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DEATH AND DYING DEATH - Also called Cerebral Death or Higher Brain Death which occurs with irreversible destruction of the cerebral cortex. INDICATORS OF CEREBRAL DEATH - Absence of response to external stimuli - Absence of reflexes - Absence of Respiration - Flat encephalogram for 30 minutes TRADITIONAL CLINICAL SIGNS OF DEATH (Heart- Lung Death) - Cessation of the apical pulse - Cessation of respiration - Cessation of blood pressure CONCEPT OF DEATH ACCORDING TO DEVELOPMENTAL STAGE DEVELOPMENTAL STAGE Infancy to 5 years 5 to 9 years 9 to 12 years 12 to 18 years 18 to 45 years 45 to 65 years 65 and above RESPONSES TO DEATH AND DYING - Anticipatory meaning - Fear - Hopelessness - Powerlessness - Caregiver role strain - Impaired family processes LEGAL ASPECTS OF DEATH AND DYING Advanced Health Care Directives - Variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become unable to make or communicate their preferences. Types of Advanced Health Care Directives 1. Living Will 2. Health Care Proxy (Durable power of attorney for health care) CONCEPT OF DEATH Reversible Temporary Sleep Death is final Can be avoided Death is inevitable Fears lingering death Religious and cultural Accepts death Multiple meaning

CREArroyo,RN

Legalities of a Health Care Proxy - It should be notarized and witnessed - It should be appointing someone else (Relative or trusted friend) to manage health care treatment decisions when the client is unable to do so Do not resuscitate Orders (DNR) - Ordered by physician to clients with TERMINAL ILLNESS, IRREVERSIBLE ILLNESS or expected death. - It is written when the CLIENT or PROXY has expressed the wish for no resuscitation in case of cardiac or respiratory arrest occurs. - The goal of treatment is a comfortable, dignified death and that further life- sustaining measures are not indicated. Euthanasia - Also called MERCY KILLING. It is the act of painlessly putting to death a persons suffering from incurable or distressing disease. Certification of Death - Formal pronouncement of death - Must be signed by attending physician - Must be filed to the local government - Relatives must be given a copy Persons Who Can Pronounce Death - Physician - Coroner - Advance Practice Nurses (In long- term care, home health and hospice agencies) Autopsy or Post- Mortem Examination - It is the examination of a dead body Indications - Sudden death - Death occurring less than 48 hours after hospital admission Purposes - To determine exact cause of death - To learn more about the disease - To assist in statistical data Important Instructions - Obtain consent for the procedure - The hospital CANNOT RETAIN any tissues or organs without the permission of the person who gave consent to the autopsy. Inquest -

Legal inquiry into the cause and manner of death. It is conducted under the jurisdiction of a coroner or medical examiner.

CREArroyo,RN

Organ Donation - Limited only to people 18 years or older, with sound mind and can give a gift of any part of his body. Common Reasons for Organ Donation - Medical of Dental education - Research - Advancement of medical, dental science - Therapy - Transplantation DEATH- RELATED RELIGIOUS AND CULTURAL PRACTICES - People prefer a peaceful death at home than in hospital - Some may request not to reveal the prognosis to dying client - Beliefs regarding cremation, autopsy, organ donation - Nurses should know who to call, when as the impending death draws near - Muslims customarily turn the body in Mecca (If Muslim) - Mormons are dressed with their temple clothes THE DYING PERSONS BILL OF RIGHTS 1. To be treated as a living human being until I die 2. To maintain a sense of hopefulness however changing its focus may be 3. To express my feelings and emotions about my approaching death in my own way 4. To participate in decisions concerning my care 5. To expect continuing medical and nursing attention though cure goals must be changed to comfort goals 6. Not to die alone 7. To be free from pain 8. To have my questions answered honestly 9. Not to be deceived 10. To have help from and for my family in accepting my death 11. To die in peace and with dignity 12. To retain my individuality and not to be judged for my decisions which may be contrary to the beliefs of others 13. To be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death NURSING PROCESS Assessment 1. Identify state of awareness of the client and the family members 2. Identify family expectations when the person dies so accurate information will be given 3. Assess for physiologic signs of impending death 3 Types of Awareness 1. CLOSED AWARENESS- client is unaware of impending death 2. MUTUAL AWARENESS- client, family, and health personnel know the prognosis but dont talk about it and make an effort not to raise the subject.

CREArroyo,RN

3. OPEN AWARENESS- client, family, health personnel know the impending death and feel comfortable discussing it even if its difficult. Signs of impending Clinical Death - Loss of muscle tone - Slowing down of the circulation - Rapid, shallow respiration - Sensory impairment HEARING IS THE LAST SENSE TO BE LOST Nursing Diagnoses 1. Fear 2. Hopelessness 3. Powerlessness 4. Risk for caregiver role strain 5. Impaired family process Planning Major Goals for Dying Clients - Maintain physiologic and psychologic comfort - Achieve a dignified death Implementation The major responsibility for a dying client is to provide peaceful death Specific Nursing Responsibilities - Provide relief from fear, loneliness and depression - Maintain the clients sense of security, self- confidence, dignity and self- worth - Help the client accept losses - Provide physical comfort Tips to make discussion of death comfortable for the Nurse and Client - Identify personal feeling about death and how they may influence interaction for client - Focus on the clients needs - Talk to the client or the family how the client usually cope with stress - Determine what the client knows about illness and prognosis - Respond with honesty and directness to the clients questions about death - Make time for the client to support, listen and respond - Establish communication that shows commitment and concern for the client Communication Strategies when talking about Death - Describe what you see - Clarify your concern - Acknowledge clients struggle - Provide a caring touch Provide Hospice and Palliative Care Focuses on SYMPTOMATIC CARE of clients for whom disease no longer respond to cure- focused treatment.

