not always present as death nears, but when it is present, pain relief is a
priority.
 As death approaches, the ultimate goal of care is to alleviate suffering and
provide the dying person with the highest level of comfort possible.
PAIN
 Pain at the end of life can interfere with the dying person’s ability to maintain control, to cope,
and to complete end-of-life tasks. It increases the likelihood of fatigue, depression, and loss of
appetite.
 Pain at the end of life is a form of suffering. Therefore, treating pain is one of the most important
priorities of the care of a dying person. The goal of pain management is to reduce pain to an
acceptable level as deter- mined by the dying person, while maintaining the level of alertness that
allows them to remain aware of daily activities and to interact with family and loved ones.
 Perform a thorough pain assessment as early as possible and as often as needed.
 Caregivers should review pain rating with the patients and encourage them to report it as soon
as they experience it. Besides intensity, pain assessment should include evaluation of the
frequency, location, quality, and duration of the pain, as well as identification of the precipitating
and relieving factors. Document all pain assessments carefully.
 During the assessment, carefully observe the patient for any responses, such as restlessness,
moaning, guarding, grimacing or striking out, when body parts are touched or moved. The
presence of any of these responses between assessments, especially during routine activities, such
as repositioning, can also indicate the likelihood of pain.
 Good pain management requires a thorough under- standing of the patient’s needs and wishes.
This involves in-depth evaluation of the dying person’s physical needs, coping abilities, and
support network, as well as the evaluation of religious and sociocultural factors that may affect
his or her pain experience. Recommendations for end-of-life pain management.
 The following is a list of evidence-based principles for the pain management at the end of life:
1. Do not give up trying to find an effective pain control regimen. It may take several attempts
to find the best combination of medication and non- pharmacologic approaches to reach a pain
level that is tolerable for the patient.
2. The likelihood of drug-drug and drug-disease interactions or adverse effects increases with
the addition of new medication or higher doses. Careful assessment is needed each time a
change in medication is made.
3. Frequently evaluate the effectiveness of pain management. Doses and frequencies of
medications might need to be changed or adjusted based on the response. Thorough assessment
reveals when the medication is no longer providing adequate pain relief.
4. Consider using a variety of routes of administration. Oral medication is the most common and
accepted route for administration, but it may cause problems for older adults who have difficulty
swallowing pills. Never crush solid medications designed for sustained release, because this
results in rapid absorption. When the person has difficulty swallowing oral medication,
consider switching to liquid, transdermal, or rectal formulations. Parenteral administration of
 medication may not be the first choice for an older adult unless he or she has an existing IV or
central line, peripherally inserted central catheter (PICC), or implanted port.
5. Pay attention to timing of pain medication. Pain medications are most effective when taken
before the pain becomes severe. Long-acting or sustained- release opioids are commonly ordered
because they are effective at maintaining pain control although eliminating the need to disturb
the patient frequently to administer pain medication. Even with long-acting pain control,
breakthrough pain may occur. Treat it promptly with a rapid-acting analgesic. Administer as-
needed (prn) medications as soon as possible when requested.
6. Never abruptly stop pain medications when they have been taken for an
extended period. Withdrawal symptoms including headache, shakiness, or
diaphoresis can occur if medications are stopped suddenly.
7. Use nonpharmacologic approaches to complement pharmacologic interventions
when managing pain. Discuss possible options and implement those that are most
acceptable to the patient. Activities that may help provide relief include (1) hot or
cold applications such as warm baths, showers, cool wash cloths, or ice packs; (2)
comfort devices such as cushions, pillows, and pads; (3) massage, foot rubs, or
reflexology; (4) relaxation breathing or other relaxation exercises; (5) imagery or
visualization; (6) distractions such as socialization, listening to music, and watching
television or movies; (7) biofeedback; (8) transcutaneous electrical nerve stimulation;
(9) hypnosis; and (10) anything else that helps reduce stress.
