CARE OF

DYING PATIENT
 “

WE CANNOT CHANGE THE

OUTCOME,
BUT WE CAN AFFECT THE
JOURNEY. ”

—ANN RICHARDSON
 DOMAINS OF CARE FOR THE DYING
PATIENT
PHYSICAL PSYCHOLOGI
ASPECT CAL ASPECT
 Plan of care is made.  Assessment of psychological
 Based on detailed assessment status
of patient and family.  If necessary psychiatric
problems are taken care of.
SOCIAL CULTURAL
ASPECT ASPECT
Client social needs Assessment and attempt tro
are assessed and meet cultural needs of the client
fulfilled
 DOMAINS

SPIRITUAL ETHICAL AND

CARE OF IMMEDIATELY DYING LEGAL
Spiritual, existential All the care , choices and
PATIENT dimensions are preferences are fulfilled
• Recognizing the
signs and assessed and are within the ethical
symptoms of respected and framework.
impeding death. responded well.
• Appropriate care is
 PHYSIOLOGICAL
NEEDS
According to the Maslow Hierarchy of
Needs, physiological needs must be met
before others, because they are essential
for existence.
Areas that are often problematic for
terminally ill patients are
 Respiration
 Fluids and nutrition
 Mobility
 Skin care
 Elimination
 01
RESPIRATION
Oxygen is frequently ordered for the client experiencing
labored breathing.Suctioning may be needed to remove
secretions that the client is unable to swallow and keep
the airway clean.
 02
FLUID AND
NUTRITION
o The refusal of food and fluids is almost universal in dying
patients.It is believed that the client is not feeling thirsty and
hungry.
o Artificial nutrition often increases the client agitation leads to
increased limb restraints and increases the risk of aspiration
pneumonia.
o Gain in IV access for fluid replacement and parental nutrition must
be checked as prescribed.
 03
SKIN CARE
 Prevention of pressure ulcers is the top priority.
 In addition to the care of pressure points keeping the skin clean
moisturized promotes healthy tissue.
 Gentle massage with soothing lotions are comforting.
 Bed bath are adequate if the patient cannot get into the tub or sit
in the shower chair.
 The skin should be inspected every time when positioning is
done.
 04 MOBILITY
 As the patient condition deterioratews,
mobility decreases. The patient become less
able to move about in the bed or to get out
of bed and requires more asssistance.
 Physical dependenace increases the risk of
complication related to immobility.
For example , atrophy and pressure ulcers
Provide meticulous skin care to ease the
pressure on skin.
05 ELIMINATION
 Constipation may occur due to side effects of analgesics and the
lack of physical activities.
 Fluid and foods with high fibre contained can be effective
preventive measures for the patient with adequate oral intake.
 It can also be alleviated by maintaing a scheduled time for bowel
elimination and administrating suppositories.
 The patient may have incontinence of bladder, so the nurse
needs to check the patient frequently , clean the skin, apply a
moisture barrier after each incontinence episode.
COMFORT
• Pain relief as prescribed.
• Keep the patient clean and dry.
• Provide safe and non- threatening environment.
• Provide a respectful , careful attitude to provide psychological
comfort by establishing good rapport .
 PHYSICAL
ENVIRONMENT
 A soothing physical environment can significantly increase increase the
clients comfort , like non- slippery floor, side rails in the room –
support to walk independently to washroom, availibility of call bell.
 Adequate lightening enhances vision without causing discomfort
associated with harsh, glaring light.
 Provide night light if patient requires.
 Provide quiet and calm environment .
 Analgesics are prescribed for the pain and it may cause sedation,
therefore precautions shall be taken that proper safe environment is
provided to the patient like bed rails raised.
 PSYCHOSOCIAL NEEDS
 Death presents a threat to not only to ones physical
existence but to ones psychological integrity.
 Even though in the presence of the nurse, the
family members should be encouraged and invited
to participate in the clients care, if they desire to do
so and the client is willing.
 Maintain a well groomed appearance is important.
Cutting the nails, shaving the beard will help to
promote patients dignity.
 Combing and brushing not only improves
appearance but is also a comforting and relaxing
activity for many, it helps to boost self- esteem,
also orient the client with time, place and person.
SPIRITUAL NEEDS
The nurses play a major role in promoting
the dying clients spiritual comfort . Dying
persons are among the most venerable
members of the human family.
 Communicate empathy
 Play music
 Use touch
 Pray with client
 Read religious literature aloud , at
the patient request.
 Contact religious preacher if
requested by the client.
HOSPICE AND PALLIATIVE CARE
Palliative Care

