1. Define important words in this chapter

1. Define important words in this chapter • anticipatory grief • a period of mourning when the dying person or his family is expecting the death. • autopsy • an examination of a body by a pathologist to try to determine the cause of death. • bereavement • the period following a loss in which mourning occurs. • complicated grief • grief complicated by disorders or conditions, such as depression and substance abuse.

1. Define important words in this chapter • cremation • the process of burning a dead body until it turns to ash. • death • the end of life; the cessation of all body functions. • grief • a deeply emotional process that is a response to loss. • grief process • the varying emotional responses to grief.

1. Define important words in this chapter • grief therapy • therapy to try to resolve problems due to separation from the deceased. • mourning • the period in which people work to adapt to a loss; influenced by culture, tradition, and society. • palliative care • care given to people who have serious, life-threatening diseases; goals are to control symptoms, reduce suffering, prevent side effects and complications, and maintain quality of life.

1. Define important words in this chapter • pathologist • a doctor with advanced training in the examination of organs and tissues. • postmortem care • care of the body after death. • rigor mortis • Latin for “stiffness of death;” refers to the stiffness that occurs after death due to muscles becoming rigid. • terminal illness • a disease or condition that will eventually cause death. • unresolved grief • grief that continues beyond what is considered a reasonable period of time; may affect the person’s ability to function.

2. Describe palliative care • Define the following term: • palliative care • care given to people who have serious, life-threatening diseases; goals are to control symptoms, reduce suffering, prevent side effects and complications, and maintain quality of life.

2. Describe palliative care • Understand the goals of palliative care: • Control symptoms • Reduce suffering • Prevent side effects • Maintain quality of life • Emphasize holistic approach

2. Describe palliative care • REMEMBER: • Palliative care works to manage symptoms, not cure the disease.

3. Discuss hospice care • Define the following terms: • terminal illness • a disease or condition that will eventually cause death. • death • the end of life; the cessation of all body functions.

3. Discuss hospice care When a serious illness is classified as a “terminal illness,” or a disease or condition that will eventually cause death, hospice care is often the next step. This type of care is a compassionate way to care for dying people and their families. Hospice care uses a holistic approach.

3. Discuss hospice care • Remember these points about and goals of hospice care: • Ordered by a doctor for a person who has six month or less to live • Can be given in a hospital, care facility, or in the home • Uses a holistic approach • Provides alternative to traditional care • Offers medically-directed, team-managed care • Focuses on resident and family as a unit

3. Discuss hospice care • Points about and goals of hospice care (cont’d.): • Offers compassionate care • Focuses on soothing and comfort care, rather than curative care • Emphasizes pain and symptom management • Offers assistance for psychosocial needs • Helps family obtain financial counseling and legal assistance

3. Discuss hospice care • REMEMBER: • You should report complaints of pain or signs of pain immediately.

3. Discuss hospice care • Think about this question: • Why is it important that residents who are dying have control over their lives for as long as they are able?

4. Discuss the grief process and related terms • Define the following term: • grief • a deeply emotional process that is a response to loss.

4. Discuss the grief process and related terms • Understand Dr. Elisabeth Kubler-Ross’s five stages of grief (On Death and Dying): • Denial: refusal to believe they are dying • Anger: “Why me?” • Bargaining: “Yes me, but…” • Depression: need to mourn and review their lives • Acceptance: preparing for death

4. Discuss the grief process and related terms • REMEMBER: • Not every resident goes through all of these stages or goes through them in this order.

4. Discuss the grief process and related terms • Some terms you may hear that are associated with death and dying include the ones that follow on the next several slides. • In working with residents who are dying, as well as their families, it is important to be familiar with these terms and what they mean.

4. Discuss the grief process and related terms • Define the following terms: • anticipatory grief • a period of mourning when the dying person or his family is expecting the death. • bereavement • the period following a loss in which mourning occurs. • complicated grief • grief complicated by disorders or conditions, such as depression and substance abuse. • grief process • the varying emotional responses to grief.

