CHAPTER 41
THE DYING PERSON
INTRODUCTION
† Some deaths are sudden, others expected
† Accepting one’s own mortality is a
developmental stage of life
† Your feelings about death
affect the care you give
† Must understand the dying
process to meet dying
person’s physical,
psychological, social,
& spiritual needs
TERMINAL ILLNESS
† Illness or injury for which no
reasonable expectation of recovery
exists
† Doctors can’t predict time of death
† Hope and the will to live strongly
influence living
and dying
ATTITUDES ABOUT DEATH
† Experiences, culture, religion, and age
influence attitudes
† Attitudes change as age &
circumstances change
† Dying people often need hospital,
nursing center, hospice, or home care
† Family often involved in process
ATTITUDES ABOUT DEATH
† When death occurs funeral director
called to take body
† Many adults & children have never had
contact with dying person or at time of
death
† Practices & attitudes
differ among cultures
† Attitudes influenced
greatly by religion
RELIGION’S AFFECT ON DYING
† Beliefs about life after death influence
attitude toward death (ex: reincarnation
is belief that spirit or soul is reborn into
another human body or into another
form of life)
† Rites & rituals during
dying process or at
death influenced by
religion
† Religion offers comfort to some people
as they or loved one are dying
AGE’S AFFECT ON DYING
† Adults:
† Fear pain & suffering, dying alone, invasion
of privacy, loneliness, and separation from
loved ones
† Worry about loved ones left behind
† Resent death ability to keep from dreams
† Age 3-5 think death is temporary
† Blame themselves
† See death as punishment
for being bad
AGE’S AFFECT ON DYING
† Age 5-7
† Know death is final
† Think death only happens to others
† Relate death to punishment & body
mutilation (ideas from TV, cartoons, video
games, movies, fairy tales)
† Older persons
† Fewer fears than younger persons, but may
fear dying alone
† Know it will come, may welcome it (free of
pain & suffering) or think of as reunion with
loved one
STAGES OF DEATH & DYING DESCRIBED BY
ELISABETH KUBLER-ROSS
Denial: “No, not me!”
Anger: “Why me?” May be
outraged & jealous of healthy
Bargaining: make promises to bargain for more
time – may be on spiritual level
Depression: mourn things lost & that will be lost
Acceptance: calm & at peace
NOTE: may not go through stages in order, may
go back & forth, may never get to last stage
PSYCHOLOGICAL, SOCIAL, AND SPIRITUAL
NEEDS
Dying person may want:
Family & friend’s present
To talk about fears & anxieties
To be alone
Listen and let them express feeling in own
way
Use touch to show caring
(along with silence)
May want to see spiritual leader
Provide privacy
Be courteous to leader
Handle spiritual objects with respect
PHYSICAL NEEDS
Dying may take minutes, hours, weeks:
Body processes slow
Person is weak
LOC change
Keep comfortable and maintain dignity
Vision blurs:
Explain what doing
May turn toward light, avoid bright lights
Dark room may frighten
Eyes may be ½ open with secretions in
corners – good eye care essential
PHYSICAL NEEDS
Hearing one of last functions lost
Assume they can hear you – provide
reassurance & explanations
Speak in normal voice
Speech become difficult
Anticipate needs
Don’t ask questions that require long
answers
Continue to talk to person
PHYSICAL NEEDS
Mouth
Oral hygiene promotes comfort
As death nears & unable to take frequent
oral fluids, frequent oral care important
(esp. if can’t swallow)
Carefully clean nose
(crusting) & apply lubricant prn
Circulation fails & body temp rises as death
nears:
Skin cool & mottled
Diaphoretic – have increased need for skin
care & changing gown/ linens, use light
covers
PHYSICAL NEEDS
• Appetite slowly decreases to point
of no intake
– Meat, first to avoid, followed by
breads/fruits/vegetables; then sweets
only then liquids onto sips
water only
– Assist family to accept this
loss of appetite
PHYSICAL NEEDS
Elimination
Incontinence may occur – pericare needed
Constipation & urinary retention may
necessitate enemas & catheters
Comfort and positioning
Good alignment & changing positions
Analgesics prn
May need Semi-Fowlers
position to make
breathing easier
PHYSICAL NEEDS
Person’s room should be comfortable &
pleasant:
Well lit & ventilated
Remove unnecessary equipment
Keep upsetting equipment out of site
Arrange mementos, religious items,
flowers, or significant items in view
Family members may
be present all the time
Room may be near
nurses’ station
FAMILY
† Hard time for family – show
feelings by being available & courteous
† Stay as long as they wish - respect the
right to privacy, but don’t ignore care of
patient
† Family members need support,
understanding, courtesy, and respect –
go thru same stages as patient
† Family may desire spiritual leader also
HOSPICE CARE
† Focuses on the physical, emotional,
social, and spiritual needs of dying
† May be part of hospital or nursing
center or separate agency – many offer
home care
† Not concerned with cure or life-saving
measures, but comfort
& preserving quality of life
† Provides follow-up care
and support groups
for survivors
LEGAL ISSUES
† Much attention given to right to die
† Consent is needed for any treatment.