 “Anapproach that improves the quality of life

of patients and their families facing the
problems associated with life threating illness,
through the prevention and relief of suffering
by means of early identification and
impeccable assessment and treatment of pain
and other problems, physical ,psychosocial
and Be spiritual”
Nursing Implication
PALLIATIVE CARE PALLIATIVE CARE REQUIRED FOR

1. Is associated with pain relief due Cardiovascular diseases-38.5%

toillness Cancer-34%
2. Relieves various other distressing Chronic Respiratory
symptoms Diseases-10.3%
3. Regards death as a normal AIDS-5.7%
process Diabetes-4.6%
4. Neither fastens or delays death
5. Act as a support system for the
client6. Act as a support system
for thefamily members and
Settings for palliative care
 Different settings for palliative care
 1-Palliative care in hospital settings
 2-Palliative care in long-term care facilities
 3-Hospice Care
Palliative Care in Hospital Settings
 The family members need consistent information
about their sick family members and the dying
patient too might need regular symptomatic
treatment for pain and other symptoms. Therefore,
in recent years, the hospital settings have been
improved and it is made sure that pain is regularly
assessed.Therefore,the dying patients generally opt
for end of life care in hospital settings.
Palliative Care in Long-term Care facilities
 The long-term care facilities are increasing rapidly across
the world and measures are taken to improve care facilities
since the resident of long-term care facilities don’t have
adequate access to high quality palliative care
 Along with providing care,long-term facilities are
involved ineducational programs for the staff, residents and
their families.The education can be based on symptons
management and pain relief.
 Hospice Care
 Hospice care is a coordinated program that focuses on support and
care of dying person and his/her family. It can be carried out in
various settings, majorly at home or hospice centers.Hospice was
founded by Cicely Saunders, who was the founder of world-renowned
St Christopher's Hospice, London, England.Hospice aims to facilitate
death peacefully, with dignity. Generally, patients are eligible for
hospice care if itis stated by the physician that the patient is likely to
diewithin next 6 months.Hospice not only cares for physical needs
but also the emotional signs of terminal illness. A regular assessment
and evaluation is needed to assess for any physical or behavioral
change.
 Barrier to palliative care
 Lack of awareness among policy makers, healthcare
professionals, and public.
 Cultural and social barriers.
 Misconception about palliative care, for example, some

consider that palliative care is only meant for cancer or AIDS

patients.
 Misconceptions regarding use of opioids in care and pain

relief.
PHYSICAL CARE OF TERMINALLY ILL PATIENT
PHYSICAL CARE Description

PAIN Administration of pain medication. • Don't ignore pain or delay pain medication.•
Opioids are essential for pain management.
DYSPNEA Administration of oxygen reposition the client by providing side position or elevating
thehead end.• Perform suctioning as indicated. • Opioids can relieve distressing
symptoms including breathlessness.
SKIN Skin changes are apparent.Monitor for breakdown and implementcertain interventions to
prevent thebreakdown.. Check for any discoloration.• Assess body temperature..
DEHYDRATION Provide plenty of fluids orally, but don't forcethe client to eat or drink.• Perform oral care
regularly. • Apply moisturizers on lips to lubricate them.
ANOREXIA,NAUSE Administer antiemetic drugs, if indicated by the physician.vomitingProvide small,
A,VOMITING frequent meals and involvefamily in providing care and following food fads
ELIMINATION Monitor output of the client.
WEAKNESS AND Allow the client to rest as much as required.• Provide support to client while walking, or
PHYSIOLOGICAL CHANGES
AFTER DEATH
 After death, the body undergoes complex
reactions and processes, which result in
physiological changes the body. These
changes can depend on wide range of factors,
such as temperature, season, cause of death,
injuries to the body, etc.
STAGES OF PHYSIOLOGICAL CHANGES
 IMMEDIATE CHANGES
 EARLY CHANGES
 LATE CHANGES
Immediate changes
 After death, all the bodily functions cease and
are irreversibly stopped.

 Vital functions such as breathing, and

circulation, etc. halt. A flat ECG can indicate
cessation of circulation.

 Cessation of nervous system takes place, which

can be manifested by flat ECG.

