Death And Dying Stages Of Grieving PDF

[DEATH AND DYING] [INTRODUCTION] Death is one of the most difficult facts for human beings to accept especially when it happens to a loved one. Death is inevitable and therefore dying and death must be accepted as a phase of life that all must meet. In the life of each individual, there is only on...

[DEATH AND DYING] [INTRODUCTION] Death is one of the most difficult facts for human beings to accept especially when it happens to a loved one. Death is inevitable and therefore dying and death must be accepted as a phase of life that all must meet. In the life of each individual, there is only one certain which is that he will die; it is the time of this event which is however unknown. Death is a time of crises for the client's family; nurse and doctors, therefore then nurse should make this experience less sorrowful. The client and the family turn to the nurse for care and assistance, therefore the nurse has to conceal some of her own feelings about death. The nurse should also understand the phases of grieving and dying. When the death cannot be prevented, it is the nurse's duty to make dying as easy as possible for the client as this is the most trying period for her. To achieve this, the nurse must lessen pain and provide comfort to allow patient die peacefully. The nurse should be aware that a semi conscious or unconscious client may hear and understand comments that are made therefore should be careful not to express any opinion about the client's condition within his hearing, and the nurse should never give up in caring for such patient as long as there is life. [DEFINITION OF DEATH] 1. Death is the irreversible ceasation of function in cells, tissues or in the whole body. Or 2. Death is the ceasation of physical and chemical process that occurs in all living organisms or their cellular components. [SIGNS OF IMPENDING DEATH] In addition to signs related to client's disease, certain other physical signs indicative of impending death may occur. The four main characteristic changes are: - a. [Loss of muscle tone] - Relaxation of the facial muscles, the jaw may sag. - There is difficulty in speaking and speech may be mumbled. - There is difficulty in swallowing and gradual loss of the gag reflex. - Decease activity of the gastro intestinal tract with nausea, accumulation of flatus (gas in the stomach) abdominal distention, retention of faeces especially if a narcotic is being used. - Motion and sensation are lost gradually. This usually begins in the extremities, particularly the feet and hands. b. [Slowing of circulation] - Diminished sensation. - Mottling and cyanosis of the extremities. The skin looks pale and grayish. - The skin and feet become cold, later coldness in the hands, ear and nose, even though the temperature is usually high and client feels warm. c. [Change of vital signs ] - Decreased, weaker pulse which may be rapid & irregular and later becomes imperceptible. - The blood pressure falls (decreased blood pressure). - Respiration becomes shallow, abnormally slow and labored. It becomes irregular and noisy. This is referred to as the death rattle due to accumulation of mucus in the throat which the patient cannot expectorate as the swallowing reflex is lost. d. [Sensory impairment ] - Blurred vision and impaired sense of taste and smell. [Note]: - other signs include: - The client may be fully conscious, semi-conscious or comatosed. - There is expression of anxiety and fear. - The patient may be very restless and pick at his bed clothes in a disorientated manner. - The patient is unable to support himself and sinks very low in bed. - There may be incontinence of urine and faeces due to loss of muscles control. - There may be a particular scent or odour around the patient. - The anxiety expression becomes one of peacefulness. - The mouth becomes dry. - The eyes are fixed in unseeing stane and the pupils do not react to light or movement. [TERMINOLGOIES] 1. [RIGOR MORTIS]: - This is stiffening of the body that occurs 2 -- 4 hours after death. It occurs as a result of lack of glycogen in the body. When this occurs, adenosine trip hosphate (ATP) is not synthesized (ATP is necessary for muscle fibre relaxation). Its lack therefore cause the muscles to contract which immobilizes the joint. Rigor mortis starts in the involuntary muscles examples, heart, bladder etc, then progresses to the head, neck, trunk and then the upper and lower extremities. 