† The Patient Self-Determination Act and
OBRA (right to accept or refuse medical
treatments) – Advance Directives:
† Living wills: document with wishes
† Durable power of attorney
† “Do not resuscitate” orders written by
MD after consulting with patient & family
QUALITY OF LIFE
† Person has right to die in peace & with dignity
† Dying person’s bill of rights (see p. 810)
† Right to privacy before & after death – drape &
screen
† Right to visit with others in privacy – family able to
come & go freely, private room if possible
† Right to confidentiality (diagnosis & condition)
† Free from mistreatment or restraints
† Right to safe & home-like setting –
protect property, keep odor-free,
neat & clean
† Right to personal choice – advance
directives – staff must respect choices
SIGNS OF DEATH
† Signs may occur rapidly or slowly:
† Movement, muscle tone,
sensation lost – mouth may stay open
† Peristalsis slows – distention, fecal incontinence or
impaction common
† Body temperature rises – feels cold, looks pale, &
perspires heavily
† Circulation fails – pulse fast, weak, irregular & BP
falls
† Respiratory system fails – Cheyne-Stokes or slow
respirations & mucous collects (death rattle)
† Pain decreases as loses consciousness
† At time of death: no pulse, respirations, or blood
pressure & pupils are fixed and dilated
† Doctor must pronounce dead (coroner or medical
examiner may pronounce or be notified)
CARE OF THE BODY AFTER DEATH –
POSTMORTEM CARE
The right to privacy and the right to be
treated with dignity and respect apply after
death (close drapes, curtains, doors)
Care begins after pronounced dead
Goal is to maintain good appearance of
body - discoloration & skin damage
prevented, handle gently
Valuables gathered
to give to family
Other patients may need support
CARE OF THE BODY AFTER DEATH –
POSTMORTEM CARE
Rigor mortis (rigidity of skeletal muscles)
develops 2-4 hours after death
Body positioned in normal body alignment
before rigor mortis sets in
Body should appear in comfortable
position for viewing by family
Moving body may cause expulsion of
air from lungs or intestines,
normal sounds produced
Standard Precautions
CARE OF THE BODY AFTER DEATH –
POSTMORTEM CARE
Raise bed to comfortable level
Place pillow under head & shoulders
Close eyelids gently by pulling lashes down
Close mouth using rolled washcloth under
chin to support closed position prn
Follow facility policy for dentures (in mouth
or in cup to be sent to mortuary)
Remove tubes, replace
dressings, inventory
valuables
CARE OF THE BODY AFTER DEATH –
POSTMORTEM CARE
Bathe soiled areas & comb hair
If family coming to view:
Apply clean gown & bed linen
Cover body to shoulders
Arrange room neatly
Provide for privacy
Identify & assemble belongings - place in
labeled bags for family – document
After body is removed, strip unit
Follow instructions per charge nurse
CARE OF THE BODY AFTER DEATH –
POSTMORTEM CARE
Observe & report:
What was done with belongings
Unusual occurrences related to care
Unusual responses of family or
residents
Any other significant
observations
Remove & discard
gloves, wash hands