DEATH and DYING

Loss – an actual or potential situation in which something that is valued is changed, no longer available, or gone.

- loss of body image, significant other, a sense of well being, a job, personal possessions, etc…

Grief – the total response to the emotional experience related to loss which is usually resolved within 6 months to 2 years.

- sorrow manifested in thoughts feelings and behavior occurring as a response to an actual or perceived loss.

Grieving Process Sequence of affective, cognitive and

physiological states through which the person responds to and finally accepts an irretrievable loss

Grief Work Adaptation process of mourning a loss,

distress, disengagement, reinvestment and resolution.

Parallel to the grieving process. Process include separating from the person

who died, readjusting to a world without him/her and forming new relationships.

Bereavement The subjective response experienced by the

surviving loved ones after the death of a person with whom they have shared a significant relationship.

Experience alteration in libido, concentration, patterns of eating, sleeping, activity and communication

Sources of Loss

1. Loss of an aspect of life – any change the person perceives a s negative in the way the person relates ton the environment is loss of self.

- include physical loss (loss of body part) physiological function ( loss of urinary bowel) or psychological function (loss of memory)

2. External Objects – loss of inanimate object that has importance to he person (jewelry, money)

Extent of Grieving Depends

a. object’s material value

b. the sentiment the person attaches to the object

c. the object’s usefulness

3. Accustomed Environment - separation from an environment and people who provide security (city, country)

4. Loved Ones – loss of valued person or loved one through illness, separation, divorce, broken relationship, moving, running away, promotion at work, or death.

5. Loss of Life – physical death, brain death, ability reason

- concern is not about death itself but about pain and loss of control, fear of separation, abandonment, loneliness or mutilation

For the nurse to be able to accurately analyze and identify appropriate nursing diagnosis for clients experiencing losses and grieving. The nurse needs to recognize the following:

A. State of Awareness of the client and the family

1. Closed Awareness

- client and family are unaware of impending death, either they do not understand completely why the cline is ill and they believe the client will recover

2. Mutual Pretense

- the client, the family and health personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject

- permits the client a degree of privacy and dignity, but it places a heavy burden on the dying person, who then has no one in whom to confide fears

3. Open Awareness

- the client and people around know about the impending death and feel comfortable about discussing it, even it is difficult.

- provides the client an opportunity to finalize affairs and even participate in planning funeral arrangements.

B. Symptoms of Grief

1. Repeated somatic distress

2. Tightness in the chest

3. Choking or shortness of breath

4. Dryness of the mouth and throat

5. Sighing

6. Empty feeling in the abdomen

7. Loss of muscular control

8. Uncontrolled trembling

9. Loss of appetite

10. Sleep disturbance

11. Intense Subjective distress

C. Factors influencing a Loss Reaction:1. Significance of the

loss-depends on

the perceptions of the individual experiencing the loss.

Factors Affecting Significance of Loss

• Age of the person• Value placed on the

lost person, body part, etc

• Degree of change required because of loss

• Person’s belief and values

• Expectations

2. Culture

- recognizes that the grief reaction expressed may not be indicative of the client’s true feelings but rather the expressions expected by his culture.

- values, attitudes, beliefs, and customs determines how grief is experienced

3. Spiritual Beliefs

- most religious groups have practices related to dying .

- include practices, rites and rituals directed toward loss experiences and the grieving.

4. Sex Role

- influenced by the social expectations of the male and female roles, men are expected to “be strong” and show very little emotion during grief but it’s acceptable for women to show grief by crying.

5. Socio-economic status

- affects support system available at a time of loss

- influences the family’s ability to utilize resources and available support mechanism in coping with the loss.

6.Growth and Development

Concepts which help the Nurse to Plan for Intervention:

1. Mourning – the behavioral process through which grief is eventually resolved or altered

- process by which people adapt to a loss which is influenced by cultural.

- customs, ritual and society’s rules for coping with loss.

- it is often influenced by culture, religious experience and custom.

2. Hope – characterized by a confident, yet uncertain expectation of achieving a goal.

3. Closure – the point at which the loss has been resolved and the grieving individual can move on with life without focusing on the loss.