8. Consider referral to a pain specialist. If the dying patient does not experience
adequate pain control, consult a pain specialist, such as clinical nurse specialist or a
palliative care practitioner.
9. Pay attention to timing of pain medication. Pain medications are most effective
when taken before the pain becomes severe. Long-acting or sustained- release
opioids are commonly ordered because they are effective at maintaining pain
control although eliminating the need to disturb the patient fre- quently to
administer pain medication. Even with long-acting pain control, breakthrough pain
may occur. Treat it promptly with a rapid-acting analge- sic. Administer as-needed
(prn) medications as soon as possible when requested.
10. Never abruptly stop pain medications when they have been taken for an
extended period. Withdrawal symptoms including headache, shaki- ness, or
diaphoresis can occur if medications are stopped suddenly.
11. Use nonpharmacologic approaches to complement pharmacologic interventions
when managing pain. Discuss possible options and implement those that are most
acceptable to the patient. Activities that may help provide relief include (1) hot or
cold applications such as warm baths, showers, cool wash cloths, or ice packs; (2)
comfort devices such as cushions, pillows, and pads; (3) massage, foot rubs, or
reflexology; (4) relaxation breathing or other relaxation exercises; (5) imagery or
visualiza- tion; (6) distractions such as socialization, listening to music, and
watching television or movies; (7) biofeedback; (8) transcutaneous electrical nerve
stimulation; (9) hypnosis; and (10) anything else that helps reduce stress.
12. Consider referral to a pain specialist. If the dying patient does not experience
adequate pain control, consult a pain specialist, such as clinical nurse spe- cialist or a
palliative care practitioner.

FATIGUE AND SLEEPINESS

 Fatigue accompanies many conditions and is not specifically a sign of impending death. Fatigue
can interfere with the dying person’s ability to carry out necessary end-of-life tasks, including
communicating with loved ones. Sometimes, stimulants such as caffeine or prescription drugs,
may help a person over- come fatigue and lethargy, but these should be used cautiously.
 Teach the patient to pace their physical activity and schedule frequent rest periods to reduce
fatigue. Because of metabolic changes, the patient may begin to sleep more and may be difficult
to arouse as the end of life nears.
CARDIOVASCULAR CHANGES
 Diminished peripheral circulation already common in older adults is likely to worsen as death
nears, result- ing in dry, pale, or cyanotic extremities.
 Peripheral pulses are often weak and difficult to palpate.
 Blood pressure typically is decreased by 20 or more points from the normal range and may be
difficult to auscultate. Body temperature may elevate significantly as death nears.
 Adjust room temperature and ventilation to promote comfort while avoiding chilling drafts. Use
comfort measures such as bed socks, shoulder wraps, and warmed blankets (never electric
because of risk for burns). Heavy or restrictive covers should not be used because they may
increase discomfort.
RESPIRATORY CHANGES
  Dyspnea is common as death nears. A dying person may experience shortness of breath, Cheyne-
Stokes respirations, and other observable signs of respiratory difficulties.
 A dying person may report feeling breathless even though oxygenation levels are
satisfactory and typical signs of breathing difficulties are absent. Treatment should
focus on symptom management and elimination of the underlying causes when
possible.
 Mild respiratory difficulty usually can be relieved by changing positioning, elevating the upper
body, opening windows, or using a fan to increase ventilation, or administering oxygen by
nasal cannula. Both physical and emotional stress can cause muscle tension, which exacerbates
respiratory problems. Encourage the dying person and their visitors to minimize stressful
experiences and to alternate episodes of activity with rest periods. Excessive talking and visiting
should be minimized if they cause problems.
 Resting in a reclining chair or elevating the head of the bed usually aids effective
breathing. Listening to music and using relaxation exercises may further help reduce
tension and improve breathing effort.
