Concept: A theory by Abraham Maslow explaining that physiological needs must be met before psychosocial needs; framework used by nurses to prioritize resident-centered care and plan outcomes.
Levels (from lowest to highest):
Physiological Needs
Nutrition (water and food), elimination (toileting), breathing/circulation (vital signs), sleep, sex, shelter, and exercise
Safety and Security
Injury prevention (call lights, hand hygiene, fall precautions, assistive devices, close observation)
Build trust (communication, reassurance, empathy)
Ensure a clean, safe environment (free from harm, recognition, and alleviation of fears) and provide resident and family education
Love and Belonging
Supportive relationships free from social isolation
Therapeutic communication skills
Meaningful relationships
Self-Esteem
Acceptance into a community or facility
Personal achievement
Sense of control or empowerment
Accepting one's physical appearance and mental capabilities
Self-Actualization
Empowering environment
Spiritual growth
Ability to recognize others' points of view
Reaching one's maximum potential
Role of the Nurse Aide (NA)
The NA is a vital link in assisting the resident to achieve individual levels of need
Context
Used within the NCDHHS/DHSR/HCPECINATI Curriculum (July 2024) for guiding resident care planning and prioritization
End-of-Life Care (Module W)
Definition List (Key Terms)
Acceptance: the final stage of grief when the person acknowledges death is imminent after working through feelings
Advance Directive: a living will written while competent or by a legal representative outlining choices about withdrawing/withholding life-sustaining procedures if terminally ill
Anger: second stage of grief; expressions of rage and resentment; may be triggered by small things; may lash out at others
Apnea: respiration stops
Bargaining: third stage of grief; seeking more time to live or finish business; may bargain with doctors or God
Cheyne-Stokes Breathing: alternating shallow breaths with periods of no breathing (5, 30, or 60 seconds); not typically causing discomfort
Death: end-of-life and cessation of bodily functions
Denial: first stage of grief; may refuse to accept diagnosis or discuss prognosis
Do Not Resuscitate (DNR): medical order not to perform CPR if the resident has no pulse or is not breathing; honors resident’s wishes to avoid extraordinary measures
Dying: near end of life and nearing cessation of bodily functions
End-of-Life Care: support and care provided around the time of death
Extraordinary Measures: interventions to restore heartbeat or respiration (e.g., CPR)
Hospice Care: care program for people who are dying (usually with less than six months to live) focusing on comfort, dignity, respect, and support for resident and family
Mottling: changes in skin color near death (pale and bluish)
Obituary: description of a resident's life published posthumously
Postmortem Care: care of the body after death
Terminal Illness: an incurable illness that leads to death
Omnibus Budget Reconciliation Act (OBRA) & Patient Self-Determination Act (PSDA): legal framework giving rights to accept/refuse treatment and make advance directives, including living wills and durable powers of attorney
Living Will: outlines medical care desired if decision-making capacity is lost
Durable Health Care Power of Attorney: appoints someone to make healthcare decisions when the individual cannot
Module Structure (S-series Overview)
S-1 Title Slide
S-2 Objectives
Define death and end-of-life care
Describe stages of grief
Explore cultural differences in dealing with death and dying
Examine own feelings about end of life
Describe the nurse aide's role in end-of-life care
S-3 Advance Care Planning
Planning for future decisions about medical care
Typically used when one becomes incapacitated or cannot speak for themselves
Based on personal values, preferences, and discussions with loved ones
S-4 Advance Directives
OBRA/PSDA rights; living wills and durable powers of attorney
Can be changed or cancelled at any time
Must be written while mentally competent or by a legal representative
Durable Health Care Power of Attorney details
Nurse aides must honor advance directives
S-5 Advance Directive – Do Not Resuscitate (DNR)
Medical order instructing not to perform CPR if no pulse or breathing