CREArroyo,RN

Interventions to meet Clients Physiologic Needs PROBLEM NURSING INTERVENTIONS Airway Clearance Position client properly Suction as needed Provide O2 (Oxygen) Hygiene Provide regular bath Change linen regularly Provide mouth care Apply moisturizers and barriers Physical Mobility Assist in position changes Assist with mobility and ambulation Support with pillows, towels or rolls Elevate legs when sitting Nutrition Give soft or liquid foods Give anti- emetics or alcoholic beverages Elimination Give foods high in fiber Give stool softeners and laxatives Provide skin care Prepare bedpan, commode, urinal and call lights within reach Give absorbent pad Change linens as needed Catheterize as necessary Sensory Perceptual Changes Check preference for a light room Speak clearly, do not whisper Touch as needed Implement pain management according to protocol Provide Spiritual Support - Facilitate expression of feeling - Prayer - Meditation - Reading - Discussion with the clergy or spiritual advisor Support the Family - Provide caring and emphatic presence - Maintain a calm and patient demeanor - Encourage family to view the body Provide Post- Mortem Care CLIENT AND FAMILY REACYIONS TO LOSS, DEATH AND DYING 1. Bereavement- subjective response by loved ones after the death of a significant person 2. Mourning- behavioral process wherein grief is resolved 3. Greif- total response to the emotional experience related to loss 4. Anticipatory loss- experienced loss before an actual loss occur

CREArroyo,RN

TYPES OF LOSS 1. Actual 2. Perceived 3. Situational 4. Developmental SOURCES OF LOSS 1. Loss of an aspect of oneself 2. Loss of an object external to oneself 3. Separation from an accustomed environment 4. Loss of a loved or valued person TYPES OF GRIEF RESPONSES 1. Anticipatory 2. Abbreviated 3. Disenfranchised grief 4. Dysfunctional 5. Unresolved 6. Inhibited NORMAL GRIEF RESPONSES - Verbalization of loss - Crying - Sleep disturbance - Loss of appetite - Difficulty concentrating FACTORS INFLUENCING THE GRIEF RESPONSES - Age - Significance of the loss - Culture - Spiritual beliefs - Gender - Socioeconomic status - Support system - Cause of loss or death INDICATORS OF DYSFUNCTIONAL GRIEVING - Failure to grieve - Avoids visiting the grave - Refuses to participate in memorial services - Recurrently symptomatic on the anniversary of a loss or during holidays - Develops persistent guilt - Lowered self- esteem - Continued search for the lost person - Grief easily triggered by relatively minor events

CREArroyo,RN

Inability to discuss the deceased without composure Experience of physical symptoms similar to those of the person who died Worsened relationship with friends and relatives

FACTORS CONTRIBUTING TO UNRESOLVED GRIEF - Ambivalence towards the lost person - Perceived need to be brave and in control - Fear of losing control in front of others - Endurance of multiple losses - Extremely high emotional value invested in the dead person - Lack of support system STAGES OF GRIEVING (Kubler- Ross, 1969) STAGE Denial Anger Bargaining Depression

Acceptance

NURSING ROLE Verbal support Do not take anger personally Promote security Listen attentively Provide spiritual guidance Encourage expression Active friendliness Convey touch Help to understand Encourage participation

(Engel, 1964) STAGE Shock and Disbelief INDICATORS Refuses to accept the loss Stunned feelings Emotional denial Conscious of the loss Directs anger to others Conducts rituals of mourning Tries to deal with the loss Talks and thinks about the memories Feels guilt Reinvests feeling in others Acceptance of the loss

Developing Awareness Restitution Resolving the loss Idealization Outcome PHASES OF BEREAVEMENT (Sander, 1998) 1. Shock 2. Awareness of loss 3. Conservation or Withdrawal 4. Healing 5. Renewal

CREArroyo,RN

FIVE CLUSTERS OF GRIEF (Martocchio, 1985) 1. Shock and Disbelief 2. Yearning and Protest 3. Anguish, disorganization and despair 4. Identification and Bereavement 5. Reorganization and Restitution CATEGORIES OF GRIEF RESPONSES (Rado, 2000) 1. Avoidance 2. Confrontation 3. Accomodation NURSING PROCESS Assessment Nursing History - Personal coping resources - Previous and current losses, the nature of the loss and the significance of such loss to the client Physical Assessment - General Appearance - Vital Signs Nursing Diagnoses 1. Anticipatory Grieving 2. Dysfunctional Grieving 3. Interrupted Family Process 4. Impaired Adjustment 5. Risk for Loneliness Planning Goals for clients with loss of body function 1. To adjust the change in ability 2. To redirect both physical and emotional energy into rehabilitation Goals for clients grieving the loss of a loved one 1. To remember that the person without intense pain 2. To redirect emotional energy into ones own life 3. To adjust to the actual and impending loss Nursing Interventions Use Therapeutic Responses - Active listening - Silence - Paraphrasing - Clarifying and reflecting feelings and summarizing

CREArroyo,RN

Avoid Non- Therapeutic Responses - Giving advice - Evaluating - Interpreting and analyzing - Unwarranted and false reassurance Facilitate Grieving - Explore and respect culture, ethnic, religion, personal values - Encourage to share and express grief with support people - Encourage to resume normal activities on schedule that promotes physical and psychological health Promote Emotional Support - Use silence and personal presence - acknowledge

CREArroyo,RN