 Muscle movements are lost.

Early changes
 The early changes are associated with cell death.

 Rigor mortis : It is defined as the stiffening of body. It

occurs after 2-4 hours of death. It begins in the
involuntary muscles of heart, lungs, etc., and reach the
other parts of the body. It is important that the dead
body looks normal, therefore, nurses must close the
eyes and mouth of deceased before rigor mortis comes
into action.

 It leaves the body after approximately 96 hours of

death.
Algor mortis: After death, the body temperature
gradually decreases due to cessation of blood
circulation. The temperature reaches the room
temperature as it falls at rate of about 1° every hour

 Livor mortis : After the blood circulation has

terminated the RBCS break to release
hemoglobin, which then dissolves the
surrounding tissues. The lack of hemoglobin
results in discoloration in lowermost areas of the
body. This is referred to as livor mortis.

 Skin changes also occur. The elasticity of skin is

lost, which results in breakage.
 ALGOR MORTIS  LIVOR MORTIS
Late changes
 Autolysis of the body takes place
 Bacterial action can also cause decomposition of body. These
bacteria can be external or internal.
CARE AFTER
DEATH
A new terminology “care after death” has been
introduced to reflect the range of nursing
responsibilities involved. These include:-
 Providing support to grieving family and care

giver.
 Honoring the religious or cultural

wishes/requirements of the patient and

allowing the family to perform any rituals but in
a legal boundary.
 Preparing the deceased for transfer to the

mortuary.
 Ensuring the privacy and dignity of the

deceased/ body.
 Ensuring the health and safety of everyone who

came in contact with the deceased is protected.

 PROCEDUR
E
ARTICLES- Clean tray
with
 Clean bed sheet 03
 Long artery Forceps,

Gauze pieces and

Absorbent cotton balls.
 Identification labels.
 Bandages
 Clean towel and water

for sponge bath.

 Kidney tray and paper

bag for waste.

 Procedure for care after death is-
Procedure Rationale
Once death has been declared by
doctor, cover patient with clean sheet.
The eyelids are closed and held in
place for few seconds to remain closed.
Body should be placed in supine To make body
position with arms either on side or sightful.
across the abdomen.

Documentation of death shall be done

in medical as well as in nursing
records. For legal safety and
recording of event
Contract relatives and breaking of news and cause of death.
is done. Offer guidance and support.
For psychological
 For cultural practice
Allow relatives to assess any religious
respect.
practice if need to be performed.
For packing body.
Assemble all articles near the
Prevent cross
bedside.
infection.
Wash hand. Wear clean gloves.
Provide privacy.
Pull curtains or close the room. Provide pleasant look
Remove all bags and tubes. Replace to body.
soiled dressing with new ones. To prevent leakage of
Cover IV punctures or any other body fluids.
wound properly. To give the face a
Provide mouth care. Clean the soiled natural appearance.
parts of the body. Prevent leakage of
Put clean gloves. Plug all the orifices fluids from orifices.
by absorbent cotton balls. Close the mouth.
Apply jaw bandage. Fold the hands
on chest in praying position and tie Prevent rigor mortis.
thumbs.
Straighten legs and tie greater toes.
Apply identification slips on left For identification of
wrist and ankle. Wrap patient in the body.
clean sheet. Tie the bedsheet at
neck. To prevent cross
If patient had infectious disease infection.
then body should be packed in
plastic bag.
Cover packed body with
bedsheet while transporting to To maintain dignity of
mortuary or handing over to the body.
relatives.
Arrange transport to mortuary
and document the details in
mortuary book while shifting the
body.
Handing over the body to the
relatives is usually done by the
mortuary.
 Termination of Procedure
 Discard all the used sponges,
dressing ,cotton ,gloves in yellow bag.
 Replace the used articles after appropriate

cleaning and disinfection.

 While shifting the body-

- check all documents available.

- hand over all the valuables and patient’s
belongings to his/her relatives and receive
signature.
- Document the procedure.
Care of unit after death
After the death of a patient in the unit, special
measures have to be taken to normalize the ward.
 First the nurse in charge and the medical staff is informed
about the death.
 The confirmation of death must be recorded in record files.

 The dead body is taken care of and is sent to the morgue.

 After this the nurse along the ward attendant , disinfect the

dead patient’s bed.

 Fresh linen is placed on the bed.