2. [ALGOR MORTIS]: - This is the gradual decrease of the body's temperature after death when blood circulation stops and the hypothalamus ceases to function. Body temperature falls about 1^0^C per hour until it reaches room temperature. The skin looses its elasticity and can easily be broken when removing dressing and adhesive tape. 3. [LIVOR MORTIS]: - This is the discolouration of the skin after death which results after blood circulation has ceased. The res blood cells breakdown releasing haemoglo bin which discolours the surrounding tissues. It appears in the lower most or depended areas of the body. Tissues after death become soft and liquefied by bacteria fermentation. The hotter the temperature, the more rapid the change. Bodies are therefore stored in cool places to delay this process through injection of some chemicals into the body to destroy bacteria. [INFORMATION TO CLIEN CONCERNING DEATH] To inform t he dying patient that the condition is terminal is difficult issue for doctors. Some authorities believe that terminal clients acquire knowledge of their condition even if they are not until the end comes. It is difficult to distinguish between what clients know, and what they are willing to accept. Health personal should therefore be concise, and not give information than the client wants. Example is a patient who has acquired the HIV and condemned to death. In delivering this information, one can say that "Even though it is not curable, drugs are available to prolong the life span". [STEPS THAT CAN BE TAKEN TO DISCUSS DEATH WITH A PATIENT] 1. Identifying personal feeling about death and how it would influence interaction with clients. Be aware of personal fears about death and discuss them with a colleague or friend. 2. Focus on client need. Client fears or beliefs are different from nurses to nurse. Avoid imposing personal fears and beliefs on client and family. 3. Understand patient and find out how he cope with stress from client or family, because patient will use their usual coping strategies from dealing with impending death (quiet or reflective). 4. Establish a communication relationship that shows concern for and commitment to the client e.g. describing what the nurse sees; "You seem sad, or would you like to talk about what is happening to you?" "I care about you and would like to help you to be more comfortable. [CARE OF THE DYING PATIENT/TERMINALLY ILL PATIENT ] A terminally ill patient is one in whom recovering is beyond reasonable expectation. A patient may know when death is approaching if he is conscious, but he may not talk about this especially to relatives or friends. A nurse shall always be present at the bed side of the dying patient and each nurse should know how best to help each individual patient at this time, and should know exactly what to do for patient to ensure his comfort and a peaceful death. [STEPS FOR CARING FOR THE TERMINALLY ILL PATIENT] 1. Reassure client and relatives. 2. Put patient in the recumbent position, change to semi-sitting position when dyspnoec and if conscious. 3. Provide side rails or nurse patient in a cot bed if restless. 4. Suck patient when necessary (using a suction machine) or by patient in the lateral position or flat on the back with the head turned to the side if conscious to drain secretions from the mouth. 5. Maintain personal hygiene, give bed bath, oil or apply pomade (e.g. Vaseline) to dry areas of the skin. Treat /care for the mouth four hourly. 6. Treat pressure areas four hourly, and change position two hourly. 7. Wipe sweat from patient's skin if necessary. 8. Tepid sponge patient when having spiking temperature. 9. Clean eye with moistened cotton wool balls (cotton wool balls soaked in normal saline) to keep eyes moist and avoid dry secretions). Instill eye drops to lubricate conjunctivae if necessary. 10. Feed patient with easily digestible food if patient can swallow. 11. Pass urethral catheter, and connect to a urine bag. 12. Stay with patient and never leave him alone. 13. Allow relatives including children to visit as long as they can. Encourage them to converse in their normal tone whiles at the bed side and not to whisper. 14. Speak to patient and touch him even if unconscious. 15. Inform and explain to relatives of every change in patient's condition and allow them to call in the priest if they wish to. 16. Administer oxygen and give analgesics when necessary. [SPIRITUAL AND EMOTIONAL NEEDS OF A DYING PATIENT] Spiritual support is a great importance in dealing with death. Majority of patients find great comfort in the support they receive from their religious faiths. The spiritual needs of the dying patient include; - Forgiveness and reconciliation with God and past human relationships so that he may be at peace with God and have a place in whatever kingdom he believes. - Prayer and religious services such as sacraments of blessings, taking communion before dying. - Spiritual assistance at the time of death from a clergyman, family or health care provider. [Note]: The nurse can attend to client's spiritual needs by arranging with individuals who can provide spiritual care. In some instances, the nurse may offer to call a clergyman when the patient or family has not expressed a desire to see one, but this must be handled tactfully. It must also be remembered that nurses should not impose their own religious or spiritual beliefs on a client but to respond to the patient in relation to client's own background and needs. [Note]: - The chaplain's visit does not replace the kind of words and gentle touch of the nurse. Rather, he should be considered as one of the health team members assisting the patient to face the terminal illness. Some of the interventions the nurse can do are: - Prayer - Meditation - Reading and discussing with appropriate clergy/advisor - Facilitating expressions of feelings It is important to help the patient feel secured and maintain self-dignity, his sense