E L N E C Geriatric Curriculum
End-of-Life Nursing Education Consortium
SESSION 10:
Preparation for and
Care at the Time of Death
Fairfield University
Quinnipiac University
School of Nursing ELDER Project
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Objectives: Upon completion of this
session, the participant will be able to …
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Describe typical changes and events at the time
of dying.
Examine the role of the palliative care team at
the time of death.
Identify self-care strategies for the health care
team that promote well-being and health.
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Dying is an Individualized
Personal Experience
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Palliative Care Team Roles at EOL
• Support older adults/residents,
families, and staff prior to and
following the death
• Coordinate care
• Advocate for patients and families
• Being present, bearing witness
• Provide pain and symptom
management
• Role model self-care behaviors
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ACTIVITY: Roles of Palliative Care
Team at EOL
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Advocate
Pain & Symptom
Management
Being Present
Modeling SelfCare Behaviors
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An 85-year-old client with end-stage heart disease arrives
unconscious at the emergency department after sustaining her
third myocardial infarction. The doctor has told the daughter
that without CPR her mother could die today. The healthcare
•worker finds the daughter crying by the client's bedside.
What should the healthcare worker do?
1. ask the daughter if she would like to reconsider treatment
2. talk to the doctor about moving the client to a more
private place
3. stay with the daughter, using silence to give comfort
4. assure the daughter that she doesn't need to stay with her
mother
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Offering Support During the
Death Vigil
• Common fears
– Being alone with
resident
– Not knowing when
death occurs
– Painful death
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Nearing-Death Phenomena
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“The Rally”
Symbolic language
Visions
Inability to let go
Saying good-bye
Two Roads to Death
Confused
Restless
THE DIFFICULT
ROAD
Tremulous
Hallucinations
Mumbling Delirium
NORMAL
Myoclonic Jerks
Sleepy
Lethargic
Seizures
Obtunded
THE USUAL
ROAD
Semicomatose
Comatose
DEAD
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Ferris et al., 2003
Frequency of Symptoms Last 48
Hours
Fürst & Doyle, 2004; Lunney et al., 2002
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Pain when Death is Imminent
• Common among NH residents at EOL
• Assume pain is present
after ruling out other
possible causes of distress!
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Opioids at EOL
• Consider routes
– Oral
– Rectal
– Subcutaneous
• There is no evidence that opioids hasten death!
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Noisy Respirations
• Noise produced by turbulent
movements of secretions in upper
airways; this symptom occurs in the
imminently dying
• Also called
“death rattle”
• Occurs in 23–92% of
dying patients
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Anticholinergics
• Hyoscine hydrobromide
(Scopolamine)
• Glycopyrrolate (Robinul)
• Hyoscyamine (Levsin)
• Atropine Sulfate
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Nondrug Strategies
• Reposition patient or resident on his
side
• Gently suction mouth
if the secretions are
easily reached
• Provide excellent oral care
• Educate and reassure family
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Terminal Restlessness
• Occurs in the last days or hours of life
• May be exhibited by thrashing, muscle
twitching or jerks, fidgeting, frequent
attempts to get out of bed, calling out,
moaning, non-purposeful movement
• Focus on providing comfort rather than
treating the cause
Ingham & Caraceni, 2002
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Symptoms of Imminent Death
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Decreased urine output
Cold and mottled extremities
Vital sign and breathing changes
Respiratory congestion
“Death rattle”
Delirium/confusion
Restlessness
Kehl, 2004; Matzo, 2009; Rousseau, 2002
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Signs That Death Has Occurred
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Absence of heartbeat, respirations
Pupils fixed
Pale color
Body temperature drops
Muscles, sphincters relax
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Grief is:
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the emotional response to a loss
the outward, social expression of a loss
the depression felt after a loss
the loss of a valued object or loved one
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The best response to a client who is
anticipating a loss is to:
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1. educate them about disease progression
2. stress that prognosis is difficult to predict
3. provide therapeutic presence and practice active
listening
4. advise the daughter to focus more on the present
than the future
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In speaking with clients and families about grief, the
healthcare worker explains that grief:
1. is a process with predictable stages of work to be done
2. begins when people expect a loss or death
3. lasts a year or less, and then survivors should adapt to the
loss
4. includes personal feelings that are understood by
everyone
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Care Following Death
• Bathing and dressing
the body
• Positioning the body
• Respect cultural
practices
• Allow for closure
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In caring for the body after
death, it is most important to:
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1. make sure the body is sent to the morgue within an hour
after death
2. have family members participate in the bathing and
dressing the deceased
3. notify all family and team members regarding the
patient's death
4. provide a clean, peaceful impression of the deceased for
the family
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The wife of a client who recently died states: "Last night I
thought I heard him say ‘Good night, Honey’ just like he
always did. Do you think I am going crazy?" The most helpful
response is:
1. "You might want some extra support accepting your husband's
death. I'll have the doctor make a referral to a psychologist."
2. "Many people see or hear the one who has died. You must miss
him saying 'good night'."
3. "Many people believe that ghosts or spirits visit their loved
ones. Do you believe in ghosts or spirits?"
4. "That must be frightening for you. Do you have a friend or
relative who can stay with you so that you are not alone?"
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Care Following Death (cont.)
• Rigor mortis 2-4 hrs after death
• Embalming
• Removal of body
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The hospice team is caring for the family of a man who died
several days ago after a long illness. His wife is concerned that
their 9 year old son has become withdrawn and is easily
angered. Which action is most appropriate?
1. Refer the boy to a specialist for complicated (abnormal)
grief reaction.
2. Suggest that the boy be excused from his usual activities.
3. Give opportunities for the boy to express his feelings.
4. Tell stories rather than facts about death to the
boy.
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Acknowledging Death
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Inform staff
Inform roommate
Memory book
Recognition wall
Paying tribute
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Lifestyle Management:
Burnout Prevention for Staff
• Healthy body
• Healthy mind
• Healthy spirit
• Healthy social life
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The healthcare team may experience feelings of
anxiety and grief when caring for dying clients. To
deal with these feelings it is important to:
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get the assistance of team members when necessary
transfer to another unit to avoid caring for dying patients
keep an emotional distance from clients and families
schedule counseling at weekly intervals to deal with loss
issues
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Activity: Self-Care Assessment
Take a moment to consider the
frequency with which you do the
following acts of self-care. Rate using
the scale below:
4 = often
3 = sometimes
2 = rarely
1 = are you kidding? It never even crosses my
mind!
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Conclusion
Family members will always remember the
last days, hours, and minutes of their loved
one’s life. Nurses have a unique
opportunity to be invited to spend these
precious moments with them and to make
those moments memorable in a positive
way.
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References
City of Hope & the American Association of Colleges of
Nursing, 2007; Revised, 2010. The End-of-Life Nursing
Education Consortium (ELNEC)- Geriatric Training
Program and Curriculum is a project of the City of Hope
(Betty R. Ferrell, PhD, FAAN, Principal Investigator) in
collaboration with the American Association of Colleges of
Nursing (Pam Malloy, RN, MN, OCN, Co-Investigator).
Supported by DHHS/HRSA/BHPR/Division of Nursing
Grant # D62HP06858
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