Care of the dying

N320: Foundations

Intercollegiate Center for Nursing Education

of Eastern Washington University, Gonzaga University, and Whitworth College, and College of Nursing, Washington State University

Care of the Dying and Their Families

1. The most importtant interventions are those that provide physical comfort. There is no reason for anyone to die in unbearable pain unless it is their choice to do so.

2. Support hope. When there is no longer hope for cure there are still other things to hope for, if only to live each day as fully or as gratefully as possible.

3. Help the person who is dying and their loved ones to live and die consciously - this will also rub off on you so that you value your days more. A person who lives consciously:
    a. Recognizes and discusses her own mortalitiy.
    b. Closes a caring circle around him.
    c. Forgives
    d. Lives with profound gratitude for each day.
    e. Lives each day in the present
    f. Lives in accord with her own spiritual and religious beliefs and seeks comfort in them.
    g. Turns toward those he loves most.
    h. Makes practical plans for death
    i. Asks for what she needs.

Signs and Symptoms of Impending Death

Withdrawal from most people except the closest family members.
Decreased talking
Decreased appetite, fluid intake, urination and BMs.
Increased sleeping
May become lethargic, difficult to arouse or comatose.
Comatose person may wake up and be lucid for a short period before lapsing back into apparent unresponsiveness.
Dying person may "see" dead loved ones standing at the end of the bed or in the room.
Skin becomes cool and mottled - peripheral first, lower extremity before upper.
When the end is close breathing becomes irregular in both rate and depth and a death rattle may be as secretions collect or as the tongue falls back partially obstructing the airway. Cessation of breathing may take many hours.
Heart rate slows and becomes irregular
Please remember that hearing is probably the very last sense to go. Encourage family members to continue to talk softly or sing to the person.

Some people will not die until they have been released by important family members. You may need to help the family member give the person permission to pass on. People with unfinished business may survive long past medical predictions waiting to complete the business.

Immediately After Death
The person may sigh or make a groaning sound when moved. This is just air expelling from the lungs but family members may think the person has revived. Passing urine and stool as the spincters relax in death is very common. Stool may continue to leak for sometime after death.

Sometimes the person's spirit is quite palpable in the room. Family members may be either frightened or comforted by this. Sometimes caregivers and family members are aware of the spirit departing long before bodily death occurs.

What to do in the first hour following a death:

Tell the family members that the person is dead. They may already know but they need confirmation from a professional.
Allow family members to express their grief in their own ways. Don't be afraid to cry with them if you feel like it.
Some people wail loudly at a death - this is often a sign of respect as well as of grief. Make sure that someone explains what is happening to other patients. Some families show almost no emotion. This does not mean they do not care.
Determine whether any special care must be given to the body, for example Orthodox Jews may require that only members of the family or the burial society touch the body and prepare it after death.
Allow family members to spend as much time with the body as they desire. Remove equipment and arrange the body if the the family desires.
Offer the services of a chaplain or offer to call the family's minister or religious leader.
Families may wish to have a short prayer service immediately after the death. They may conduct this themselves or ask a chaplain or religious leader to conduct it. Join them if you are comfortable doing so. Your presence may be a comfort to the family especially if you have been caring for the client for a long time or have developed a special relationship with the patient and/or family.
Contact the funeral home specified by the family.
If the person dies at home and the death is expected - the person has a Do Not Resucitate (DNR) order and the physician will sign the death certificate - you need only call the funeral home. IF the death is unexpected and there is no DNR order you must call 911. When you do, please warn the family that the police, the fire department and the paramedics will all come.

Some suggestions for helping the grieving person:

Ask the greiving person how he/she is feeling. Recognize and acknowledge the feelings the person expresses. Be truly present. Don't try to make the person feel better, analyze or define their feelings. Listen to their story. Hold them physically if appropriate.
Talk about the person who has died. This gives the grieving person an opportunity to talk about the deceased too. It also validates what has happened. Bringing up the deceased person's name does not "make" the bereaved person feel bad - it gives permission to express those feelings.
Ask the bereaved person whether they feel the presence of the dead person or have seen or heard the person in visions or dreams. This is a very common experience. People need to be able to talk about it without feeling "crazy". Your asking gives them permission to talk about these experiences or to choose not to.
Assess the bereaved person's support system. Who are they? What are they doing that helps? What is not helpful? What else is needed?
Assess the grieving person's physical status. Is the person eating, sleeping, exercising, reaching out to others.
Encourage the bereaved to identify and implement spiritual practices that provide comfort and support.
When the time is right, you might recommend that the bereaved join a support group. This is especially important for persons who have had miscarriages, lost children or spouses.
The nursing diagnosis: dysfunctional grieving is really a value judgement. No one really knows how or how long a person should grieve. Your 80 year old client whose husband of 60 years has died will probably never stop grieving. The 72 year old who had to give up her cat to move to the nursing home may never stop grieving the loss if that animal was her only constant source of love and companionship.

Near Death Experience (NDE)

Individuals who have had a cardiac arrest or have been clinical dead consistently repost similiar experiences. The characteristics of the experience are the same regardless of age, culture or religion.
These characteristics include:
                Seeing or being engulfed in a bright light
                Being in a tunnel
                Seeing a religious figure or relative or friend who has predeceased them
                Watching their own body and the resucitation efforts from above or from a corner of the                      room as though watching another person.

Descriptions of resucitation activities are very accurate. Dr. Michael Morse , a Pediatric Critical Care physician has children draw their experiences. These drawings are accurate down to the color and type of clothing worn by staff and the words said by the staff caring for the child when he/she was clinically dead.

People who have had NDEs almost invariably exhibit the following characteristics after the near death experience:

    Increased sense of meaning and purpose in their lives
    Lack of fear of death
    Increased generosity
    A strong need to live life to the fullest

References
Byock, I. (1997). Dying well: The prospect for growth at the end of life. New York, NY: G.P. Putnam and Sons.

Eakes, G, Burke, M., Hainsworth, M. (1998). Middle-range theory of chronic sorrow. Image 30 (2), 179-184.

Kagawa-Singer, M. (1998). Introduction: death rituals and mourning: A multicultural perspective. Oncology Nurse Forum. 25 (10), 1751
Introduction to a series of articles about multicultural death rituals and mourning.

Moody, RA (1988). The light beyond. Basingstoke: Mc Millian

Nuland, S. (1994). How we die. New York: Random Books.

Steen, K. (1998). A comprehensive approach to bereavement. Nurse Practitioner 23(3), 54, 59-60, 62-4.