By

Sheila Marie P. Oconer, RN, MAN

REALITY TELLS US THAT

EVERY PERSON WILL DIE

LESS THAN 10% WILL DIE

SUDDENLY AND 90% WILL

DIE AFTER PROLONGED

ILLNESS

Experiences throughout lifetime defines the

way he or she wishes the end of own life

Family, culture, life events influences a

person choices facing life and death come

sooner rather than later

Anthropologist Margaret Mead says,

“When a person is born we rejoice, and

when they get married we jubilate, but

when they die we pretend nothing

happens”.

Talking about death and dying is often difficult

for nurses and patients, if nurses does not

want to talk about it there is no discussion, and

death become the "elephant in the room”---

something unavoidable and taboo.

Communicating bad news is an essential skills

for the physician, nurses and interdisciplinary

team members who interacts with the patient

and families

6 Steps to communicating Bad News

1. Get started

-plan what to say based on medical facts, create

conducive environment, determine who are others

persons present, and allocate ample time.

2. Find out what the patient knows

-assess his or her ability to comprehend bad news

3. Find out what the patient wants to know

-recognize and support patient’s preference to

decline information and designate someone else to

communicate in his/her behalf, consider cultural,

religious, and socioeconomic influences

4. Share information

-say it then stop. Pause frequently, check for

understanding and use silence and body language, avoid

vagueness, jargon and euphemism

5. Respond to feelings

- expect affective, cognitive and fight-flight responses., be

prepared for strong emotions and a broad range of

reactions. Give time to react, listen and encourage

description of feelings. Use nonverbal communication of

touch and eye contact

6. Plan/follow up

-provide additional test, symptom treatment, and

referrals as needed, discuss potential sources of

support, assess safety of the patient and home

supports before he/she leaves . Repeat the news at

future visits.

Advance directives Help individual identify their

personal wishes in a legal manner and to share

that information with the people around them,

including medical personnel.

Durable power of attorney, living will declaration,

appointment of health care representative, DNR

and life prolonging procedures declaration are all

legally recognized documents for indicating one’s

health care wishes

Five Wishes (towey,2005) and Allow Natural Death

(AND) are 2 more recent options for stating end-

of-life care wishes.

CURATIVE/ACUTE CURE

Life-prolonging and acute care options focus on cure

HOSPICE CARE

Nonlife prolonging care, provide comfort and dignity at

end of life.

PALLIATIVE CARE

Refers to comprehensive management of physical,

psychological, social, spiritual and existential needs of

the patient.

Care of people with incurable and progressive illnesses

Achieve the best quality of life, control of pain, and other

symptoms

Nurse’s primary

responsibilities is to

coordinate patient’s

care and to assist

with Symptom

Management or

Focus on treating

Symptom

Physical Non pain

symptoms

Respiratory – difficulty of

breathing, excess secretions,

anxiety

Gastrointestinal –

constipation, nausea/vomiting

Anxiety and Delirium

Anxiety at end of life – loss of control, loss of self

esteem, loss of independence

treating physical symptoms of pain and SOB, anti-

anxiety meds

Delirium – fluctuating cognitive disturbance, changes in

mental status, occurs in the last hours to days of most

dying patients

environmental comfort by reducing stimuli,

reorientation, familiar person at bedside, health team

members providing emotional, social and spiritual

support, music therapy, therapeutic/healing touch,

nonmedical nursing interventions, anti-anxiety meds

given cautiously

NUTRITION AND HYDRATION

Declining appetite for Dying persons,

less active body requires less

nourishment

Hydration is detrimental to fluid

overload

Give bites rather than regular portions,

foods in variety

Provide small amounts of fluid like

popsicles or ice chips, meticulous mouth

care for dry mouth

PHYSICAL, PAIN SYMPTOMS

“We all must die. But if I can save him from

days of torture, that is what I feel is my great

and ever new privilege. Pain is more terrible

Lord of mankind than even death itself”

Albert Schweitzer

Unrelieved pain can contribute to unnecessary suffering,

evidenced by sleep disturbance, hopelessness, loss of

control and impaired social interactions

Pain may hasten death by increasing physiological stress,

decreasing mobility, contributing to pneumonia and

thromboemboli

Nurse must be able to assess pain, assist patient in

describing their pain, use Wong-Baker Pain Rating scale

Treatment of pain based on origins and systematic

approach (pain meds and adjuvant)

Pain meds remain the 1st line of tx

Opiods are used if nonopiods ineffective

Understanding between addiction and tolerance,

physical dependence

Physiological Type of Pain

Nociceptive

- Somatic

Tissue injury

Skeletal system, soft tissue, joints, skin or connective tissue

Localized pain can be point by finger

Describe as throbbing, dull, aching, gnawing in nature

Treated with NSAIDs, steroids partially responsive to opiod

therapy or combinations

- Visceral

Activation of nociceptors

Internal organs

Unable to localze, may use open hand to show affected

area,pain is diffuse

Deep, aching, cramping or sensation of pressure

Very responsive to opiod therapy

Example is shoulder pain secondary to lung or liver metatases

Neuropathic

-injury to peripheral nerve or CNS

Shooting, stabbing, burning, shock-like

Constant or intermittent

Less responsive to opiods, responds best to

anticonvulsants, tricyclic antidepressants

Ex. Herpes zoster or diabetic neuropathy

LOSS AND GRIEF

Primary Losses

Loss of people close to them – spouses,

children, parents, siblings

Secondary Losses

Are those resulting from the primary Loss-

companionship, roles the deceased assume

in relationship and independence

Grief – is the natural and normal loss of any kind

and is experienced psychologically, behaviorally,

socially and physically. It involves changes over

time

Mourning- is the cultural and/or public display of

grief through one’s behaviors. These include

accepting the reality of loss, reacting to separation,

and finding ways to channel reactions, handling

the unfinished business, and transferring the

attachment to the deceased from physical

presence to symbolic interaction.

COMPONENTS OF PEACEFUL DYING

“The key to peaceful dying is achieving the

components of peaceful living during the time you

have left” (Preston, 2000)

Instilling good memories

Uniting with family and medical staff

Avoiding suffering, with relief of pain and other

symptoms

Maintaining alertness, control, privacy, dignity

and support

Becoming spiritually ready

Saying goodbye

Dying quietly

GOOD DEATH

Is possible and can be facilitated by

the nurse who advocates for and

works to ensure that the patients,

families, and caregivers are free from

avoidable distress and suffering, that

the process is in accord with the wishes

of the patient, family, and that is

consistent with clinical, cultural, and

ethical standards.

POSTMORTEM CARE

Pronouncing Death

Pronouncing the death of the person varies from state to

state and institution to institution, nurses may pronounce the

death, in some may not be allowed

Policies differ and individual institutional polices are

followed

In pronouncing death, it is customary to identify the patient

and note the following;

General appearance of the body

Lack of reaction to verbal or tactile stimulation

Lack of pupillary light reflex (pupils fixed and dilated)

Absent breathing and lung sounds

Absent carotid and apical pulses (listening for apical pulse is

full minute)

PHYSICAL CARE OF THE BODY

IS AN IMPORTANT NURSING FUNCTION

Careful and gentle handling of the body communicates

care and concern on the part of the nurse

Rituals and customs should have been identified before

the death, to be incorporated into the care, reflecting

the patient/family wishes

Nursing care also includes removal of drains, tubes, IVs

and other devices

The Nurse’s gratification does not come from caring, but

rather from supporting the patient in a peaceful and

dignified “ good death”.