Nursing Care of Death & Dying

Death

Death is a irreversible cessation of circulatory, respiratory function or the irreversible cessation of all functions of the entire brain, including the brainstem.

Signs of Dying

This includes the following changes:

• Loss of appetite
• Decreased oral fluid intake and decreased thirst.
• Increasing weakness and/or fatique
• Decreasing blood perfusion, including decreased urine output, peripheral cyanosis and cool extremities.
• Neurologic dysfunction, including delirium, lethargy and coma and changes in respiratory patterns.
• Loss of ability to close eyes.
• Noisy breathing as pharyngeal muscle relax.
• In particular, neurologic dysfunction can sometimes result in terminal delirium. Which can include a mounting syndrome of confusion, hallucinations, delirium, myocardial jerks and seizures prior to death.
• Pitting edema develops, especially of the extremities and sacrum
• Movement and sensation are gradually lost.
• Temperature elevation will be there, but the skin feels cold and clammy.
• Pulse becomes irregular, weak and fast.
• BP falls as the peripheral circulation decreases.
• The skin cyanosed as circulation decreases.
• Respiration become noisy
• Reflexes disappear
• Urine decreases
• Pain usually subsides
• Mental alertness varies 
•  Jaw and facial muscles relax with the expression becoming peaceful.

STAGES OF DYING

According to Kubler- Ross, the five stages of dying are:

1.      Denial

On being told that one is dying, there is an initial reaction of shock. The patient may appear dazed at first and may then refuse to believe the diagnosis or deny that anything is wrong. Some patients never pass beyond this stage and may go from doctor to doctor until they find one who supports their position. 

2.   Anger

Patients become frustrated, irritable and angry that they are sick. A common response is “Why me? ” They may become angry at God, their fate, a friend, or a family member. The anger may be displaced onto the hospital staff or the doctors who are blamed for the illness.

 3.   Bargaining
The patient may attempt to negotiate with physicians, friends or even God, that in return for a cure, the person will fulfill one or many promises, such as giving to charity or reaffirm an earlier faith in God.

4.      Depression

The patient shows clinical signs of depression- withdrawal, psychomotor retardation, sleep disturbances, hopelessness and possibly suicidal ideation.  The depression may be a reaction to the effects of the illness on his or her life or it may be in anticipation of the approaching death.

5.      Acceptance

The patient realizes that death is inevitable and accepts the universality of the experience. Under ideal circumstances, the patient is courageous and is able to talk about his or her death as he or she faces the unknown.

Physical Signs of Dying

• Confusion – about time, place, and identity of loved ones; visions of people and places that are not present
• A decreased need for food and drink, as well as loss of appetite – this may be caused by the body’s need to conserve energy and its decreasing ability to use foods properly
• Drowsiness – an increased need for sleep and unresponsiveness
• Withdrawal and decreased socialization – can be caused by mentally preparing for dying, decreased oxygen to the brain and decreased blood flow
• Loss of bowel or bladder control – caused by relaxing muscles in the pelvic area
• Skin becomes cool to the touch – especially in the hands and feet, skin may become bluish in color caused by decreased circulation to the extremities
• Rattling or gurgling sounds while breathing or breathing that is irregular and shallow, decreased number of breaths per minute, or breathing that switches between rapid and slow
• Involuntary movements (called myoclonus), changes in heart rate, and loss of reflexes in the legs and arms also mean that the end of life is near .

MANAGEMENT OF DYING PATIENT

Cassen (1991) suggests seven essential features in the management of the dying patient:

• Concern: Empathy, compassion, and involvement are essential
• Competence: Skill and knowledge can be as reassuring as warmth and concern. Patients benefit immeasurably from the reassurance that their providers will not allow them to live or die in pain.
• Communication: Allow patients to speak their minds and get to know them.
• Children: If children want to visit the dying, it is generally advisable; they bring consolation to dying patients.
• Cohesion: Family cohesion reassures both the patient and family. The clinician who gets to know the family maximizes patient support and is prepared to help the family through bereavement.
• Cheerfulness: A gentle, appropriate sense of humor can be palliative; a somber or anxious demeanor should be avoided.
• Consistency: Continuing, persistent attention is highly valued by patients who often fear that they are a burden and will be abandoned; consistent physician involvement mitigates these fears.

NURSING CARE OF DYING PATIENT

• Creating a peaceful environment to the patient’s liking.
• Preparing instructions about whom to call (usually not all) when death occurs. 
• Give the relatives time to witness what is happening.
• Creating and using rituals that can help mark the occasion in the respectful way.
• When death occurs, families should encouraged to take whatever time they need to feel what has happened, and say their goodbyes. There is no need to rush the body to a funeral home, and some families want to stay with the body for a period of time after death.

Meeting physical needs:

• A patient in the terminal stages of a disease, is given all the nursing care possible to ensure the most comfort and freedom from pain. Physical comfort is important as well as emotional and spiritual comfort.