 All the waste generated during the life saving procedures is

disposed of.
 Bedside lockers are cleaned and the articles are replaced.

 The other patients are educated and are made to feel

relaxed.
 Proper documentation should be done, including the date

and time of death.

 Death of one patient should not cause any issue in caring

for other patients.

 Death declaration Certificate
A death certificate is a legal document, issued by the
govt. to the family of deceased. This certificate states the
day, date, cause of death etc.
It’s the responsibility of family members to
register death and obtain the death certificate to prove
death. A death certificate is required for various
purposes :
 Monetary issues
 Insurance policies
 Legal purposes
 Inheriting jobs, property etc.
AUTOPSY
 AUTOPSY/POST MORTEM
 An autopsy or post mortem is a
procedure performed after the death of
a person, to rule out the exact cause of
death. It is the surgical dissection of the
body, which is helpful to discover the
circumstances.
 TYPES OF AUTOPSIES
 Following are the types of autopsies:
 Medicolegal or forensic or coroner’s autopsy
 Clinical or pathological autopsy
 Anatomical or academic autopsies
 Types of Autopsies
Medicolegal or forensic or coroner’s autopsy: It is done to
find the cause of death and to identify the reason. It is mainly
performed when prescribed by law, mysterious death, violent
or suspicious death occurs.
Clinical or pathological autopsy: It is performed to diagnose a
disease for research purpose, ultimate aim is to identify or
confirm diagnosis which has been unclear or unknown before
the death of the individual.
Anatomical or academic autopsies: It is performed by medical
students for learning purpose mainly the anatomy of the
human body.
 Purposes
 To find the cause of death
 To ascertain if the death was natural or unnatural
 To identify the unknown body
 Medicolegal cases
 To acknowledge the time of death
 For research and academic studies
 Nurses Responsibility
 Obtain the consent for performing autopsy
 Ensure that autopsy doesn't deform natural body shape or structure
 Explain that autopsy may be useful for medical research and
advancement in the technology
 Answer any questions put forward by the family
 Motivate for organ donation
 Respect the family’s final wishes and honour their decision on organ
donation.
 EMBLAMING
• DEFINITION OF EMBLAMING
• Emblaming is the process of prevention of body from
being decomposed .It is performed by treating the
body with chemicals ,which help to prevent
decomposition .
It delays the natural process of all cell breakdown ,which
starts immediately after the person dies.
 What is need to emblamed patients

 It temporarily preserves the body for public display at funeral

or at anatomical specimen. Some people get their loved ones
emblamed so as to spend some more time with them .
 Method of emblaming patients
 Some of the solutions used in emblaming the patients are
 Formaldehyde
 Glutaraldehyde
 Ethanol

These solution are used to delay the first few stages of

decomposition .
In emblaming body fluid are replaced with the above
mentioned fluid since the natural body fluid no longer circulate
inside the body
 Method of emblaming patients
 Some of the solutions used in emblaming the patients are
 Formaldehyde
 Glutaraldehyde
 Ethanol

These solution are used to delay the first few stages of

decomposition .
In emblaming body fluid are replaced with the above
mentioned fluid since the natural body fluid no longer circulate
inside the body
 Types of emblaming
Types of emblaming are as follows
 Aterial emblaming
 Cavity emblaming
 Surface emblaming
 Hypodermic emblaming
 Aterial Emblaming
 In this type of emblaming, the body fluids are drained
through the veins and the emblaming fluids are replaced
through the arteries.
 The fluid replacement is done through the tubes which are

connected to the machine. This machine pumps the

emblaming fluid into the body . The vein of choice is
generally jugular or femoral.
 Cavity Emblaming
 The fluid inside the body is removed surgically, as an
incision is done and a tube is inserted in the body through
the incision.
 A suction machine is attached to the tube to remove the

fluids. The fluids are replaced by emblaming fluids and

then the incision is closed.
 Hypodermic Emblaming
 It is the supplement method of injecting the emblaming fluid
using the emblaming fluids using the hypodermic needles and
syringes.
 This method is used when areas are left and aterial fluids has

not been distributed successfully during the aterial injection

in aterial emblaming.
 Surface Emblaming
 Surface emblaming is also supplement method , which is used
to emblam the areas directly on the skin surface. Also other
superficial area of the body can be preserved.
 If the deceased happened due to the accident, surface

emblaming can help fix the area damaged due to the

accident.
 In addition, the damage due to cancerous growth and skin

grafting or donation can be fixed.

