Terminal Illness And

Death

DEATH ACROSS THE LIFESPAN: CAUSES &

REACTIONS
We associate death with old age, but death occurs
throughout the life span.
Infant and Childhood Deaths: the US has a high infant
mortality rate.

Parents dealing with infant death have a very hard time and depression is a
common reaction.
Prenatal death (Miscarriage) is also difficult, especially since others do not
attribute much meaning to a miscarriage so parents feel isolated.

DEATH IN ADOLESCENCE
Adolescents views of death are also unrealistic &
often highly romantic.

Personal Fable (beliefs that they are unique & special) lead to a sense of
invulnerability

The most frequent cause of adolescent death is

accidents (usually motor vehicle)
Other frequent causes include homicide, suicide,
cancer, AIDS
Adolescents tend to feel invulnerable so confronting a
terminal illness can be difficult; they often feel
angry and "cheated".

DEATH IN YOUNG ADULTHOOD

Death is young adulthood is particularly difficult
because it is the time in life when people feel
most ready to begin their own lives.
Young adults facing death have several concerns.
Developing intimate relationships and one's
sexuality.
Future planning (e.g., marry or not? have children?).
Like adolescents, young adults are outraged at
impending death and may direct anger toward
their care providers.

DEATH IN MIDDLE ADULTHOOD

Life-threatening disease is the most
common cause of death in middle-aged
adults.
These adults are more aware and
accepting of death but also have a lot
of fears (more than any other time in
lifespan).
Most frequent causes are heart attack or
stoke - both of which are sudden

DEATH IN LATE ADULTHOOD

The prevalence of death and losses around
older adults makes them less anxious
about dying than at any other time of life.
Suicide rate increases with age for men.
Caucasian men over age 85 have the highest
rate of suicide.
A major issue for seniors with a terminal
disease is whether their lives still have
value and how much of a burden they
are.

The Dying Child

Terminally ill children as young as 3 years old
come to know that they are dying, and that death
is a final and irreversible process
Children may not be able to talk about death but
express their understanding of their approaching
death in their behavior
Fear of wasting time, wanting to have things done right
away
Dislike of talking about the future
Absorption with death and disease
Setting up a distance from others but acts of anger and
silence

The Dying Child

Stages:
Initial awareness of the seriousness of the illness
Learning names of various drugs and medical
procedures, perceives that he/she is seriously ill but will
get better
Learns the purpose of various medical procedures and
perceives that she is always ill but will get better
After series of relapses he perceives that he will never
get better
After numerous relapses and remissions understands
that he/she is dying (often associated with leaning about
death of a peer with the same disease)

Feelings of a Dying Child

Fear and anxiety

Separation from parents and other family members
Increasing anxiety of medical procedures
Increased anxiety because of feelings of fear and anxiety in their family
members

Anger
Loss of self-control and independence
Often results in developmental regress to an emotional level at which they
are no loner independent
Some children overcompensate by refusal of help from family and hospital
personnel

Sadness
Grieving loss of what they had before the illness (decline in contact with
friends, absence from social and other activities, pain, discomfort,
decreasing mobility, alterations in body image etc.)

Loneliness and Isolation

Because of mutual presence of the approaching death, there may be no
opportunity for parents and the dying child to truly share their concerns
and fears and provide comfort, security, and reassurance
Childrens feelings about death sometimes become masked and repressed

Feelings of a dying child

Often marked by mutual pretense of the approaching death
Children may want to maintain the pretense that they are
feeling well because they are afraid of being abandoned or
rejected
To let children talk about death, about their fears and
feelings, their hopes and despairs, their certainties and
uncertainties, their love, and hate, means we are allowing
them to talk about life, their life, and we are providing them
with the only possible help: the presence of another human
being until the end.
Spiritual needs
Prominent in the lives of dying children
A positive image of what lies beyond death
Reassurance that they will be remembered

Individual differences
Some children are resilient and playful even when their life is
ending

Emotional and Physical Reasons People

May Fear Death.

Helplessness
Dependence on others
Physical faculties
Mutilation by surgery or disease
Uncontrollable pain
Being unprepared for death

Social Reasons People May Fear

Death
Fear of separation from family or
home
Fear of leaving behind unfinished
tasks or responsibilities

Dr. Elizabeth Kubler-Russ

Identified five stages of grieving that
dying patients and their families and
friends may experience.
They may not be in order and may
overlap or repeat a stage at times.
Others may not experience all stages.
Stages include denial, anger,
bargaining, depression, and
acceptance.

Denial
Usually occurs when the person is
first told of the illness.
Individuals may say,
The tests are wrong.
This cant be happening to me.
I dont believe it.

Others dont talk about it.

Health care workers should listen
without confirming or denying it.

Anger
This stage occurs when the patient
can no longer deny death.
The patient may blame themselves,
their loved ones, or health care
workers for their illness.
Health care workers must understand
this is not a personal attack.