4. Discuss the grief process and related terms • Define the following terms: • grief therapy • therapy to try to resolve problems due to separation from the deceased. • mourning • the period in which people work to adapt to a loss; influenced by culture, tradition, and society. • unresolved grief • grief that continues beyond what is considered a reasonable period of time; may affect the person’s ability to function.

5. Explain the dying person’s rights • When a person is dying, there are legal rights that must be respected. Remembering these rights will help you provide proper care, as well as promote the dying person’s dignity.

Transparency 27-1: Rights to Remember When Caring for the Terminally Ill • The right to have visitors • The right to privacy • The right to be free from pain • The right to honest and accurate information • The right to refuse treatment

5. Explain the dying person’s rights • The right to have visitors • It may be inconvenient to have visitors coming and going at odd hours, but when death is close, it is an emotional time for all those involved. • Saying goodbye can be a very important part of dealing with a loved one’s death. • It may also be very reassuring to the dying person to have someone in the room, even if they don’t seem to be aware of their surroundings. • Only report a visitor if he is disruptive or he becomes a threat.

5. Explain the dying person’s rights • 2. The right to privacy • Privacy is a basic right, but why may privacy for visiting be even more important now?

5. Explain the dying person’s rights • 3. The right to be free from pain • It is very important to monitor dying residents for signs that they are in pain. If they can no longer speak, how else can you tell if a resident may be in pain?

5. Explain the dying person’s rights • 4. The right to honest and accurate information • Residents have the right to honest information about what is happening and what their diagnosis is. Refer medical questions that are outside your scope of practice to the nurse.

5. Explain the dying person’s rights • 5. The right to refuse treatment • Have you ever cared for someone who did not want more treatment? How did you feel about that? • We need to remember that whether we agree or disagree with the decisions, the choice is not ours, but belongs to the person involved. • Sometimes, when residents are not capable of making a decision, they have told their family how they wish things to be done. Be supportive of family members; do not judge them. They are probably following the person’s wishes.

Handout 27-1: The Dying Person’s Bill of Rights • I have the right to: • be treated as a living human being until I die. • maintain a sense of hopefulness, however changing its focus may be. • be cared for by those who can maintain a sense of hopefulness, however changing this may be. • express my feelings and emotions about my approaching death in my own way. • participate in decisions concerning my care. • expect continuing medical and nursing attentions even though “cure” goals must be changed to “comfort” goals. • not die alone. • be free from pain. • have my questions answered honestly. • not be deceived.

Handout 27-1: The Dying Person’s Bill of Rights (cont’d.) • I have the right to: • have help from and for my family in accepting my death. • die in peace and dignity. • retain my individuality and not be judged for my decisions which may be contrary to beliefs of others. • discuss and enlarge my religious and/or spiritual experiences, whatever these may mean to others. • expect that the sanctity of the human body will be respected after death. • 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. • (This was created at a workshop on “The Terminally Ill Patient and the Helping Person,” sponsored by Southwestern Michigan In-service Education Council, and appeared in the American Journal of Nursing, Vol. 75, January, 1975, p. 911.)

5. Explain the dying person’s rights • Think about this question: • Why are these rights important for the dying person?

6. Explain how to care for a dying resident • Remember these guidelines for care of the dying resident: • Skin, Nose and Mouth care • Give frequent skin care. • Bathe often. • Change gowns and sheets often. • Give incontinence care promptly. • Turn and reposition often. • Give oral care frequently. • Offer ice chips. • Use lubricant on nose and mouth.

6. Explain how to care for a dying resident • Guidelines for care of the dying resident (cont’d.): • Pain Control and Comfort • Pain relief is critical. • Observe and report signs of pain. • Adjust blankets for temperature changes.

6. Explain how to care for a dying resident • Guidelines for care of the dying resident (cont’d.): • Diminished Senses • Keep room softly lit. • Use alternate forms of communication. • Speak normally and describe care that is being performed.

6. Explain how to care for a dying resident • Guidelines for care of the dying resident (cont’d.): • Breathing Problems • Report gurgling or rattling. • Elevate the head of the bed and change positions as ordered.

