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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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