Type of Loss

1. Personal Loss - any significant loss of someone or something that can no longer be seen or felt, heard, known or experience \d and that requires individual adaptation through the grieving process ( perceived beauty, roles, pleasure, satisfaction with life).

2. Perceived Loss- loss that is less tangible and uniquely

defined by the grieving client ( loss of confidence, prestige)

- experienced by one person but cannot be verified by others .

- psychological losses as a women who leaves her employment to care for her children at home may perceive a loss of freedom and independence.

3. Maturational Loss

- change on developmental process that is normally expected during a lifetime

- loss that occur on the process of normal development (departure of grown children from the home, retirement from a career, death of aged parents)

4. Situational Loss

- loss of a person, thing, or quality resulting from a change on a life situation, including a changes related to illness, body image, environment and death.

- any sudden, unexpected and definable event that is not predictable (loss of one’s job, death of child, etc)

5. Actual Loss

- can be identified by others and can arise either in response to or anticipation of a situation.

- any loss of a person or object that can no longer be felt, heard, known or experienced by the individual.

Rando’s Phase of Grieving

Phase Behavioral Response

1. Avoidance - Shock, denial ,confusion, numbness, withdrawal, disbelief and disorganization are well to temporarily avoid the loss.

Phase Behavioral Response

2. Confrontation - Client is in a highly charged emotional state, in which the client repeatedly faces his or her loss- Grief is most intense and felt most acutely.- exhibit emotions such as anxiety, fear, anger, etc.- anger may be turned inward or unto others

Phase Behavioral Response

3. Accommodation -Includes a gradual decline of acute grief and the beginning of an emotional and social reentry into the everyday world.- client learns to live or adapt to the loss- individual is able to invest energy in new persons, things and ideas.

Types of Grief

Abbreviated Grief

- grief which is brief but genuinely felt

- lost objects may not have been sufficiently important to the grieving person or may have been replaced immediately by another, equally esteemed object.

Anticipatory Grief- Process of accomplishing part of the grief work

before actual loss- Grief response in which the person begins the

grieving process before an actual loss.- Normal mourning that occurs when a patient or

family expecting a death.

Disenfranchised Grief- occurs when societal norms do not define the loss as a loss within its traditional definition.

- client is not acknowledged for the loss and does not gain support form others, changes n grades, interest, relationships, death of a same-sex lover, loss of innocence.

- survivor’s grief must be hidden to avoid negative social pressures.

Dysfunctional Grief/ Pathologic Grief - Occurs when there is prolonged emotional instability,

withdrawal from usual task or activities that previously gave pleasure and the lack of progression from one level to successful coping with the loss.

- Extended grief, unsuccessful use of intellectual and emotional responses by which individual attempt to work through the process of modification.

- Manifested as exaggerated, prolonged or absence of grief.

- Unresolved or inhibited

Characteristic of Pathological Grief Reaction

1. Delusions

2. Hallucinations

3. Phobias

4. Obsessions

5. Isolation

6. Conversion hysteria

7. Agitated depression

8. Delay grief work

9. Suicidal indications

10. Difficulty crying/ controlling crying

11. Loss of control of environment

12. Intense reactions loner than 6months with few sigh of relief

13. Restriction of pleasure

Dysfunctional Grief is inferred from:

a) Client fails to grieve following death of a loved one

b) Client becomes recurrently symptomatic on anniversary of a loss or during holidays

c) Client avoids visiting the rave and refuses to participate in religious memorial services of a loved one

d) Client develops persistent guilt and lowered self-esteem

e) Client continues to search for the lost person (suicide to effect reunion)

f) Minor event trigger symptoms of grief

g) Client is unable to discuss the deceased with equanimity even after a period of time.

h) Interview with client is characterized by loss.

i) Client experiences physical symptoms similar to those of person who died even after period of grief.

j) Client’s relationship with friends and relatives worsen following the death.

Dysfunctional Grief may be:

Unresolved grief Extended in length and severity; bereaved may

also have difficulty expressing the grief, may deny the loss or may grieve beyond expected time, sever chronic grief reaction in which the person does not complete the resolution stage of the grieving process within a reasonable time.

