Caring for Client When Death is Imminent

7/28/2019 Caring for Client When Death is Imminent

1/23

SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS

Unit 5: Caring for Client when Death is ImminentPrimary Objective: Provides Care to Client when Death is Imminent Time: Class: L

Objective: 2.5.1 Discusses own feelings and attitude about death.

Competency Course Content

After the completion of the

lecture/discussion, the student will:

1. List how the nurse aidesown feelings about death canaffect the care of a dying

client

1. The health care provider must recognize and deal withher/his own feelings and attitudes towards death in order toprovide essential support to dying clients.

Many factors influence attitudes toward death. Examplesinclude age, personal experiences, culture, and religion.

First encounters with death and the dying process can befrightening. The nurse aide can utilize co-workers assupport system for dealing with the experience.


2/23

SUPPLEMENTAL MATERIALS: HANDOUTS

2.5.1

USE A SELF-INVENTORY TO DETERMINE YOUR FEELINGS ABOUT

CARING FOR DYING PATIENTS

LEARNING ACTIVITY 3:

How Do I Feel

Purpose: In this activity, you will answer questions that will

help you understand more about your feelings aboutcaring for dying patients. The better you understand

your own responses to death and loss, the better you

will be able to deal with patients and families

experiencing death and loss. Regardless of the type ofnursing you plan to do, you will have patients who

die. This activity will help prepare you to care for

dying patients.

Instructions: Work individually on this activity

Read the self-inventory and mark the number that most

describes your feelings about the statement

Total your score and compare it to the scoring scale

Special tools/equipment: None needed for this activity

Application: After scoring your self-inventory, write a paragraph

about your strengths and weaknesses in caring for

dying patients.- What experiences in your life have given you insight into

loss?

- What experiences have given you a desire to avoid beingnear others who are grieving?

- How will you draw on and overcome these experiences to

care for dying patients?

Hand in your paragraph to your facilitator

(continued on next page)

Page 1 of 3


3/23


2.5.1

LEARNING ACTIVITY:

How Do I Feel

Self-Inventory of Attitudes Towards Caring for Dying Patients

Place a checkmark in the space that corresponds to your feelings about each statement.

Statement StronglyAgree

Agree Undecided Disagree StronglyDisagree

I am afraid to care for a dying

patient.

I am very uncomfortable around

people who are sad or crying.

I do not want to touch a dying

patient.

Dying patients should be left in

peace, not given usual nursing

care such as bathing andturning.

Terminally ill patients should

not be told that they are dying.

If I cry around dying patients or

their families, I am not being

professional.

I am afraid to go into the roomafter a patient has died.

If one of my patients were to dieunexpectedly, I would feel that I

must have made an error in care.

I dont want dying patients totalk to me about their feelings; it

makes me feel frightened.

I am afraid that I might have to

care for dying children or young

adults.

(continued on next page)

Page 2 of 3


4/23


2.5.1

LEARNING ACTIVITY

How Do I Feel?

Scoring the self-inventory:

Give yourself 5 points for every answer marked Strongly Agree.

Give yourself 4 points for every answer marked Agree.Give yourself 3 points for every answer marked Undecided

Give yourself 2 points for every answer marked Disagree.

Give yourself 1 point for every answer marked Strongly Disagree.

Interpreting the score:

Scores of 41-50 indicate that you have a great deal of anxiety about caring fordying patients.

Scores of 31-40 indicate that you are unsure and slightly anxious about caring fordying patients.

Scores of 21-30 indicate that you are fairly confident in your ability to care

for dying patients.

Scores of 10-20 indicate that you are quite confident in your ability to care for

dying patients.

Student Workbook: Nursing Skill Information Sheet: Module 17. Skills for Care of a DyingPatient, pg. 10.

Page 3 of 3


5/23



Objective: 2.5.2 Explains how culture and religion influence a persons attitude toward death.

Competencies Course Content



1. List how cultural andreligious influences canaffect how a dying client

vies death

2. List 3, probing questionsthat can help the team

indemnify specific cultural

needs

3. List 4 examples of culturalvariations/beliefs regardingdeath

1. Culture and religion provide a framework within whichpersonal experiences with death take on meaning.

Personal experiences, culture, religion, and age influencea persons individual set of beliefs in ways that maydiffer from your personal beliefs about death.

The nurse aide must NOT impose his/her beliefs uponthe dying client, the family, or those people close to thedying client.

The nurse aide must show respect for the clients beliefsand the clients need for spiritual support. It is veryimportant to identify the clients particular beliefs orpractices before death occurs.