of worth and belongingness. The factors which help client face death are important, even if it is known that nothing available can prolong a patient's life, hope continues and the patient benefits when helped to feel secured. Hope is a desire accompanied by a feeling of anticipation. Without hope, despair exists. As patient begins to face impending death, he may hope to be free from pain, nausea, or to be able to walk again. The patient's hopes should be identified and supported if realistic. The nurse should work towards the fulfillment of this hope and assist the family towards accepting the patient's wishes. [CARE OF BEREAVED RELATIVES] The relatives should be informed of any deterioration in a patient's condition, but if they are not available, or if patient dies suddenly, it may become necessary to inform the relative of the fact of death with no prior preparation. If the relatives are actually present in the hospital, they can be asked to sit down (offer them a seat) before the news is broken to them. A difficulty does arise if the news has to be given over the telephone to a relative who happens to be alone in the house. If possible invite the person to the hospital or he should be asked to sit down before the news is broken to him. If possible ask him to fetch a neighbor to be with him, but this may really be practicable as he will realize something dreadful has happened. The nurse should make sure that the relative is all right before ringing off. Serve relatives a drink after offering them seat to make them feel relaxed. (If necessary). The relatives should be given the opportunity of seeing the patient's body after death. Relatives should be reassured as they may experience shock. An appointment may be made for the relatives to see the medial social worker for advice about the social agencies available to help. If the relative came to the hospital alone, it is best if arrangement is made for a friend or another relative to spend the night with the bereaved person to give support and care. Bereaved relatives should also be directed as to the acquisition of death certificate etc. [LAST OFFICES] This is the term given to the care of the body after death before being taken to the mortuary. When the nurse realizes a patient is dead, she does the following: - 1. Screen the bed 2. Contact nurse in charge to inform the doctor 3. Note the time vital functions ceases and record 4. Ensure doctor certifies death before proceeding to the next step 5. Remove all bed appliances and equipment used on the patient e.g. I/V infusion, NG tubes etc. 6. Straighten t he limbs 7. Gently close eyes and mouth if not closed, apply small wet pieces of cotton wool swabs and place over the eyelid to stabilize them. 8. Cover head and body with a sheet and leave for one (1) hour. 9. Inform relatives, if they wish to see the body, allow them to do so. Give emotional support to the grieving relatives. [PREPARATION OF THE BODY REQUIREMENTS] A trolley with the following: - - Articles for bed bath (refer) - Receiver containing forceps e.g. 2 pairs of dressing forceps and scissors - A gallipot with cotton wool swabs - Dressings (gauze & cotton wool swabs) - Bandages - Receiver - Towel and face towel - Plaster - Identification band or label - Clean personal linen or mortuary gown (shroud) and 2sheet [STEPS] \*The nurse works under a quiet atmosphere. 1. Turn patient to lateral position. a. With a receiver in position to collect secretions. b. To the supine position, a gentle pressure over the lower abdomen will help empty the bladder into a receiver. 2. Give the patient a bed bath. 3. Clean nostrils, eyes and mouthy. 4. Replace dentures if any. 5. Trim the nail and shave male patient's if necessary. 6. Remove all jewelry including wedding rings, unless requested by relatives to remain. 7. Redress wound if any, secure dressing with tape or loose bandage. 8. Pack orifices, thus nostrils, ears, rectum and vagina if necessary, with cotton wool swabs using forceps to prevent leakage and discharge. 9. Put a label on the patient's arm or chest bearing the following: - - Full name - Age - Ward - Diagnosis - Date and time of admission - Date and time of death 10. Wrap the body in a sheet, ensuring that the face and feet are covered, and all limbs are held securely in position. 11. Place patient on a special mortuary trolley if available. 12. Make arrangement to transfer the body to the mortuary by mortuary attendants. 13. Check patient's property with a second nurse. - List property in the available property book, lock the property in a safe place. - Hand them over to the next of kin if available and ask this person to sign the valuables book. 14. Clear away any equipment used. 15. Clean the bed, side locker and all appliances (refer discharge) of a patient. 16. Document in admission and discharge book. 17. Take patient's folder to the revenue office for calculation of hospital bill depending on the policy of the hospital. 18. Inform relatives to come to the ward, prior to going to the mortuary. [MANAGEMENT OF PATIENT BROUGHT IN DEAD] 1. Reassure the relatives 2. Offer them a seat 3. Call in the doctor to certify death and fill the coroner's forms. 