NUR 220: FINAL- Death + Dying

Loss

the experience of losing someone or something significant

Grief

A natural reaction in response to the death of a loved one or to a significant life change

Anticipatory Grief

Grief in the expectation of loss

Mourning

Period of mourning and grief following the death

Bereavement

Having lost someone close encompassing both the emotional response and the period of adjustment following the loss.

Sheldon’s Stages of Grief

7 stages of grief:

1. Shock + denial

2. Guilt

3. Anger

4. Bargaining

5. Depression

6. Testing

7. Acceptance

What is important in Informed End of Life Care?

Having scientific and clinical knowledge of disease processes and biological dying

Complicated grief

• unresolved grief or complex bereavement

• distressing symptoms lasting at least 6 months after the death of a significant person

Disenfranchised grief

• Any loss that is not validated or recognized

• May not be able to be shared or acknowledged publicly by the grieving person

____ is a healing process. There can’t be healing without it.

Grief

What are factors affecting grief + bereavement?

Age, health status, cognitive status, relationship, coping styles, available support systems, religion, type of loss

Assessment of Caregiver

• general health checkup

• physical, emotional, mental assessment

• assess nutritional status + sleep

• assess social network

Physical assessment of the patient

• physical symptoms at the end of life

• signs and symptoms of impending death

• signs and symptoms of death

Stages of Dying: early stage

• Human body begins to conserve energy → reduced appetite, lack of interest in food

• Trouble swallowing, feeling full after consuming little food, decreased pleasure from food

• Chewing, swallowing, and digestion may become painful due to dry mouth, oral sores, dry throat, and bloating

Stages of Dying: middle stage

Lasts anywhere from hours to days

• reduction in peripheral circulation as blood flow is redirected to primary organs

• changes in internal blood circulation → leads to low BP, irregular breathing patterns, bradycardia

• cool hands + feet, paling, darkening of skin, mottling (spotting of skin)

• weakness + fatigue → can lead to not being able to speak

Can patients in the middle stage of dying still experience touch, hearing, and emotions?

Yes → just because they can’t communicate doesn’t mean they can’t experience other sensations

Stages of dying: Late stage

Progressive failure of body organ systems

• Breathing muscles less effective + unable to clear secretions

• Sporadic, shallow, or noisy breathing

• Labored breathing, periods of apnea, temporary pauses in breathing

• Bowel + bladder incontinence but little or no urine/stool output

• Widespread mottling

• Patients extremely restless

Stages of Dying: Physical Signs of Impending Death

Occur during the last hours before death

• Terminal restlessness or terminal agitation

• Fading consciousness or periods of unconsciousness

• Illusions, delusions, hallucinations, + death awareness

• CHEYNE-STOKES (abnormal breathing characterized by progressively deeper and sometimes faster breathing followed by a gradual decrease that results in a temporary stop in breathing)

Stages of Dying: Death Occurs

• Absence of pulse and heartbeat

• Unresponsiveness to verbal or physical stimuli

• Lack of breath/respiratory effort

• Coolness of the skin

• Rigor mortis

• Incontinence or release of bodily fluids

• Pale or bluish hue

Declaration of Death

Post-mortem care begins after the client has been officially declared deceased by TWO licensed healthcare professionals

Nursing Diagnoses

• Grief

• Chronic sadness

• Death anxiety

• Fear

• Social isolation

• Spiritual distress

Nursing Planning

Possible SMART goals:

• Husband will express feelings toward the anticipated loss of his wife during her last few days

Nursing Implementation (Interventions)

• Provide education (about stages of grief)

• Encourage healthy behaviors

• Listen while the patient tells stories

• Include the entire family in assessment + planning

• Use community resources + make referrals

Grief comes in ____ rather than stages + emotions don’t follow a set pattern. Grief hits people differently.

waves

Advance care planning for end of life

An ongoing process that involves making decisions about future health care

• Advance directives: legal documents that can inform providers about a patient’s goals of care and who to contact for decisions about that care.

Palliative care

Fulfills needs of patients who were not terminally ill but needed high-quality symptom control for a serious or life-threatening illness

Communication

• Simple, uncomplicated terms

• Avoid overloading/overwhelming pt. or family

• Telling the family the pt. has died is done in an open and honest manner with compassion and support

Care of the dying patient

• Favorite belongings

• Allow pets to visit

• Unrestricted visiting hours

• Time for privacy

• Space for necessary closeness and intimacy

• Only conduct tests if treatment measures will be implemented

• Basic nursing care: bathing, oral care, turning and repositioning

• Control symptoms

If your patient is dying, do you still treat them for a UTI?

Yes → Even if they are dying you should treat them because it is tied to comfort care

T or F: People who are grieving need to demonstrate that they can talk about the meaning of their loss, use available support systems, and deal with the loss.

TRUE → it is important that family members can grieve their loss

Postmortem Care: care of the patient at time of death

• Pronouncement of death

• Remove unnecessary items, clean the room

• Ask the family whether any religious or cultural practices need to be followed

Postmortem Care: Organ Donation

• Recognize a potential situation in which organ donation may be a possibility

• Work collaboratively with patient/family and interprofessionals