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DEATH AND DYINGDEATH AND DYING

CAROL S. BONGAR RN

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Death is the end of life. Dying is the

process of approaching death, includingthe choices and actions involved in thatprocess.

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Definitionof Terms:

LOSS actualor potentialsituationinwhicha valuedobject , personis

inaccessiblesothatitisnolongerperceived valuable

BEREAVEMENT subjectresponsetoalossthroughadeathof person

MOURNING behavioral processthroughwhichgriefiseventuallyresolvedoraltered

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GRIEF totalresponsetotheemotional

experienceofthelossmanipulatedinthoughts, feelingsandbehaviors

anticipatorygrief referstotheprocessofaccomplishing partofthegrief

workbeforetheactuallossdysfunctionlgrief occurs whenthere

is prolongedemotionalinstability,withdrawalfromtheusualtask

disenfranchisedgrief occurs whensocietalnormsdonotdefinetheloss withitstradionaldefinition

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Typesof Loss:

a. Personalloss:anysignificantlossosomeoneorsomethingthatcannolongerbeseenorfelt

b. Perceivedloss:lossthatislesstangible

anduniquelydefinedbythegrievingclient

c. Maturationalloss:changeinmaturational process

d. Situationalloss:includesanysuddenunexpectedanddefinableeventthatisnot predictable

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Whenitisnot possibleto preventa patientdying,andmedicalcareisnolonger possibleoruseful,

thenurse providessupportivecaretothe patient

andfamily. Themaingoalsareto:

y keep the patientcomfortableandfreeof pain

y makethe patient'sfinaldaysasgoodas possibleforboth patientandfamily, withaslittlesufferingas possible

y help the patienttodie peacefully

y providecomforttothefamily.

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Elisabeth Kubler-Ross Stagesof GriefThestages, popularlyknownbytheacronym DABDA,

include:

Denial "I feelfine.";"Thiscan'tbehappening, nottome."Denialisusuallyonlyatemporarydefensefortheindividual. Thisfeelingisgenerallyreplaced with

heightenedawarenessof possessionsandindividualsthatwillbeleftbehindafterdeath.

Anger "Whyme? It'snotfair!";"How canthishappentome?";'"Whoistoblame?"

Onceinthesecondstage, theindividualrecognizesthatdenialcannotcontinue. Becauseofanger, the personisverydifficulttocareforduetomisplacedfeelingsofrageandenvy.

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Bargaining "I'lldoanythingforafew moreyears.";"I willgivemylifesavingsif..."Thethirdstageinvolvesthehopethattheindividualcan

somehow postponeordelaydeath. Usually, thenegotiationforanextendedlifeismade withahigher powerinexchangeforareformedlifestyle. Psychologically, theindividualissaying, "I understand I willdie, butif I couldjustdosomethingtobuymoretime...

Depression "I'msosad, whybother withanything?";"I'mgoingtodie... What'sthe point?";"I missmylovedone, whygoon?"Duringthefourthstage, thedying personbeginstounderstandthecertaintyofdeath. Becauseofthis, theindividualmaybecomesilent, refuse visitorsandspendmuchofthetimecryingandgrieving. This processallowsthedying persontodisconnectfromthingsofloveandaffection. Itisnotrecommendedtoattempttocheerup anindividual whoisinthisstage. Itisanimportanttimefor

grievingthatmustbe processed.

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Acceptance "It'sgoingtobeokay.";"I can'tfightit, Imayas well prepareforit."

Inthislaststage, theindividualbeginstocometotermswithher/hismortalityorthatofalovedone

Parkes 1986 Stages of grieving

a. Numbness

b. Yearning

c. Disorganization

d. Reorganization

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ENGELS STAGES OF GRIEVING

Shock &disbelief- Behavioralresponses- Refusetoacceptloss. Hasstunnedfeelings. Acceptsthesituationintellectually, butdeniesitemotionally

Developingawareness Behavioralresponses-Realityofbeginto penetrateconsciousness.Angermaybedirectedatagency, nursesorothers.

