Dying and death

1. Dying and death HAIVN Havard Medical School AIDS Initiative in Vietnam

2. Learning objectives By the end of this session, participants should be able to: • Review the five (5) emotional stages of death and dying • Discuss five (5) things that can help ease the dying process • Describe the course of physical death • Provide physical care for dying patients • Support patient’s family members and others to complete 4 specific tasks at the funeral

3. 5 stages of dying • The stages might not occur in exact order • Patients can move back and forth between stages • Patient’s family might experience similar stages • Patient and his/her family members may be in different stages, which can make interactions difficult

4. Denial stage Patients: • DON’T believe that they are dying • DON’T want to hear the prognosis about their remaining time • For Example: • “Not me” • “Not now”

5. Anger stage • Patients will be very angry and feel that it’s not fair for them to die before other people • It’s very difficulte to communicate with patients at this stage • For example: • “Why me?” • “I am not ready for this yet”

6. Bargaining stage • Patients will try their best to bargain • For example: • “I will be nice, very nice if you let me live until my son grows up” • “I will never use drugs again if you give me a chance to fix this”

7. Depression stage • Sense death is impending • Think about everyone and everything that will happen after: • Loss of control: cannot take care of themselves • Loss of mental competency: cannot work much longer • Loss of family and friends • Might isolate themselves and avoid seeing people • Feel hopeless / depressed

8. Acceptance stage • Not all patients go through this stage • Patients are sad but accept that their life will end • Sort out assets and clarify remaining tasks for the person who will accepted fiscal responsibility • Say “goodbye” to their family and close friends

9. Taking care of dying patients (1) • Avoid mentioning death when communicating with patients and their families • Don’t make patient’s family upset • Prepare to answer patient’s questions: • What will happen to my body when I die? • What are some signs of dying? • Will it hurt?

10. Taking care of dying patients (2) • Support patients and their families: • Comfort, encourage them to reduce / alleviate their concerns • Patients might be concerned about what will happen to their families after they die • Help patients select desired / appropriate setting: • At home or at hospital • Determine who will be at patient’s bedside during dying process

11. Resting in peace: 5 things that help patients reconcile and obtain closure Patients often desire to: • Apologize for what they have done wrong in their lives • Ask for forgiveness from their family & friends • Forgive other people for what those people have done wrong to patient • Thank their family and friends • Say their goodbyes

12. Support from nurses to help patients have a peaceful death • Nurses need to be aware that it’s not easy for patients to complete the 5 tasks listed previously • Nurses can help them to have a peaceful death by: • Encouraging them to think about life • Helping them communicate with their family and friends: • Directly • Via mail / email • Via videos

13. Process of physical death of patients (1) • Death due to illness is a process, in which physical changes will happen over a period of time • Usually, the body will become weaker and weaker and then stop functioning

14. Process of physical death of patients (2) • Reduce their food and drink intake • Don’t feel hungry or thirsty much • Become weaker and reduce their physical movement • Might not be able to voluntarily control urination and defecation • Experience changes in resting and sleeping habits • Wake up at midnight and sleep during the day

15. Process of physical death of patients (3) • Pay less attention to surrounding, environment • May describe odd feelings / sensations / visions • Visits from relative(s) who are deceased • May experience alterations in senses: • Reduced vision, sensation in feet • Retained sounds in ears for longer periods • May experience changes in breathing: • Breathing might become more rapid and shallow • Occurrence of cessations during breathing (apneas) increases

16. Signs that death is near…(1) • More difficult to arouse/ wake patient up • Might need a few seconds • When awakened, patient might not talk • Patients “stare blankly into space” • Patients experience visual hallucinations

17. Signs that death is near…(2) • Hands & feet are cold to touch and become pale in color • Eyes and mouth remain ajar • Heart rate can be rapid and peripheral veins are weak • Lower jaw drops down • Increased frequency of apneas

18. Physical care for dying patients (1) • Dying cannot be stopped • Goal of care during this time is to help patients and their families feel more comfortable and at ease with process • Treatment process during dying stage is not acute treatment but more palliative in nature • Discuss with family what will occur

19. Physical care for dying patients (2) • Do not try to force food or drink on the patient • Losing appetite is common for dying patients • Keep mouth wet / moist • Evaluate frequency of pain and provide pain medications regularly

20. Physical care for dying patients (3) • Continue taking good care: • Keep patients clean and dry • Change bed sheets regularly • Change posture for patients regularly • Oral care • Keep eyes wet • Create personal space for patients and their families

21. When taking care of dying patients… • Taking care of dying patients and their families is an emotional challenge: • Nurses can feel loss and sadness when patients die • Expressing feelings is important, therefore it is necessary to provide: • Support for nurses and have group discussion(s) • Personal counseling

22. Four missions of the “farewell” (1) • Completion of 4 missions of the farewell is a part of caring • These missions: • Need to happen in order • Can be applied for any loss or grief

23. Four missions of the “farewell” (2)

24. Key points • Taking good care of dying patients physically and mentally is very helpful for patients and their families • Nurses, when taking care of dying patients and suffering from loss, need to have emotional support • Providers can assist patients’ families to complete 4 missions of the farewell

25. Thank you! Questions?