Death and DyingDeath and Dying

Teresa RogersTeresa Rogers

Butler County ATCButler County ATC

Summer 2010Summer 2010

ObjectivesObjectives

The student will:The student will:• Explain the stages of death and dying including Explain the stages of death and dying including

the philosophy of hospice carethe philosophy of hospice care

ContentsContents

• Stages of Death and DyingStages of Death and Dying

• Right to Life IssuesRight to Life Issues

• Advance DirectivesAdvance Directives

• Living Will Living Will

• Medical Power of AttorneyMedical Power of Attorney

Terminal IllnessTerminal Illness

• Any disease that cannot be cured and will result Any disease that cannot be cured and will result in death.in death.

• Everyone reacts differently to news of a terminal Everyone reacts differently to news of a terminal illness.illness.

• Some react with fear and anxiety.Some react with fear and anxiety.• Many fear pain, abandonment, loneliness, and Many fear pain, abandonment, loneliness, and

the unknown.the unknown.

• They may become anxious about their loved They may become anxious about their loved ones, unfinished work, or dreamsones, unfinished work, or dreams..

Emotional and Physical Reasons Emotional and Physical Reasons People May Fear Death.People May Fear Death.

• Helplessness Helplessness

• Dependence on others Dependence on others

• Physical faculties Physical faculties

• Mutilation by surgery or disease Mutilation by surgery or disease

• Uncontrollable pain Uncontrollable pain

• Being unprepared for death Being unprepared for death

Social Reasons People May Fear DeathSocial Reasons People May Fear Death

• Fear of separation from family or home Fear of separation from family or home

• Fear of leaving behind unfinished tasks or Fear of leaving behind unfinished tasks or responsibilities responsibilities

Dr. Elizabeth Kubler-RussDr. Elizabeth Kubler-Russ

• Identified five stages of grieving that dying Identified five stages of grieving that dying patients and their families and friends may patients and their families and friends may experience.experience.

• They may not be in order and may overlap They may not be in order and may overlap or repeat a stage at times.or repeat a stage at times.

• Others may not experience all stages.Others may not experience all stages.

• Stages include denial, anger, bargaining, Stages include denial, anger, bargaining, depression, and acceptance.depression, and acceptance.

DenialDenial

• Usually occurs when the person is first told Usually occurs when the person is first told of the illness.of the illness.

• Individual’s may say,Individual’s may say,• ““The tests are wrong.”The tests are wrong.”• ““This can’t be happening to me.”This can’t be happening to me.”• ““I don’t believe it.”I don’t believe it.”

• Others don’t talk about it.Others don’t talk about it.

• Health care workers should listen without Health care workers should listen without confirming or denying it.confirming or denying it.

AngerAnger

• This stage occurs when the patient can no This stage occurs when the patient can no longer deny death.longer deny death.

• The patient may blame themselves, their The patient may blame themselves, their loved ones, or health care workers for their loved ones, or health care workers for their illness.illness.

• Health care workers must understand this Health care workers must understand this is not a personal attack.is not a personal attack.

BargainingBargaining

• Usually occurs when patient accepts death but Usually occurs when patient accepts death but wants more time to live.wants more time to live.

• Patients turn to religion and spiritual beliefs Patients turn to religion and spiritual beliefs during this period.during this period.

• They want to see their child gradate, get They want to see their child gradate, get married, or hold a grandchild.married, or hold a grandchild.

• Making promises to God to try and obtain more Making promises to God to try and obtain more time sometimes occurs.time sometimes occurs.

DepressionDepression

• This stage occurs when the patient This stage occurs when the patient realizes that death will come soon and realizes that death will come soon and they won’t be with their families any they won’t be with their families any longer.longer.

• They realize that some goals they set will They realize that some goals they set will not be met.not be met.

• Health care workers need to let the patient Health care workers need to let the patient know that depression is “OK”.know that depression is “OK”.

AcceptanceAcceptance

• This is normally the final stage.This is normally the final stage.• The patient understands that they are going The patient understands that they are going

to die.to die.• May complete unfinished business and try May complete unfinished business and try

to help those around them deal with death.to help those around them deal with death.• Patients will slowly get farther away from the Patients will slowly get farther away from the

world and other people.world and other people.• They need emotional support during this They need emotional support during this

stage.stage.

Interventions for Health Care Interventions for Health Care Professionals Professionals

• Talk as needed Talk as needed • Avoid superficial answers, i.e. “It’s God’s Avoid superficial answers, i.e. “It’s God’s will.” or “It will be OK.”will.” or “It will be OK.”• Provide religious support as appropriate Provide religious support as appropriate • Stay with the patient as needed Stay with the patient as needed • Work with the family so they might be Work with the family so they might be strong enough to offer support to the dying strong enough to offer support to the dying

person. person.