Bargaining
Usually occurs when patient accepts death
but wants more time to live.
Patients turn to religion and spiritual
beliefs during this period.
They want to see their child gradate, get
married, or hold a grandchild.
Making promises to God to try and obtain
more time sometimes occurs.

Depression
This stage occurs when the patient
realizes that death will come soon
and they wont be with their families
any longer.
They realize that some goals they set
will not be met.
Health care workers need to let the
patient know that depression is OK.

Acceptance
This is normally the final stage.
The patient understands that they are
going to die.
May complete unfinished business and
try to help those around them deal with
death.
Patients will slowly get farther away from
the world and other people.
They need emotional support during this
stage.

Interventions for Health Care

Professionals
Talk as needed
Avoid superficial answers, i.e. Its
Gods
will. or It will be OK.
Provide religious support as appropriate
Stay with the patient as needed
Work with the family so they might be
strong enough to offer support to the
dying person.

Physical Changes
Of
Death

Respiratory System
1.Unable to oxygenate the body enough for
adequate gas diffusion
2.Respirations become stridorous or noisy,
leading to death rattle
3. Cheyne-Stokes respiration sign of
pulmonary system failure
a. Consists of alternate hyperpneic and
apneic phases

Cardiovascular System
Heart unable to pump strongly enough to keep blood
moving
Decreased blood causes decreased circulation to the
body

Skin becomes cool to the touch, pale

Person appears cyanotic, possibly mottled
Failure of peripheral circulation frequently results in a drenching
sweat cooling the body surface.

Pulse becomes weak and thready, ultimately

irregular

A stronger pulse typically means death is hours away

A weak, irregular pulse typically means that death is imminent
in the next couple of hours.
An apical pulse might be required.

Other Changes
Metabolism rates decrease.
The person might retain feces or become
incontinent.
Urinary output decreases.
Dying person may turn toward light as sight
diminishes.
Dying person may hear only what is distinctly
spoken.
Dying person may remain consciousness or
become unconscious/comatose

Other Changes
Some dying people rally in clarity and
consciousness just prior to their death
A persons eyes might be open even if
unconscious
Dying people might turn toward or speak to
someone who is not visible to anyone else in
room
Pain might be present
Pain medication should not be withheld as
person nears death.

Right to Die
Most people with terminal illness believe that
someone with a terminal illness should be
allowed to refuse measures that would
prolong their life.
This is the right to die.
Respirators, pacemakers, and other medical
devices can be withheld and the person can
die with dignity.
DNR Do Not Resuscitate Order

Caring for the terminally ill: The Place of Death

Most people in the United States die

in hospitals.
For the terminally ill, hospitals may
not be the best places to die.
Hospitals are impersonal, expensive,
and designed to make people better
and many people die alone.

Several alternatives to hospitalization have become

increasingly popular in the last few decades
In HOME CARE, an alternative to the
hospital, people stay in their homes and
receive comfort and treatment from their
families and visiting medical staff.
Many people prefer to die in familiar
surroundings with the people and things they
have loved around them.
Home care can be very difficult for the family.

In the final stage, people reach an accommodation

stage where they pick up the pieces of their lives and
move on.
Ultimately, most people are able to live new lives,
independently from the person who has died
Form new relationships
Become more self reliant and appreciate of life
Not everyone passes through the stages of grief in
the the same order or in the exact same way
Personality differences
Relationship with the deceased
Opportunities available for continuing their lives

Hospice Care
This philosophy is to allow the patient to
die with dignity and comfort.
Pain is controlled so that the patient can
remain active as long as possible.
Specially trained volunteers are an
important part of many hospice
programs.

Advance Directives
A general term that describes two
types of legal documents.
Living Will
Healthcare (Medical) Power of
Attorney

Living Will
Allows a person their wishes about
medical treatments for the end of life
in writing in the event that they
cannot communicate those wishes
directly.
Different states may use different
names.

Healthcare Power of
Attorney
Also know as a healthcare proxy,
appointment of a healthcare agent, or
durable power of attorney for
healthcare.
The person you appoint will be
authorized to deal with all medical
situations when you cannot speak for
yourself.

(Choosing death)
Assisted suicide is a death in which a person provides
the means for a terminally ill patient to commit
suicide.
Dr. Jack Kevorkian is best know for this role and has
been prosecuted in the U.S.
Laws are more accepting in other countries.
Assisted suicide is one form of EUTHANASIA, the
practice of assisting terminally ill people to die more
quickly.
Euthanasia is high controversial since it centers on
decisions about who should control life.

Decisions About Ending Life

Some people argue that we should have the
absolute right to be in control of our own lives
Freedom as an ideal in our society
Absolute right to create life (creating children),
why not ending own?
Opponents
Morally wrong
Physicians are not accurate in predicting
outcomes
SUPPORT Study, next slide

How Long Do Terminal Patients Really Live?

SUPPORT study: A significant percentage of a group of 3,693 patients told they

had no more than a 50% chance of living for 6 months survived well beyond this
period. Why do you think this happened?