Locate your facilitys policy regarding religiousobservances and requirements to be followed when death

occurs.

2. It is important for the team to discover specific, culturalissues in order to provide respectful care to the dying client.

Probing questions are:

Who is allowed to provide personal care? (In somecultures, a member of the opposite sex cannot providecare.)

Does the client or family have any special customs? Are there customs unique to their culture? What is the clients/caregivers understanding about

medications? Are there specific post-mortem customs that the staff

should know?

3. Samples of cultural variations regarding death and dying: Chinese culture Traditional healing practices include

using herbal preparations that are given only once.

Autopsy and disposal of the body are not permitted byreligion; therefore, organ donation is encouraged.


6/23



Objective: 2.5.2 Explains how culture and religion influence a persons attitude toward death.


Japanese culture The number 4 means death, sogetting medication four times a day (Q.I.D.) could be

problematic.

Some cultures view talking about funeral arrangementsas problematic.

Some cultures believe dying at home is preferable whileothers fear death at home.

Vietnamese culture they believe in reincarnation, soquality of life is more important than the length of life.

Hinduculture Persons are often accepting of Godswill. The clients desire to be clear headed at the time ofdeath is critical. Prayer helps deal with anxiety and

conflict. Blood transfusions, organ transplants, and

autopsies are allowed. Cremation is preferred.

Reincarnation is a Hindu belief.


7/23


2.5.2

SPECIFIC RELIGIOUS PRACTICES

Judaism (Orthodox)

Visits to dying person is a religious duty

Witness must be present when death occurs

Conversation kept to minimum

Someone stays with body until burial (within 24 hours)

Do not touch or wash body

Buddhism

Buddhist priest is present at death

Last rites chanted at bedside

Hinduism

Priest ties thread around neck or wrist of deceased and pours water in mouth

Islam (Muslim)

Before death reads Koran and prays

Client confesses sins and asks forgiveness of family

Only family touches and washes body

After death body is turned toward Mecca

Baptist

Clergy ministers through counseling and prayers

Roman Catholic

Sacrament of sick administered to ill clients, to clients displaying signs of approachingdeath, or shortly after death.

Lutheran & Episcopalian

Last rites optional

Eastern Orthodox Christian

Last rites are mandatory and handled by an ordained priest.


8/23


2.5.2

CASE STUDY:

Mrs. Jones is a 90 year old client who has resided in a long term care facility for 15 years. Over

the years she has developed close bonds with the staff and her roommate, Mrs. Smith. One night

Mrs. Jones passed away in her sleep unexpectedly. Mrs. Smith was in the room at the time Mrs.

Jones expires.

Mrs. Jones is Jewish and her religion requires that she be buried prior to sunset the next day. Her

family is located out of state and wishes to see her prior to burial.

QUESTION:

1. Identify you own feelings about death and how you would feel if you were in the same

room when your room mate expired.

2. How could the staff effectively express feelings of grief?

3. How could you balance Mrs. Jones religious doctrines with the wishes of the family?

4. How would you address needs of the roommate in terms of her loss?

Source Unknown: Submitted by a PA Nurse Aide Training Program, 2011


9/23



Objective: 2.5.3 Discusses the stages of dying.



lecture/discussion, the student will:1. List the 5 stages of death and

dying that a client may go

through

Dr. Elizabeth Kubler-Ross distinguished five stages that dying

people may experience. These stages are emotional experiences thatare common to terminally ill patients.

The experience is not the same for every person. Family and friendsof the client may also go through the stages of loss and grief.

The stages are not experienced in the exact order at all times and

may fluctuate between any stage, in any order.

The client may not show the same stage to all personnel at the same

time.

1. The stages of death and dying are: Denial No, not me.

a. The client and/or family refuse to believe the clientis dying. They may feel a mistake has been made.

They are not able to talk about death during this

phase.

Anger Why me?a. As the client faces death, they may be angry. Anger

may be expressed at anyone or anything. It is

important that the nurse aide not take the angerpersonally.

Bargaining Yes, but if I could live to dance at mydaughters wedding.a. Client may start a bargaining process with God in

hopes of recovery or extended life.

Depression Sadnessa. As the dying client becomes weaker or symptoms

become more obvious, they may become deeply sador depressed.

b. It is important to listen if the client wishes to talk.


10/23



Objective: 2.5.3 Discusses the stages of dying.


Acceptance Peacea. Some clients eventually are able to accept death and

prepare for it.

b.

They may ask to see an attorney, accountant, clergy,and family members.


11/23


2.5.3

DEATH AND DYING: A SIMULATION GAME

CAUTION: Make sure this activity is appropriate for your students (e.g. anyone suffered a

recent loss?)