Factors Contributing to unresolved Grief

a) Ambivalence toward the lost person

b) Perceived need to be brave and in control

c) Endurance to multiple losses, which bereaved find too overwhelming to contemplated

d) Extremely high emotions value invested in the dead person. (reality of loss is avoided)

e) Uncertain about the loss (missing in action)

f) Lack of support persons

g) Subjection to socially unacceptable loss that can’t spoken about. (suicide ,abortion)

Inhibited Grief

Many of normal symptoms of grief are suppressed and other effects, including somatic are experienced instead.

Signs of Impeding Death

1. Loss of muscle tonea) Relaxation of the facial muscle (jaw may sag)b) difficulty in speaking c) Difficulty swallowing and gradual loss of the

gag reflexd) Decreased activity of the GT, with

subsequent nausea, accumulation of flatus, abdominal distention and retention of feces

e) Possible urinary and rectal incontinence due to decrease in sphincter control

f) Diminished body movement

2. Slowing of the Circulation

a. diminished sensation

b. mottling and cyanosis of the extremities

c. cold skin, first in the feet and later in the hands, ears and nose (however, client, may feel warm due to elevated temperature.)

3. Changes in Vital Signs

a. decelerated and weaker pulse

b. decreased BP

c. rapid shallow, irregular, or abnormally slow respirations, chynestroke respiration, noisy breathing, refered to as the death rattle, due to collecting of mucus on the throat; mouth-breathing which leads to dry oral mucous membranes.

4. Sensory impairment

a. Blurred vision

b. Impaired senses of taste and smell (hearing is the last sense to disappear)

Clinical Signs of Death

Cessation of the apical pulse, respirations and blood pressure.

a) Total lack of response to external stimuli

b) No muscular movement, especially breathing

c) No reflexes

d) Flat encephalogram for 24hrs.

Cerebral Death

Occurs when the higher brain center, the cerebral cortex is irreversibly destroyed.

It is believed that the cerebral cortex which holds the capacity for thought, volutary action and movement in the individual.

Documentation

“if it is not written, it is not done”1. Time of death and actions taken to prevent the death

if applicable.

2. Who pronounced the death of the client

3. Any special preparation and type of donation, including time, staff and company

4. Who was called and who came to the hospital - donor organization, morgue, funeral home, chaplain and individual family members making any decision

5. Personal articles left on the body and taped to the skin or tubes left in place

6. Personal items given to the family – specific names and description of items

7. Time of discharge and destination of the body

8. Location of name tags on the body

9. Special requests by the family

10. Any other personal statements that might be needed to clarify the situation.

Body Changes

Rigor Mortis – the stiffening of the body that occurs about 2 to 4 hours after death due to lack of ATP, which is not synthesized because lack of glycogen in the body, ATP is necessary for muscle fiber relaxation. Its lack causes the muscles to contract which in turn immobilizes the join.- Starts in the involuntary muscles then progress to the

head, neck, trunk and finally reaches the extremities.

- Rigor mortis leaves the body about 96hrs after death

Algor Mortis – gradual decrease of the body’s temperature after death. When blood circulation terminates and the hypothalamus ceases to function, body temperature falls about 1° per hour until reaches room temperature.

- simultaneously skin loses its elasticity and can easily broken when removing dressing and adhesive tapes.

Livor Mortis – skin discoloration. After blood circulation has ceased, skin becomes discolored. The RBC breakdown, releasing hemoglobin, which discolors the surrounding tissues. Appears in the lowermost or dependent areas of the body.

Embalming – injection of chemicals into the body to destroy the bacteria. Tissues after death become soft and eventually liquefied by bacterial fermentation. The hotter the temperature, the more rapid the change. Therefore, bodies are often stored in cool places to delay the process

Therapeutic Communication

Effective listening techniques and communication of concern and understanding helps client move through the grieving process.

1. Use open-ended questions Allows client to speak about concerns rather than

about what the nurse.2. Schedule adequate time with client and family

To promote open communication.3. Provide a private location for the interview conducive

to sharing of perceptions 4. Words and actions should convey acceptance of all

grief reactions.

5. Acknowledge grief through touching the client and expressing concern to evoke client’s trust and build self-esteem.

6. Convey willingness to be available when needed if client chooses not to share feelings or concerns

7. Avoid erecting barriers to communication (Denying clients grief, providing false reassurance, avoiding discussion of the problem and focusing on caregiver’s needs instead of the client’s needs)]

8. Non-verbal (facial expressions, posture, inflections, lack if eye contact and spacing )

Maintenance of Self- Esteem

Dignity – persons ability to maintain his concept of himself as a person

- ability to function as a significant and integrated person.