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Restitution/resolvingtheloss Behavioralresponses- Conductsritualsofmourning(e.g.

Funeral)attemptstodeal with painful void. Stillunabletoacceptnew loveobjecttoreplacelostpersonorobject

Idealization- Behavioralresponses Produces

imageoflostobjectthatisalmostdevoidofundesirablefeatures. Repressesallnegative &hostilefeelingstowardslostobject. Mayfeelguiltyabout pastinconsiderateorunkindactsto

lost person. Unconsciouslyinternalizesadmiredqualitiesoflostobject. Reinvestfeelingsintoothers.

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Outcome- Behavioralresponses- Behaviorinfluencedbyseveralfactors:- importanceoflost

objectasasourceofsupport, degreeofdependenceonrelationship, degreeofambivalencetowardslostobject, numberandnatureof previousgriefexperiences.

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SANDERSPHASES OF BEREAVEMENT

Shock- Survivorsareleft withthefeelingofconfusion, unreality &disbeliefthatthelosshasoccurred. Theyareoftenunableto processthenormalthoughtsequences. Phasemaylastfor

few minutestofew days

Awarenessofloss- Friendsandfamilyresumenormalactivity. Thebereavedexperiencethefull

significanceofhisloss.

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Conservation/ withdrawal- Duringthis phase,survivorsfeelaneedtobealonetoconserveand

replenishboth physical &emotionalenergy. Thesocialsupportavailabletothebereavedhasdecreasedandtheymayexperiencedespairandhelplessness.

Healing:theturning point-Thebereavedmovefromdistressaboutliving withouttheirlovedonetolearntolivemoreindependently

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Renewal- Heresurvivormoveontoanew

self-awareness, anacceptanceofresponsibilityforselfandlearningtolivewithoutthelovedone.

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How tohelp the patienttoa peaceful

Deathy Ifthe patientstaysinthehospital, try, as

muchas possible, todo whatheorshe

andthefamily want. Itisimportantto

provide physicalcomfort.y Itisalsoimportanttomakethe patient

feelsecuretocalmanyfears,

andgivehimorherhope.

Providespiritualcare

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NURSES ROLE

1. Therapeuticcommunication2. Maintenanceofselfesteem

3. Promotionofareturntolifeactivities

DYING CLIENT- Assessingthe physiological signsof

approachingdeath

- Helpingclientdie withdignity

- Meting phsyiologic needsofthedyingclient

- Providingnutritionalsupport

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TheDying Patients Billof Rightsy

I HAVE THE RIGHT TObetreatedasalivinghumanbeinguntil I die.

y I HAVE THE RIGHT TO

maintainasenseofhopefulness, howeverchangingitsfocusmaybe.

y I HAVE THE RIGHT TO

becaredforbythose whocanmaintainasenseofhopefulness, howeverchanging

thismightbe.

y I HAVE THE RIGHT TOexpressmyfeelingsandemotionsaboutmyapproachingdeathinmyown way.

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y I HAVE THE RIGHT TO

participateindecisionsconcerningmycare.

y I HAVE THE RIGHT TO

expectcontinuingmedicalandnursingattention,eventhough curegoalsmustbechangedtocomfortgoals.

y I HAVE THE RIGHT TOnotdiealone

y I HAVE THE RIGHT TO

befreefrom pain.

y I HAVE THE RIGHT TOhavemyquestionsansweredhonestly.

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y I HAVE THE RIGHT TO

notbedeceived.

y I HAVE THE RIGHT TO

havehelp fromandformyfamilyinacceptingmydeath.

y I HAVE THE RIGHT TO

diein peaceanddignityy I HAVE THE RIGHT TO

retainmyindividualityandnottobejudgedformydecisions whichmaybecontrarytothe

beliefsofothers.y I HAVE THE RIGHT TO

expectthatthesanctityofthehumanbody willberespectedafterdeath.