Meeting nutritional need:

• Patients suffer discomfort due to decreased gastrointestinal activity.
• Nutrients and fluids are given intravenously when they are not tolerated orally.
• Sips of water is given as long the swallowing reflex is present.
• When there is a problem gauze soaked with water may be placed in the patient’s mouth for him to suck and moisten the mouth.

Meeting special needs:

•  Mucus that collects in the throat is removed by placing the patient in a lateral position, wiping it way, or by suctioning.
• Frequent oral hygiene is done to keep the mouth free of dried secretions, and feeling fresh to the patient.
• Vaseline or cream is applied to the lips to keep them soft.
• The nostrils are kept cleans and lubricated as necessary.
• The eyes are cleaned with cotton balls miostened with normal saline.
• Lubricating drops or ointment may be applied to the eyes.
• The patient may perspire profusely even though the skin feels cool.
• Bath the patient and change the linen needed.
• Light weight bed covering should be used. Heavy covering seems to be uncomfortable to dying patients.
• Urinary and fecal incontinence often occur due to relaxing of the sphincter muscles. Pads are used to keep the bed linen from being soiled. The patient is checked frequently and pads or linen changed as necessary. The patient’s skin is washed and dried each time it is soiled.
• Frequent change of position (make sure the position permits each breathing)
• §  Pain is a great problem in some diseases. The doctor orders sufficient medication to control pain. It must be given as frequently as permitted. If it does not adequately control the pain, inform the doctor.
• Nursing measures for pain are used to make the patient comfortable on a minimum of medication.
• Dimness and shadows are confusing and increase a sense of loneliness. So we have to provide adequate light facility to the patient.

Meeting Emotional Needs:

• Touch is an important method of communication with a dying person. The patient appropriates some one holding his hand or playing a hand on an arm, his head or some other part of the body. It conveys a feeling of caring and concern. Quiet, encouraging conversation to the patient is helpful.
• Speak in a normal voice to the patient or to others in his presence.
• Do no speak in a whisper in the patient’s presence. It is very distressing to most sick people.
• Hearing is believed to the last sense to disappear. Weeping is disclosed in the patient’s presence or nearby.

Signs of Death

•  Absence of heartbeat and respirations.
•  Fixed pupils
• Skin color turns to a waxen pallor and extremities may darken.
• Body temperatures drops
• Muscles and sphincters relax, sometimes resulting in release of stool or urine

PHYSIOLOGICAL CHANGES AFTER DEATH

1. Rigor mortis

• Stiffening of the body that occurs about 2-4hrs after death.
• Results from a lack of ATP, which causes the muscles to contract, which in turn immobilize the joints
• It starts in the involuntary muscles( heart, bladder) then progress to head, neck, trunk , extremities.

2.Algor mortis

• Gradual decrease of the body temperature after death.
• When blood circulation terminates and hypothalamus ceases to function , body temperature falls down.

3.Livor mortis

• Discolouration of body after death.
• After blood circulation has ceased , the RBC broken down , - leads to discolouration of surrounding tissues

4. Decomposition

• Tissues after death become soft and eventually liquified by bacterial fermentation .
• The hotter the temperature, the more rapid the change.
• So bodies are stored in cool places / embalming

 

CARE AFTER DEATH

After death the body undergoes many physical changes. So care must be provided as early to prevent tissue damage /disfigurement of body parts.

• Physician must certify the death
• Consent form for autopsy
• Provide options for organ donation
• If death due to any accident, suicide , poisoning etc., it should be informed to legal authorities . The body should not be handed over without any legal written permission.
• Care of dead body ,often depends upon the customs and religious beliefs
• Nurses provide dignity and sensitivity to the client and family

1.      Check orders for any specimens

2.      Ask for special requests to family (eg: shaving , a special gown , Bible in hand , rosary at the bedside)

3.      Remove al equipments , tubes , supplies and dirty linens.

4.      Cleanse the body thoroughly , apply clean sheets

5.      Brush and comb the hairs

6.      The eyelids are closed and held in place for a few seconds , so they remain closed.

7.      Dentures should be in the mouth to maintain facial alignment.

8.      Mouth should be closed.

9.      Remove all the ornaments , except wedding bands ( in some instances)

10.  Absorbent pads are placed under the buttocks to take up any faces and urine released because of muscle sphincter relaxation

11.  All the orifices should be closed.

12.  Cover with a clean sheet up to the chin.

13.  Spray a deodorizer to remove unpleasant odour.

14.  Apply name tag  ( wrist , right big toe)

15.  Allow the family members to view the dead body

16.  The body is wrapped in a “ shroud” a large piece or plastic or cotton material used to enclose a body after death. Identification is then applied outside of the shroud.

17.  Hand over all the belongings to the relatives.

18.  Do complete documentation in the nursing notes.

• Time of death and actions taken to prevent the death.
• Who pronounced the death.
• Any organ donation
• Personal articles left on the body
• Personal items given to family
• Time of discharge and destination of the body 
• Location of name tags on the body
• Special request by family

19.Handed over the dead body to the relatives / sent to the mortuary.