Purpose:To help individuals reach a conscious awareness of their thoughts, feelings, attitudes,and values associated with loss through dying and death.

Objectives:

At the completions of the simulation, each participant will be able to:

Personalize issues of loss through dying and death Identify own thoughts, feelings, and attitudes about loss through dying and death Clarify own values about loss through dying or death Enable further private self-encounters about loss through dying and death

Type: Group experience

Equipment:

One packet of twelve slips of paper for each individual in the group One pencil for each individual in the group Overhead transparency of questions for discussion (optional)

Procedure and Instructions: Distribute the packets of paper and give the followinginstructions:

On each of the small slips of paper, write one from each of the following twelve items:

Three people who are very dear to you Three things you own that you regard as very special Three activities in which you enjoy participating, and Three personal attributes of which you are very proud

Arrange the twelve slips of paper in front of you so that you can see all of them. Now get into a

comfortable position and take a deep, relaxing breath. Listen without comment and follow the

instructions I give you while I describe some happenings, some situations, and some people.

Page 1 of 3


12/23


2.5.3

Scenarios:

(Scenarios should be developed carefully, with effort to awaken all the senses)

1. You are at your doctors officeyou hear the diagnosis. You have thirty seconds

to select and tear up three of your slips of paper.

2. You are back at homewho is there? Who do you want to be there? What do yousay? What do you want to hear? Tear up another three slips of paper.

3. Two months lateryou are aware your symptoms are worsening and you arefeeling weaker. Where are you? What is your lifestyle? What do you continue to

do? What can you do? Tear up another two slips of paper.

4. Four months lateryou are undeniably ill. The pain has increased considerably.Where are you? Who stays with you? Who visits you? Who are the people you

want around you? Tear up another two slips of paper.

5. Six months have passed, and you find that even the smallest activity of daily livingtakes most of your energy. How do you feel about yourself? Where are you? Whois with you? Turn over the last two slips of paper on the desk in front of you. I

will take one from you at random. (Go to each participant and take one slip if

paper.)

6. Say only: Tear up your last slip of paper. You are dead.

Discussion of Experience

1. Give participants 15-20 seconds to react and follow the last instruction. Saysomething reassuring, such as "Thanks for your involvement; Everyones

reaction to this simulation is different; This can be painful for you, depending

upon your experience with death and dying; I appreciate the thoughtfulness

and effort you have put into this experience; You have done well, and now are

ready for the next part."

2. In small groups of three to four people, with one person acting as recorder, initiatediscussion of some or all of the following questions:

What issues came up for you with each scenario? Fears? Concerns?

What were the easiest items to give up? The most difficult?

When did this experience stop being just a game?

Page 2 of 3


13/23


2.5.3

What emotional reactions did you have with each scenario? (Watch fordenial, anger, bargaining, depression, acceptance, avoidance, relief,comfort)

What did you think, feel, and/or experience when I took a slip of paper from

you at random? Did I take the right one?

Did you anticipate or expect the content of the last scenario?

What were your thoughts, feelings and /or reactions to the tearing up of thelast slip of paper?

*Note: The original Death and Dying Simulation Game was provided by Reverend Dick Lentz at St. Vincents

Hospice in Indianapolis, IN. It was first introduced to a group of students on the Bloomington campus in April,

1986 by Carol Ebeling, executive director, Hospice of Bloomington.

Page 3 of 3


14/23



Objective: 2.5.4 Identifies goals of hospice care.




1. Define hospice services2. List 7 goals of hospice

1. Hospice care, also known as end-of-life care, focuses on theemotional, social, physical, and spiritual needs of dyingpersons and their families.

Emphasis is placed on palliative care such as pain reliefand comfort measures and not life-saving measures.

Most people opt to have hospice service in their home.Generally, hospice is extended to individuals who have alife expectancy of 6 months or less.

The goal is to improve the dying persons quality of life. Hospice also offers support groups for familys survivors

or health team members.