 Acute distress, fear, and panic frequently accompany severe shortness of breath. When
the dying person does not want aggressive medical treatment, the most common
method used to manage shortness of breath is administration of morphine. The
patient, family, and team of caregivers need to be aware of and be comfortable with
the fact that morphine, when given in a dosage that is adequate to relieve the
respiratory distress (via pulmonary vasodilation), can cause drowsiness, sleep, and
even loss of consciousness.

GASTROINTESTINAL CHANGES
 Loss of appetite (anorexia) and muscle wasting (cachexia) often accompany
advanced terminal conditions, particularly some forms of cancer. Many factors
contribute to poor appetite and weight loss in the terminal patient, including
medications, sores in the mouth, changes in taste, nausea and vomiting, metabolic
changes, absorption problems, and emotional depression. Treatment of anorexia
and cachexia is difficult because many of the underlying physiologic actions are
poorly understood.
 The end of life is not a time for special or restricted diets. Encourage the person to
eat anything that appeals to him or her. Present food in an appealing manner and
in a quantity that is not overwhelming. Whenever possible, serve meals in an
odor-free environment. Food is intimately attached to good times and social
events.
 Dry mouth (xerostomia) and ulcerations of the mouth can be caused by many
things such as advanced age, medications, and decreased fluid intake. This
problem, although not unique to the dying person, causes increased distress and
discomfort that can and should be avoided as the end of life nears.
 Common measures used to treat dry mouth include frequent swabbing with
mouth sponges, spraying the mouth with water mist from an atomizer, and
brushing the teeth. Avoid alcohol-based swabs because they tend to further
dry mucous membranes. Commercial lip balms or liquid vitamin E may be
helpful in easing the discomfort of dry lips. Petroleum- based products, such as
Vaseline, may cause respiratory problems if they are inhaled and should not be
used on the mouth.
 Vomiting increases the risk for aspiration, so it is best to position the patient in
a side-lying or sitting (Fowler) position rather than supine. Temporary relief
from nausea and vomiting may be obtained by rectal or parenteral
administration of anti- emetic medications, but the underlying cause must be
identified and corrected before the symptoms will go away. If a medication
reaction is suspected, contact the prescribing practitioner.
 Constipation is a common and distressing problem for the terminal patient.
Common causes of constipation near the end of life include disease factors such
as tumor compression, calcium imbalance, adhesions, dehydration, inadequate
fiber intake, pain, immobility, and medications (e.g., opioids, antidepressants,
and antacids).
 A high-fiber diet, bulk-forming supplements such as psyllium, and adequate
fluid intake might prevent problems while the patient is able and willing to eat.
Stool softeners, laxatives, suppositories, or enemas are indicated when dietary
intake is not adequate, but they may cause electrolyte imbalance.
 As the end of life approaches and muscle tone in the rectum decreases, manual
disimpaction might be required to decrease rectal pressure and pain.
 Disimpaction should be done gently and carefully using adequate lubrication
(K-Y Lubricating Jelly or petroleum jelly). Use extreme caution before
performing rectal examination or digital removal when the person has
thrombocytopenia.
 Repeated episodes of diarrhea contribute to electrolyte imbalance,
dehydration, skin breakdown, fatigue, and depression. . Diarrhea can be
caused by numerous factors, including disease processes, psychological
factors, medications, herbal remedies bacterial or parasitic infections, and
antibiotic therapy. Treatment may include increased clear fluid intake to
replace electrolytes, antibiotics to treat infectious diseases, steroids to decrease
bowel inflammation, medications, or bulk-forming agents to slow intestinal
peristalsis. To avoid an obstruction, use bulk-forming agents only when the
person has adequate fluid intake of approximately 2000 mL/day.
URINARY CHANGES
 Oliguria is commonly observed because of decreases in fluid intake, blood pressure, and kidney
perfusion. Urinary incontinence is also common. Absorbent pads or an indwelling catheter can
be used to reduce the need for bed changes that may disturb the dying person.
