Nursing Care for the Dying and Kubler-Ross Stages

Actual Loss: This refers to a loss that can be recognized by others as well as the person sustaining the loss. An example provided includes a $26$ -year-old patient reminiscing about their four years of college, the friendships made, and the independence from current responsibilities (such as paying rent and working an $8-5$ job). In this context, the transition from one life stage to another and the loss of that environment is classified as an actual loss.
Other Types of Loss (Contextual): * Perceived Loss: Experienced by the person but intangible to others. * Anticipatory Loss: Occurs when a person displays loss and grief behaviors for a loss that has yet to take place. * Situational Loss: Occurs as a result of an unpredictable event. * Dysfunctional Grief: Abnormal or distorted grief that may be unresolved or inhibited.

Clinical Criteria for Death Certification: Specific medical indicators are used to legally and medically certify death. These include: * A respiratory rate of $0\,\text{bpm}$ . * An encephalogram (EEG) showing flat brain waves, indicating a lack of electrical activity in the brain. * The patient showing no response to deep painful stimuli.
Exclusions: While a drop in blood pressure is common during the dying process, a specific rate like "dropping by $20$ systolic each hour" is not a standard standalone criterion for certifying death. The presence of a gag reflex would indicate brainstem function and count against a certification of death.

Physical Manifestations: As a patient nears death, several physiological changes occur: * Urinary Incontinence: Loss of control over the bladder. * Decreasing Body Temperature: The body loses the ability to regulate heat, often resulting in skin that feels cool to the touch. * Mottling of the Extremities: A bluish or purple marbled appearance of the skin, typically starting on the feet and moving up the legs, caused by diminished peripheral circulation.
Inconclusive Signs: While abdominal distention can occur, it is not listed as a primary sign of impending death in this specific clinical context. Behavioral changes like combativeness and aggression are sometimes seen in terminal restlessness but are not universal clinical markers of the final stages of impending death.

Definitions of the Five Stages: 1. Denial: A refusal to accept reality or the facts of the situation. 2. Anger: An emotional response characterized by frustration, agitation, and "why me?" feelings. 3. Bargaining: An attempt to regain control or postpone the inevitable through negotiation (often with a higher power). 4. Depression: Characterized by profound sadness, withdrawal, and a period of preparatory grief. 5. Acceptance: The final stage where the individual reaches an acknowledgment of the situation and comes to terms with reality.
Dynamics of the Stages: * A person may be in more than one stage at any given time. * A person may return to a previous stage (the process is non-linear). * The stages do not have to occur in a specific order (e.g., they do not always move strictly from denial to acceptance). * These stages are not limited solely to the dying process; they can apply to various forms of significant loss. * There is no fixed timeframe for stages (e.g., they do not necessarily last for $2-3$ weeks each).

Legal Authority: A coroner has the legal authority to order that an autopsy be performed, regardless of family consent in certain jurisdictions or situations.
Notification Requirements: The coroner must be notified if a death occurs by suicide.
Purposes of an Autopsy: Autopsies may be performed to gain scientific knowledge or to determine the cause of death in suspicious circumstances.
Consent Sovereignty: Consent from the family is generally required to perform an autopsy unless the death is considered suspicious or falls under the coroner's jurisdiction.
Role of the Physician: While a physician or provider pronounces the time of death, they do not determine if an autopsy is required in all cases; this often falls to legal authorities (coroners/medical examiners) or specific facility/state protocols.

Patient Comfort and Psychological Support: * Ensure physical comfort by making sure bed sheets are not wrinkled. * Administer pain medications as ordered by the provider to manage terminal pain. * Provide the patient with time and a safe space to express their fear of dying. * Support the patient’s religious or spiritual needs through appropriate interventions or referrals.
Family Support: * Provide family members with resources to help them through the grieving process.
End-of-Life Coordination: * Obtain provider orders to stop nutritional feeds when appropriate for the patient's status and goals of care.
Post-Mortem Care and Procedures: * Wash the body after death has occurred, following specific facility policies. * Place an identification tag on the dead body. * Critical Constraint regarding Autopsies: If an autopsy is to be performed, the nurse should not remove tubes. All tubes and lines must remain in place for the coroner's examination.

Cumulative Knowledge Alert: Information covered in previous courses (such as NSG 142) remains testable. This includes: * Palliative care and Hospice care definitions and differences. * Ethical and legal dimensions of end-of-life care. * POLST Forms: Physician Orders for Life-Sustaining Treatment. * DNR Status: Do Not Resuscitate orders. * Euthanasia: Concepts of active and passive euthanasia.