2. The goals of hospice are: Offer compassionate care for a person with a terminal

illness Focus on the client and family as a unit Include entire health care team in a medically managed

plan of care

Emphasize pain and symptom control Provide an alternative to traditional hospital care


15/23


2.5.4

The Dying Persons Bill of Rights

I have the right to:

be treated as a living human being until I die

maintain a sense of hopefulness, however changing its focus may be

be cared for by those who can maintain a sense of hopefulness, however changingthis might be

express my feelings and emotions about my approaching death my own way

participate in decisions concerning my care

expect continuing medical and nursing attentions even though cure goals must bechanged to comfort goals

not die alone

be free from pain

have my questions answered honestly

not be deceived

have help from and for my family in accepting my death

die in peace and dignity

retain my individuality and not be judged for my decisions which may be contrary tobeliefs of others

discuss and enlarge my religious and/or spiritual experiences, whatever these maymean to others

expect that the sanctity of the human body will be respected after death

be cared for by caring, sensitive, knowledgeable people who will attempt tounderstand my needs and will be able to gain some satisfaction in helping me facemy death

(This was created at a workshop on The Terminally Ill Patient and the Helping Person, sponsored bySouthwestern Michigan In-service Education Council, and appeared in the American Journal of Nursing,Vol. 75, January, 1975, p.99.)


16/23



Objective: 2.5.5 Identifies complementary therapies utilized during the stages of dying.




1. List the members of theteam and what they provideduring the stages of dying

Care of a client during the stages of dying is supported by a holistic

continuum of professionals and volunteers.

1. The team directs care to satisfy the client and family needs inthe following way:

Attending Physician:a. Present throughout the stagesb. Certifies the terminal diagnosisc. Assesses the clients needs and prescribes treatmentd. Directs and approves the clients care plane. Coordinates therapies

Social Worker:a. Assesses the clients and familys emotional needs

through all stages

b.

Provides support during depressionc. Refers to community agency as needed duringacceptance (e.g., funeral arrangements and attorneyfor will)

d. At the final stage, provides bereavement support. Chaplain:

a. Provides support throughoutb. Instrumental in assisting the client and family at the

bargaining stage

c. At the final stage, assists with memorial service andbereavement

Volunteers:a. Provide companionship through, especially during

depressionb. Services during acceptance stage (e.g., letter writing,

errands, respite time for family)

c. Support during bereavementd. Contemporary therapy. E.g. Raki, massage, music,

aroma


17/23



Objective: 2.5.5 Identifies complementary therapies utilized during the stages of dying.


Home Health Aide/Nurse Aide:a. Provides direct personal care throughout all stagesb. Provides comfort measures throughoutc.

Provides emotional support at time of death andbereavement

RN:a. Assesses needs through all stagesb. Develops plan of care throughout all stages and

coordinates the team

c. Ensures symptom control and pain managementd. Provides client and family teaching as needed

Physical Therapy as needed by physician to helpmaintain joint range and help with pain control (e.g.,

hydrotherapy and TENS)

Occupational Therapy assists with ADLs, especiallywith adaptive devices


18/23



Objective: 2.5.6 Explains and reports the common signs of approaching death.




1. List the signs of approachingdeath for 7, different bodysystems

2. List how the nurse aide canmeet the needs of the dyingclient and family

3. Define what happens withthe sense of hearing as a

client is dying

4. List 4 signs of death

1. Physiological changes occur, either suddenly or gradually,that indicate approaching death.

Physiological changes associated with approaching deathinclude:a. Changes in vital signs

i. Lower blood pressureii. Temperature may be below normal or elevated

iii. Pulse is weak, irregular, rapidiv. Respirations may be

- Shallow, rapid

- Slower, labored

- Cheyne-Stokes slow and irregular breathing.

- Death Rattle mucous collects in throat andbronchial tubes

b. Changes in circulationi. Blood flow slows down

ii. Skin cool, perhaps clammyiii. Mottling

c. Changes in muscle tonei. Bowel or bladder incontinence

ii. Flatusiii. Body limpiv. Jaw may hang openv. Eyes fail to close client appears to be staring

d. Changes in visioni. Increased secretions

ii. Blurrediii. Pupils non-reactive to lightiv. No eye movement

e. Changes in mental statei. May be lucid, confused or alert

ii. Loss of consciousnessf. Changes in speech

i. Difficulty speaking, understanding


19/23



Objective: 2.5.6 Explains and reports the common signs of approaching death.


g. Changes in touchi. Decreased sense of touch

ii. Loss of feeling beginning in the legs and feet2. The nurse aide has a responsibility to meet the needs of the

client approaching death as well as his/her significant others

Interact with family/significant others in a professionalpositive manner

Permit family members (if they desire) to assist insimple care-giving activities

If client is unconscious, continue to speak in normal toneof voice and treat the client as if he/she can hear

Provide routine ADLs Report any changes in the clients condition to licensed

nurse immediately Be aware of current Advanced Directives of DNR [Do

Not Resuscitate status], as the status of directives can

change

3. Hearing is thought to be the last sense to leave the body. Donot speak unprofessionally in any manner around a client

who is dying or has just died.