6. Explain how to care for a dying resident • Guidelines for care of the dying resident (cont’d.): • Food and Fluid Issues • Feed residents slowly. • Encourage fluids. • Do not force residents to eat or drink. • Report nausea, vomiting and diarrhea. • Elevate head of bed.

7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs • Define the following term: • cremation • the process of burning a dead body until it turns to ash.

7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs • Know the factors that influence feelings and attitudes about death: • Experience with death • Personality type • Religious beliefs • Cultural background

7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs • After death, cultural and spiritual beliefs play an important role. Some groups share food, play music, and talk about the person who has died. Customs may include burying personal items with the body or having specific rules on washing the body after a person has died. Some bury their dead in a coffin, while others prefer to be cremated.

7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs • REMEMBER: • It is important to honor individual practices and traditions without judging them.

7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs • Think about this question: • Are there practices or traditions regarding death that are different from your own that bother you? Think about why this may be and what you can do to address this.

7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs • Remember these guidelines for understanding the psychosocial and spiritual needs of dying residents: • Do not isolate or avoid resident. • Listen more; talk less. • Do not judge. • Do not discuss personal religious beliefs or try to change resident’s beliefs.

7. Discuss factors that influence feelings about death and list ways to meet residents’ individual needs • Guidelines for understanding psychosocial and spiritual needs of dying residents (cont’d.): • Notify the nurse if resident requests visit from spiritual leader. • Provide privacy for visits. • Never share anything private with others, except for the nurse. • Inform the nurse if resident has expressed fear of dying.

8. Identify common signs of approaching death • When a person is dying, all body systems are affected. • Know these signs of approaching death: • Cyanotic, pale, or darkening skin or mucous membranes • Cold skin • Skin that looks bruised (mottling) • Heavy perspiration • Fever

8. Identify common signs of approaching death • Signs of approaching death (cont’d.): • Extreme weakness and exhaustion • Loss of muscle tone • Fallen jaw, causing the mouth to stay open • Decreased sense of touch • Loss of feeling, beginning in the legs and feet

8. Identify common signs of approaching death • Signs of approaching death (cont’d.): • Loss of vision • Dilated pupils and staring eyes • Inability to speak • Extreme drowsiness • Disorientation or confusion

8. Identify common signs of approaching death • Signs of approaching death (cont’d.): • Hallucinations • Low blood pressure • Increased pulse • Cheyne-Stokes breathing • Gurgling and rattling sound when breathing

8. Identify common signs of approaching death • Signs of approaching death (cont’d.): • Difficulty swallowing • Decreased appetite and sense of thirst • Dry mouth • Nausea, vomiting, and diarrhea • Urinary and fecal incontinence

8. Identify common signs of approaching death • Signs of approaching death (cont’d.): • Decreased urinary output • Loss of hearing

Transparency 27-2: Signs of Approaching Death • Cyanotic, pale, or darkening skin or mucous membranes • Cold skin • Skin that looks bruised (mottling) • Heavy perspiration • Fever • Extreme weakness and exhaustion • Loss of muscle tone • Fallen jaw, causing the mouth to stay open • Decreased sense of touch • Loss of feeling, beginning in the legs and feet • Loss of vision • Dilated pupils and staring eyes

Transparency 27-2: Signs of Approaching Death (cont’d.) • Inability to speak • Extreme drowsiness • Disorientation or confusion • Hallucinations • Low blood pressure • Increased pulse • Cheyne-Stokes breathing • Gurgling and rattling sound when breathing • Difficulty swallowing • Decreased appetite and sense of thirst • Dry mouth • Nausea, vomiting, and diarrhea • Urinary and fecal incontinence • Decreased urinary output • Loss of hearing

9. List changes that may occur in the human body after death • Remember these points about the body after death: • No pulse, respiration, or blood pressure • Jaw drops • Eyelids partially open • Urinary and fecal incontinence • Fixed and dilated pupils

1. Define important words in this chapter