Physical ChangesPhysical Changes

Of Of

DeathDeath

1.Unable to oxygenate the body enough for 1.Unable to oxygenate the body enough for adequate gas diffusionadequate gas diffusion

2.Respirations become stridorous or noisy, leading 2.Respirations become stridorous or noisy, leading

to “death rattle”to “death rattle”

3. Cheyne-Stokes respiration sign of pulmonary 3. Cheyne-Stokes respiration sign of pulmonary system failure system failure a. Consists of alternate hyperpneic and apneic a. Consists of alternate hyperpneic and apneic

phases phases

Respiratory SystemRespiratory System

Cardiovascular SystemCardiovascular System

• Heart unable to pump strongly enough to keep blood Heart unable to pump strongly enough to keep blood moving moving

• Decreased blood causes decreased circulation to the Decreased blood causes decreased circulation to the body body

o Skin becomes cool to the touch, pale Skin becomes cool to the touch, pale

o Person appears cyanotic, possibly mottled Person appears cyanotic, possibly mottled

o Failure of peripheral circulation frequently results in a drenching Failure of peripheral circulation frequently results in a drenching

sweat cooling the body surface. sweat cooling the body surface.

• Pulse becomes weak and thready, ultimately irregular Pulse becomes weak and thready, ultimately irregular o A stronger pulse typically means death is hours away A stronger pulse typically means death is hours away

o A weak, irregular pulse typically means that death is imminent in the A weak, irregular pulse typically means that death is imminent in the next couple of hours. next couple of hours.

o An apical pulse might be required. An apical pulse might be required.

Other ChangesOther Changes

• Metabolism rates decrease.Metabolism rates decrease.• The person might retain feces or become The person might retain feces or become

incontinent. incontinent. • Urinary output decreases. Urinary output decreases. • Dying person may turn toward light as sight Dying person may turn toward light as sight

diminishes. diminishes. • Dying person may hear only what is distinctly Dying person may hear only what is distinctly

spoken.spoken.• Dying person may remain consciousness or Dying person may remain consciousness or

become unconscious/comatose become unconscious/comatose

Other ChangesOther Changes

• Some dying people rally in clarity and Some dying people rally in clarity and consciousness just prior to their death consciousness just prior to their death

• A person’s eyes might be open even if A person’s eyes might be open even if unconscious unconscious

• Dying people might turn toward or speak to Dying people might turn toward or speak to someone who is not visible to anyone else in room someone who is not visible to anyone else in room

• Pain might be present Pain might be present • Pain medication should not be withheld as person Pain medication should not be withheld as person

nears death. nears death.

Right to DieRight to Die

• Most people with terminal illness believe that Most people with terminal illness believe that someone with a terminal illness should be allowed someone with a terminal illness should be allowed to refuse measures that would prolong their life.to refuse measures that would prolong their life.

• This is the right to dieThis is the right to die..

• Respirators, pacemakers, and other medical Respirators, pacemakers, and other medical devices can be withheld and the person can die devices can be withheld and the person can die with dignity.with dignity.

• DNR – Do Not Resuscitate OrderDNR – Do Not Resuscitate Order

DNRDNR

• Do Not Resuscitate OrderDo Not Resuscitate Order

Hospice CareHospice Care

• This philosophy is to allow the patient to This philosophy is to allow the patient to die with dignity and comfort.die with dignity and comfort.

• Pain is controlled so that the patient can Pain is controlled so that the patient can remain active as long as possible.remain active as long as possible.

• Specially trained volunteers are an Specially trained volunteers are an important part of many hospice programs.important part of many hospice programs.

Advance DirectivesAdvance Directives

• A general term that describes two types of A general term that describes two types of legal documents.legal documents.

• Living WillLiving Will

• Healthcare (Medical) Power of AttorneyHealthcare (Medical) Power of Attorney

Living WillLiving Will

• Allows a person their wishes about Allows a person their wishes about medical treatments for the end of life in medical treatments for the end of life in writing in the event that they cannot writing in the event that they cannot communicate those wishes directly.communicate those wishes directly.

• Different states may use different names.Different states may use different names.

Healthcare Power of AttorneyHealthcare Power of Attorney

• Also know as a “healthcare proxy,” “ Also know as a “healthcare proxy,” “ appointment of a healthcare agent,” or appointment of a healthcare agent,” or “durable power of attorney for healthcare.”“durable power of attorney for healthcare.”

• The person you appoint will be authorized The person you appoint will be authorized to deal with all medical situations when to deal with all medical situations when you cannot speak for yourself.you cannot speak for yourself.