 Disadvantages of emblaming
 Formalin treated surface and irritant to other eyes and
mucosa and need gloves for handling.
 The natural colour of specimen is changed.
 The solution need to be replaced frequently.
 In the mortuary
Placing the body
Department of Forensic Medicine provide mortuary services and
preserves the body
 Body is transferred ton the morgue after proper labelling.

 Nursing staff should ensure that all the orifices and drainage

sites are wrapped appropriately.

 Mortuary attendant must be informed about pickup of the dead

body.
 Mortuary staff is responsible for assessing the identification

band on the dead body and keeping the body in the

refrigeration and maintenance of the temperature.
 Body is kept safe until it is released.
 In the mortuary

Releasing the body
If the relatives wish to receive the body, a dead body slip is
issued and signed by the nursing officer and a copy is
preserved in the records . The other slip is given to the
relatives by which they can receive the dead body from the
morgue easily .
Medicolegal Cases
INTRODUCTION
 Medico-legal case (MLC) refers to a case of injury or illness
that indicates investigation by law enforcement agencies to
establish and fix the criminal responsibility for the case
according to the law of the country.
Dying Declaration
1. Statement of a dying person, relating to the cause and
circumstances of his death
2. Magistrate having jurisdiction should be called to record the
declaration
3. Before recording doctor should certify that person and
his/her mental faculties are normal
Dying Declaration

4. If situation
demands the doctor
himself can record in
the presence of two
witnesses
5. The declaration is
then sent to the
magistrate in a
sealed envelope with
a letter
Injury/Wound Report
 Record details of the injuries found in the Accident Register
cum Injury or Wound Report/Certificate.
 The original is the Injury or WoundReport/Certificate,which is

to be detached and issued to the Police Officer,the carbon

copy will remain in the register and serve as a permanent
record for the Medical Officer
WILL
 A living will is a document which attempts to set out the kind of health care
that would be authorised by a patient who is unable to choose, for example,
because he or she is unconscious, delirious or otherwise incapacitated.
 Any person who is above the age of 18 years has the right to make a will.
 It may or may not require a lawyer’s aid.
Organ Donation
 Organ donation and transplantation
is removing an organ from one
person (the donor) and surgically
placing it in another (the recipient)
whose organ has failed.
 Organs that can be donated include
the liver, kidney, pancreas and
heart.
 It can be done when a person is
dead or alive.
 Most donations are done after the
death of the patient.
Death certificate
Death Certificate is Issued only :
• If cause of death is known beyond all doubts
• A person is admitted in hospital, clinical diagnosis is made
based on signs, symptoms and diagnostic procedures
• Death occurs due to natural consequences after diagnosis is
made
Death certificate
Don’t certify death in the following conditions:
• Person brought death/dead on arrival to casualty
• Persons dying after admission and before making a
diagnosis • In all alleged cases of unnatural
death(accident/suicide/homicide)
• Anaesthetic deaths
• Snakebites
• Death of a woman in her husband’s house within 7 yrs of
marriage
Medical Negligence
“the ommission to do something which a reasonable
man guided by those ordinary considerations which
ordinarily regulate human affairs,would do,or the doing
of something which a reasonable and prudent man
would not do”
 EUTHANASIA
DEFINITION :-
Euthanasia is defined as painless killing of patient suffering from an
incurable and painfull disease
Classification
1. Voluntary Euthanasia
It is conducted with consent of the patient. It is of two types active
and passive. It is concerned as a right to choice of the patient.
2. Nonvoluntary Euthanasia
It is conducted when consent of the patientis not available like who
is mentally incompetent or comatose patient. In this case the family
membersmake the choice of nonvoluntary Euthanasia.
3.Active Euthanasia
Death of individual caused when medical professional or any other
person deliberately does an action like using lethal injection to
painlessly resulting in death of terminally ill patient.
4.Passive Euthanasia
It is by means of withdrawal of life support which is
essential for continuance of life and gradually patient
moves to death. It is legal in throughout US.
Euthanasia In India
 On 9 March 2018 the supreme court of india legalized passive
Euthanasia by means of the withdrawal of life support to
patients in a permanent vegetative state. The decision was
made as part of the verdict in a case involving Aruna
Shahnbaug(nurse by profession), who had been in a persistent
vegetative state (PVS) for 42 Year Until her death in 2015.