4. Signs of death include: No pulse No respiration No blood pressure Eyes fixed and dilated When death occurs, the physician or head nurse

(depending on facility policy) are responsible for:a. Certifying deathb. Notifying the family (The nurse aide NEVER

informs the family that death has occurred)

c. The supervisor will direct the nurse aide as to whento provide postmortem care


20/23



Objective: 2.5.7 Provides post-mortem care while maintaining the clients right to dignity and respect.




1. Define post-mortem care2. List the goals of post-

mortem care

3. List 3, general guidelines tofollow in providing post-

mortem care

1. The care of the body after death is call post-mortem care. The nurse aide is usually responsible for performing

post-mortem care.

2. In providing post-mortem care, the goals are to: Appropriately identify the body Sustain the bodys appearance Prevent discoloration and skin damage Position in normal alignment before rigor mortis

develops

Allow family viewing before body is taken to morgue Provide respect and gentle care Maintain privacy

3. General guidelines include: Following the facility policy/procedure when providing

post-mortem care

Not beginning until directed by nurse to do so Reporting to the nurse:

a. The time the body was taken (to morgue or bymortician)

b. What was done with jewelry and personal items,including dentures


21/23

SUPPLEMENTAL MATERIAL: HANDOUTS

2.5.7

GUIDELINES FOR POSTMORTEM CARE

Assemble equipment:

1. Gloves

2. Basin with warm water, washcloth, towels

3. Pads as needed4. Postmortem kit (facility oriented: shroud/body bag/sheet, tags)

Maintain attitude of respect; work quietly and efficiently:

1. Put on gloves

2. Remove tubing, appliances and used articles only if instructed to do so

3. Bed flat, body in supine position (flat on back) -elevate head and shoulders on pillow4. Close the eyes by grasping the eyelashes and gently pulling the eyelids down

5. Insert dentures if included in facility policy. If they are not to be inserted in the mouth,

place the dentures in a labeled denture container

6. If used, replace artificial eye according to facility policy7. Straighten arms and legs and place arms by sides

8. Remove jewelry

9. Bathe the body as needed10. Place disposable pads under buttocks

11. Comb hair

12. Put clean gown on client13. Replace top bed linen

14. Collect the clients belongings-package appropriately and label

If family is to view the body:

1. Make sure room is neat

2. Provide privacy

3. Give clients belongings to the family or follow facility policy4. Complete the information on the identification tags, or obtain the tags from the nurse

5. Apply ID tags as required by facility policy (Example, one on right great toe, one on top

of shroud)

6. After the family has left the room, apply the shroud, body bag or sheet7. Bring the top down over the head, bring the bottom up over the feet, fold one side over the

body and fold the remaining side over the body-tape closed or secure with safety pins

(Attach the second ID tag to the shroud)

Final steps:

1. Leave the body on the bed for the mortician or

2. Transport to the in-facility morgue via cart3. Strip the unit after the body has been removed

4. Wash hands


22/23

PROCEDURE EVALUATION CHECKLIST: PROVIDES POSTMORTEM CARE

2.5.7

PROCEDURE EVALUATION CHECKLIST

NATCEP

Procedure: Provides Postmortem Care

Students Name:_____________________________ Program No.__________Class Start/End Date:_________________________ Student ID#___________

S=Satisfactory U=Unsatisfactory

Procedure Guidelines S U Comments

1. Assemble equipment:

a. Glovesb.Basin with warm water, washcloth, towelsc. Pads as neededd.Postmortem kit

2. Maintain attitude of respect, work quietly andefficiently

3. Put on gloves

4. Remove tubing, appliances and used articles and

jewelry if instructed to do so

5. Place body in supine position; straighten arms andlegs; place arms by sides

6. Close the eyes by grasping the eyelashes and gentlypulling the eyelids down

7. Insert dentures if included in facility policy. If they

are not to be inserted in the mouth, place thedentures in a labeled denture container

8. Bathe the body as needed, combing hair and dressing

in a clean gown

9. Apply completed ID tags as required by facility

policy

10. Apply shroud, body bag or sheet:

a. Bring the top down over the headb.Bring the bottom up over the feetc. Fold one side over the body and fold the

remaining side over the body

d.Tape closed or secure with safety pinse. Attach the second ID tag to the shroud

Page 1 of 2


23/23

2.5.7

11. Leave the body on the bed for the mortician (as per

facility policy) Close curtains and dispose of

supplies

12. Wash hands

_________________________________________________ ___________(Signature of Instructor(s) (Date)

_________________________________________________ ___________(Signature of Student) (Date)

Page 2 of 2

Documents

Caring for Client When Death is Imminent