Indicates no extraordinary measures during cardiac/respiratory arrest
Nurse aide must honor DNR
S-12 End-of-Life Care – The Healthcare Team
Staff and family may be unprepared for death; may feel shocked
Recognize variety of feelings and respond empathetically
Demonstrate caring, interested attitude
Observe for changes in other residents; report and record information
S-13 Signs of Impending Death
Psychological and physical withdrawal
Decreased alertness, more sleep
Temperature changes (rise), cooling, pale appearance, perspiration
Circulatory decline; pulse irregularity; BP drop
Extremities cold and mottled; respiratory decline; Cheyne-Stokes breathing
Death rattle (airways with saliva/mucus); focus on preventing choking
Diminished muscle tone; limbs become limp; head/neck relaxation; sensory decline including hearing
Pain may decrease with loss of consciousness
S-14 Signs of Death
Notify nurse immediately
No pulse, no respirations, no blood pressure
Pupils fixed and dilated; no response to voice or touch; eyes may remain open
Mouth may remain open; possible incontinence
S-15 Exploring Responses to Death
Reactions vary by personal, cultural, religious beliefs
Nurse aide feelings impact care; caregiver closeness in long-term care
Understanding dying helps ensure care with dignity and respect
S-16 Stages of Grief (Kubler-Ross model)
Denial, Anger, Bargaining, Depression, Acceptance
Stages are experienced differently by individuals; rates vary; may not pass through all stages; can be non-linear
Anger is not personal—use active listening and support
S-17 Denial (1st Stage)
“No, not me” response; may refuse prognosis or discuss prognosis; may believe a mistake occurred
S-18 Anger (2nd Stage)
“Why me” stage; expressions of rage; may target nurse aides; do not take personally
S-19 Bargaining (3rd Stage)
“Yes me, but”; seeks more time or to complete unfinished business; usually private/spiritual
S-20 Depression (4th Stage)
Mourning, withdrawal; may become weaker or unable to perform tasks; emotional support needed
S-21 Acceptance (5th Stage)
Not a guarantee that death is imminent; may plan affairs; may or may not reach before death
S-22 Meaning (6th Stage, added by David Kessler in 2019)
Personal and evolving; takes time; does not require immediate understanding; involves saying goodbye to the life lived and embracing the future
S-23 Dealing with Grief – An Obituary
Obituaries can be part of the grieving process; honors the deceased; sharing with others aids processing
S-24 Postmortem Care
Follow facility policy; privacy; prepare postmortem kit; hand hygiene; gloves
Close eyes; bed bath; dress in clean gown; pad beneath perineal area; dentures as instructed; remove jewelry per policy
Rigour mortis develops 2–4 hours after death; position body to normal alignment before rigor
Movement of body and release of air/contents may cause sounds; these are normal
Position: supine, legs straight, arms folded across abdomen, pillow under head
S-25 Role of the Nurse Aide — Care of the Family
Provide private space for family; identify who should be contacted
Offer water or a beverage; respect privacy; close door as needed
Nurse aides should respond with sincerity and compassion; offer an empathetic statement such as “I’m sorry”
End-of-Life Care: Focus on the Resident and Team
The goal is to provide care that is as normal as possible and preserves dignity
Environment considerations: well-lit, well-ventilated room; position for comfort; consider favorite music; keep the patient in a comfortable position; use back rubs; facilitate mouth care and food/fluid intake as tolerated
Cultural sensitivity is essential
Do not impose beliefs; ask about practices
Questions the team may ask: who provides personal care; cultural post-mortem customs; any special practices the family expects
Cultural examples (from the module):
Chinese culture: herbal remedies; autopsy/disposal may be restricted
Japanese culture: the number four is associated with death, which can affect scheduling of medications
Vietnamese culture: belief in reincarnation; prioritizes quality of life
Hindu culture: acceptance of God’s will; prayer for anxiety management; transfusions/organ transplants/autopsies allowed; cremation often preferred; belief in reincarnation
The healthcare team’s emotional readiness
Staff and families may be unprepared for death; some may be