INTEGUMENTARY CHANGES
 Soft, nonconstricting, nonirritating (free from harsh detergents and other chemicals) clothing
promotes comfort and minimizes risk for skin dryness and rashes. Comfort should take
precedence over style. Older, loose, cotton clothing is often best, particularly when the person is
diaphoretic. A major advantage of cotton is that it breathes, allowing perspiration to escape,
which helps keep the skin dry.

SENSORY CHANGES
 Vision diminishes, and the visual field narrows as death nears.
 Indirect lighting with minimal shadows is most restful and least disturbing. Hearing remains
acute until death, even if the dying person does not respond. All caregivers and visitors must
remember this when they speak in the presence of a dying person. Calm, supportive, loving
messages should be delivered to the person even when he or she does not respond. Avoid
negative or disturbing con- versations because they can cause the dying person to become
distressed and more agitated.
CHANGES IN COGNITION
 As death nears, periods of delirium may be combined with periods of coherent thought.
Common symptoms include decreased ability to think and process information, perceptual
changes, disorientation, loss of consciousness, insomnia with daytime sleepiness, nightmares,
agitation, irritability, anxiety, hypersensitivity to light and sound, fleeting illusions, visual
hallucinations, delusions, mood swings, attention deficits, and memory disturbances.
 Causes of delirium include: hypotension; oxygen deprivation resulting from apnea or
hypoventilation; fever; neurologic changes; metabolic abnormalities, such as
hyperglycemia and uremia; dehydration; and other physiologic or emotional
disturbances. Medications such as antibiotics and opioid analgesics can also contribute
to delirium. Vital signs, oxygen saturation, and laboratory values may provide
valuable information about under- lying problems.
DEATH
The following strategies can help caregivers provide the support to the family through
this experience:
 Discuss the family’s wishes early, so that appropriate notification of family, clergy, and
others can take place.
 Record and communicate instructions on who to call, how they can be reached, and
whether there are any limitations regarding time of day.
 Offer family members the opportunity to participate in the care of the dying person.
Families often want to be helpful. Educate them and provide them with opportunities
to participate in the care.
 Allow family members to express their emotions and provide them with
support. Some family members may be hesitant and may need permission to
express their emotions, although others might be very demonstrative when it
comes to grief. Ensure they feel comfortable and supported.
 Provide frequent updates on the condition of the dying person, and be available to
answer questions. Families often need assurance that the person is comfortable.
Provide comfort measures and be sensitive to the needs of the family members.
RECOGNIZING IMMINENT DEATH
Some indicators of imminent death may include, but are not limited to, the following:
 1. Increased sleepiness
2. Decreased responsiveness
3. Confusion in a person who has been oriented
4. Hallucinations about people (sometimes deceased family members)
5. Increased withdrawal from visitors or other social interaction
6. Loss of interest in food and fluids
7. Loss of control of bowel and bladder in a person who has been continent
8. Altered breathing patterns such as shallow breath- ing, Cheyne-Stokes respirations, and
rattling or gur- gling respirations
9. Involuntary muscle movements and diminished reflexes
 Signs of death include absence of heartbeat and spontaneous respirations; open
eyes without blink; nonreactive pupils; flaccid jaw with slightly open mouth;
and lack of response to touch, speech, or painful stimuli. Legal pronouncement
of death is made by the physician.
 If family members are present when the patient expires, they should be allowed to sit at the
bedside and say farewells or grieve as long as necessary.
 Discretely remove oxygen, IV lines, and other visible medical devices, and turn off monitors and
other noise-creating equipment.
 Accommodate and show respect for cultural practices regarding grieving and preparation of the
body whenever possible.
 Give the family adequate amount of time and provide them with nursing care until they are
ready to leave. This is not the time to avoid the family.
 A word of support, a simple hug, or other demonstration of sympathy by the nurse is long
remembered by family members.
BEREAVEMENT
Kübler-Ross Stages of Grief
