Bellringer:Yesterday, we dealt with our own

feelings about death & dying. Today, we will talk about the emotional changes of a patient through the process.

How do YOUR beliefs about death/dying affect the care that you give a patient through the dying process?

Emotional Changes of a patient through end of life

care Jackilyn Malone,

RN, BSN Montgomery

County ATC

DeathCessation of heart & lung

function OR

Cessation of whole brain function

Terminal IllnessA disease that cannot be

cured and will result in death

Time frame??◦Days,◦Months◦Years

Reactions to DiagnosisHelplessnessFear

◦Pain, separation from family, unknown

AnxietyLoss of independence/controlUnprepared/unfinished

Five StagesElizabeth Kubler-Ross

◦Psychiatrist◦Encouraged hospice care◦1969— “On Death & Dying” ◦Believed there are five stages of

grief in the dying process◦Not necessarily linear

1. Denial2. Anger3. Bargaining4. Depression5. Acceptance

DABDA

Stage 1: DenialUsually the first stage when

newly diagnosedInitial reaction of shockDazed at first, then refusal to

believeMay seek second, third, fourth

medical opinion“This can’t be happening.” “Must

be some mistake”

Stage 1: DenialTips for the Health Care Provider

(HCP)◦Listen to the patient without

confirming or denying the diagnosis

Stage 2: AngerNo longer denies deathFrustrated, angry, irritable, bitterMay blame self and/or others,

God“Why me?”

Bad habits may begin◦Drinking, smoking, speeding

“Why follow rules and take care of myself if I’m going to die?”

Stage 2: AngerTips for the HCP:

◦Understand that displaced anger is not a personal attack.

◦Try to be understanding

Stage 3: BargainingUsually occurs when patient

accepts death but wants more time to live

Turns to religions, bargains with God

“If you let me live long enough to see my grandson graduate college, I’ll donate everything I have to charity.”

Stage 3: BargainingTips for HCP

◦Just listen

Stage 4: DepressionOccurs when patient realizes

death is coming and they no longer have control

Clinical s/s:◦Withdrawal◦Sleep changes◦Hopelessness/crying◦Decreased appetite◦Possible suicidal ideation

Stage 4: DepressionTips for the HCP

◦Depression is okay and normal◦Listen◦Use comforting touch◦Offer encouragement

Stage 5: AcceptanceNormally, this is the final stageRealizes death is inevitable and

accepts itMay be able to talk about death,

tries to comfort family & friendsIf religious, may be comforted by

beliefs of afterlifeMay complete unfinished

business◦Make amends, pay off loans

Stage 5: AcceptanceTips for HCP

◦Listen◦Encourage

Five StagesNot always linearCan jump back and forth, skip

stagesMay or may not go through all

fiveOne stage may be more intense

than othersEvery patient will be different

Tips for HCPsLISTENTalk as neededProvide religious support as

requestedSupport familyIdentify appropriate resourcesAvoid statements such as:

“It’s God’s will,” “Everything happens for a reason,” “Everything will be ok”

ActivityI will divide students into groups

with sticksI will give each group a packet of

scenariosRead through the scenarios and

then decide what stage of grief the patient is in.

The first one, we will do together as a class

Break timeTake a 5 minute break

◦Get water◦Use restroom◦Stretch legs

Death AnxietyPatients experience some degree

of anxiety when dyingDifferent for each patient

Managing Death AnxietySpirituality/Religion

◦Solely up to patient◦HCP can ask the patient if they want

clergy but must respect their wishes regardless

◦Encourage them in their wishes and pursuits

Managing Death AnxietyCreative Outlets

◦Art◦Music◦Scrapbooks◦Writing◦Videos◦Quilts

Managing Death AnxietyMany people are now making

videos for their loved ones◦Gives them a chance to say what

they want to say about life’s milestones

◦http://www.cnn.com/2013/12/22/us/iowa-wife-dying-wish/

Traits for HCP to showConcern

◦Empathy, compassion, involvementCompetence-skill & knowledge =

reassuranceCommunication-know when to

listen and when to talkCohesion-family & medical

personnel on same page

Traits for HCP to showCheerfulness-gentle, not

obnoxious; light humor okay if a regular part of rapport with patient

Consistency

A Dying Patient’s Bill of Last RightsThe Right to be in control.

◦Grant me the right to make as many decisions as possible regarding my care. Please do not take choices from me. Let me make my own decisions

A Dying Patient’s Bill of Last RightsThe right to have a sense of

purpose. ◦I have lost my job. I can no longer

fulfill my role in my family. Please help me find some sense of purpose in my last days

A Dying Patient’s Bill of Last RightsThe right to reminisce

◦There has been pleasure in my life, moments of pride, moments of love. Please give me some time to recollect those moments. And please listen to my recollections.

A Dying Patient’s Bill of Last RightsThe right to be angry and sad

◦It is difficult to leave behind all my attachments and all that I love. Please allow me the opportunity to be angry and sad.

A Dying Patient’s Bill of Last RightsThe right to hear the truth.

◦If you withhold the truth from me, you treat me as if I am no longer living. I am still living, and I need to know the truth about my life. Please help me find that truth.

A Dying Patient’s Bill of Last RightsThe right to be in denial.

◦If I hear the truth and choose not to accept it, that is my right.

A Dying Patient’s Bill of Last RightsThe right to have respected

spirituality◦Whether I am questioning or

affirming, doubting or praising, I sometimes need you ear, a non-judging ear. Please let my spirit travel its own journey, without judging its direction.

A Dying Patient’s Bill of Last RightsThe Right to touch and be

touched◦Sometimes I need distance. Yet

sometimes I have a strong need to be close. When I want to reach out, please come to me and hold me as I hold you.

A Dying Patient’s Bill of Last RightsThe Right to Laugh

◦People often—far too often– come to me wearing masks of seriousness. Although I am dying, I still need to laugh. Please laugh with me and help others to laugh as well.

A Dying Patient’s Bill of Last RightsHonor these rights. One day you,

too, will want the same rights.

Exit slipWhat character trait do you

possess that you feel will help a dying patient?