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DO NOT RESUSCITATE (DNR)STATUS1. Allhealthcareagenciesarerequiredtohave

DNR procedurestomeetaccreditationstandards

2. DNR ordersmustbeincludedintheclientsmedicalrecordad periodicallyupdated

3. Mostimportantfactorsconsideredarethe

clients wishes, the prognosis, theclientsabilitytocope, and whethercardiopulmonaryresuscitation(CPR) will providebenefitssufficienttomakeit worthwhile

4. Inmanystates , therighttorequestaDNRstatusismandated withinthe Patients BillofRights, andhospitalsmustalso provideeducationontheissueofDNR toclients

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5. A DNR mustbeateamdecision, andtheclientandthefamilymustbeincludedinthedecision-

making

AdvanceDirectives

1. Concepts

a. LivingWillsallow clientstostatetheir wish

todieincertainsituationsandnothavelifeprolonged bytheuseofmedications, artificialmeans, orheroicmeasures;theliving willsetsforththeclients wishesregardinghealthcaredecisions;itincludes whichmedical proceduresareauthorizedordeclined

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b. A healthcare proxydesignatesanagenttomakehealthcaredecisionsaccordingtothe

clients planor wishes;itincludesthe powerofstoppingornotgivingtreatmentnecessaryforlife whentheclientisunabletodoso

2. Advantagesofliving willsandhealthcareproxiesarethatthey permitexpressionofthe

clients preferences, promotecommunicationbetweentheclient andcaregivers, fosterrespectfortheclientasa person, andsupportthebeliefthatclienthavetherighttoself-determination

3. The Patients SelfDetermination Actof 1991mandatesthathealthcareagenciesreceivingMedicareand Medicaidreimbursementadviseclientsoftheirrighttoadvancedirectives

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CARING FOR THE BODY AFTER DEATHPallor mortis palenessofdeath

a postmortem paleness whichhappensinthosewithlightskinalmostinstantly(inthe 15120minutesafterthedeath)becauseofalackof capillary circulationthroughoutthe body

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y Algor mortis coldnessisthereductioninbodytemperature

following death. Thisisgenerallyasteadydeclineuntilmatching ambienttemperature, althoughexternalfactorscanhaveasignificantinfluence

. Rigor mortis "stiffnessofdeath

isoneoftherecognizablesignsof death thatiscausedbyachemicalchangeinthe muscles afterdeath, causingthelimbsofthe corpse tobecomestiffanddifficulttomoveormanipulate.Inhumansitcommencesafterabout3hours, reachesmaximumstiffnessafter12hours, andgraduallydissipatesuntilapproximately 72hours(3days)afterdeath

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y Livor mortis "bluishcolor, postmortem

lividity, hypostasisstartstwentyminutestothreehoursafterdeathandiscongealedinthecapillariesinfourtofivehours. Maximumlividityoccurs within 6-12hours. Theblood poolsintotheinterstitialtissues

ofthebody.

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LEGAL ASPECTS

y Death Certificate

y Autopsy

y Republic Act No. 7170 January 7, 1992

AN ACT AUTHORIZING THE LEGACY OR DONATION

OF ALL OR PART OF A HUMAN BODY AFTERDEATH FOR SPECIFIED PURPOSES

"Organ Donation Act of 1991".

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ORGAN DONATION Undertheuniformanatomicalgiftactandthenationalorgantransplantactin

theunitedstates, people 18 yearsorolderandofsoundmindmaymakeagiftofallorany partoftheirownbodiesforthefollowing purposes: Formedicalanddentaleducation Research

AdvancementofmedicalanddentalscienceTherapyortransplantation. Thedonationcanbemadeby provisionina willorbysigningacardlikeform. Thiscardisusuallycarriedatalltimesbythe person whosignsit

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"Yesterday is history, tomorrow is a

mystery, and today is a gift; that's whythey call it the present." - EleanorRoosevelt(1884-1962)

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