1. Listen, respond quickly and positively to request, maintain confidentiality and privacy and provide comfort and support.

2. Implement comfort measures in a caring, unhurried manner to reinforce clients feeling of self-worth and dignity and to decrees the fear of rejection, isolation and sense of hopelessness

3. Make client believe that his opinions are valuable in decisions that will affect the course of his dying.

4. Give attention to clients appearance, show an attitude of respect and helpfulness' rather than encourage dependence or feelings of guilt

Three Stages of Living Fully Until Death:

1. Developing and growing – client can be assisted to paint, sculpt, go to a library, visit an art gallery; an occupational therapist can help clients do what they still can do and what is pleasurable.

2. Lying Fallow – physiotherapy measures help client to relax and enhance self-esteem.

3. Letting go and becoming dependent – nursing interventions should meet both physical and psychological needs.

Promotion of Comfort

1. Relief of pain is critically important, the sooner the dying client obtains pain relief, the more energy the client can direct toward maintaining quality in the remainder of his life.

2. Provide personal hygiene measures, control pain, relieve reparatory difficulties, assist with movements, nutrition, hydration and elimination, provide measures related to sensory changes.

Promotion of Spiritual Comfort

1. Support client in his expressions o the philosophy he has chosen for his life

2. Attentive listening encourages client to express feelings, clarify them and accept his fate.

3. Praying silently with the client 4. Make referrals for spiritual counseling5. Facilitate expressions of feeling, prayer,

mediations, reading and discussion with appropriate clergy/ spiritual advisor

Spiritual Needs of the Dying

1. Forgiveness and reconciliation with God and past human relationships

2. Prayer and religious services (sacraments or blessing)

3. Spirituals assistance at the time of deaht from clergy, family, or health care providers

4. Peace and tranquility of spirit

Care of the Body

1. Placed in supine position with arms at the side, palms down, or across he abdomen (to make the body looks as natural and comfortable as possible)

2. Place a small pillow or folded towel under the head. ( to prevent discoloration form blood pooling)

3. Gently hold eyelids close for a few seconds to make it remain close

4. Insert clients dentures to maintain the normal facial features

5. Place a rolled-up towerl under the chin to keep mouth closed.

6. Wash any spoiled body parts, dress the body in a clean gown and cover the body up to the shoulder s with clean linen.

7. Place absorbent pads under the perineal and rectal area to collect any oozing feces or urine

8. Removes all jewelries and present it and any valuables to the family.

9. If the wedding band is left in place, tape it securely to the finger.

10. Allow family members to enter the rrom when body is prepared never allow single family member to enter the room alone (for emotional support)

11. Special tags containing the deceased name, hospital number and name of attending physician are placed on the wrist and ankles and on the outside of the shroud.

12. In the morgue, body is place in a special cooling unit to slow decomposition.

Death Certificate

Made out when a person dies, usually signed by the attending physicians and filled with a local health or other government office.

Family is given a copy to use for legal matters.

Labeling of the Deceased

If inappropriate identified and prepared incorrect can create legal problems

Placed on the wrist, ankle and on the shroud. Contains name of deceased, hospital number

and name of the attending physician.

AUTOPSY or Postmortem Examination

An examination of the body after death and is performed only in certain cases When death is sudden or occurs within 48 hrs

of admission to a hospital, the organs and tissues of the body are examined to established the exact cause of death

To learn more about a disease To assists in the accumulation of statistical

data.

Consent should be obtained by the physician form the descendent (before death) or by the next of kin (surviving spouse, adult children, parents siblings)

Hospitals cannot retain any tissues or organs without the permission of the person who consented to the autopsy.

Organ Donation

Any person 18yrs and older and of sound mind may make a gift of all or any part of the body for the following purposes: Medical or dental education Research Advancement of medical or dental science Therapy Transplantation

Donations can be made by a provision in will or by singing a card like form in the presence of two witnesses

Euthanasia

The act of painlessly putting to death persons suffering form incurable or distressing disease.

The End