4. Direct relatives to send the form to the police station. 5. Manage the corpse as done to those who die in the hospital. (Refer last offices). [GRIEF AND THE GRIEVING PROESS] [GRIEVING] It is an emotional response to loss. The loss object can vary. It may be loss of a dear one, thus through death or merely by separation. It can also be loss of a body part or function, loss of job, loss of a home or a pet or any thing else meaningful to the person. The one who is terminally ill can also grief for his/her own loss of capabilities or impending loss of life. The process of grieving is normal and essential to recover from the loss. Many factors affect the process of grieving. When the loss one had chronic illness, the family may have passed through the early phases of grieving before he dies. When the death is sudden, the grieving process is so great. If the death is not sudden, relatives as well as the dying patient may go through the stage of grieving. [STAGES OF GRIEVING (ELISABETH KUBLER ROSS)] She came out with 5 stages of grieving. These are: 1. [DENIAL]: - It is a conscious or unconscious refusal to accept the fact information, reality, relating to the situation concerned and it is followed by dumbness, feeling of tightness in the throat, experiencing feelings of fatigue, tension and anxiety. At this stage, the person usually reacts to the feeling of loneliness and non acceptance of his/her condition. He/she responds to expressions like "No! this is not happening to me". "This can't be true". He/she pretends not to know and continues to talk about his/her future plans. The person needs reassurance at this stage. [ANGER] The person becomes angry and hostile. The hostile reactions is sometimes directed to family members, health personnel and friends. Anger can manifest in different ways. People dealing with emotional upset can be angry with themselves or with others, especially those close to them. The person will ask "why is this happening to me"? "What have I done to deserve this"? "Why me"? [BARGAINING] The stage of bargaining is often a promise to God in an exchange for an extension of life. Traditionally, the bargaining stage for people facing death can involve attempting to bargain with whatever God the person believes in. He/she may promise to repent from his /her sins and make up for previous errors, if he can just live a little longer. The person may say "God, first let me live to see my children graduate, and I will serve you". [DEPRESSION/DESPAIR] Depression is a sort of acceptance with emotional attachment. It is natural to feel sad and regret, fear, uncertainty etc. It shows that the person has at least accepted the reality. At this stage, the person becomes conscious and very concerned about how his or her family is going to make it when he/she is gone. The dying person tries to put the affairs together. He/she may wish to see only those nearest and dearest, and may request for a chaplain. The person may say "I'm so sad why bother me with anything?" [ACCEPTANCE] At this stage, the person is usually tired but at peace. This stage perfectly varies according to the person's situation although broadly it is implication, to others it is an emotional detachment and objectivity. The person may say "come what may it's going to be over". [NOTE] - A person may be growing in acceptance and still experience denial, bargaining, anger and despair. To come to full acceptance, we are supposed to gain objectivity and clarity of thinking. It is often useful to get assistance from those who have experienced a similar loss e.g. groups of parents who have experienced the death of a child. - These stages of grieving can recur during a loss experience, and one stage can last longer than the other or last for a long time uninterrupted. - The five stages can occur in either the sequence presented above or in any variety of sequence. - The loss process can last anywhere from months to years. - These stags of grieving are normal and they are to be expected. - It is healthier to accept these stages and recognize them for what they are, rather than to fight through or to ignore them. - Working out stages of the loss response ensure a return to emotional health and adaptive functioning. - Getting outside support and help during the grieving process will assist in gaining objectivity and understanding. [FACTORS INFLUENCING A LOSS REACTION ] \* [AGE & PERSONAL SIGNIFICANCE OF THE LOSS]: - One person may experience a great loss, others may find it only mildly disrupting because of age of the person, value placed on the loss. \* [BELIEFS]: - The person's beliefs and values with aged, they may be apathetic instead of reactive. \* [CULTURE]: - Experience of grief can be determined by the custom of the culture. The death of a family member and the nuclear European family leaves a great void because of its small size which emphasizes self reliance and independence. In cultures where several generations and extended family members either reside in the same household or are physically close, the impact of a family member's death may be softened because the roles of the deceased are limited. \- other factors include: - Spiritual belief - Sex role - Socio economic status