Care of Death and Dying

Introduction

Everyone will experience birth and death, which are two phases of existence that are a normal part of living a human life. Death might happen quickly as a result of an accident, an injury, a pathologic crisis like a heart attack, or it can happen after a protracted battle with a crippling illness like cancer. For those who are dying and the people who are caring for them, dying and death are traumatic and private events. Each person engaged in a death is impacted by it in a variety of ways, including materially, spiritually, psychologically, emotionally, and emotionally. Healing and overall wellbeing are directly impacted by how people handle loss. It should be possible to address the effects of dying and death regardless of whether death occurs suddenly and unexpectedly or gradually and as predicted. By encouraging people to talk about their losses and utilizing therapeutic dialogue to affirm feelings, we can help them through the grieving process.

Definition of Death

Death is defined as irreversible cessation of circulatory, respiratory function or the irreversible cessation of all functions of the entire brain including the brainstem. It is the permanent cessation of all biological functions that sustain a living organism.

Emotional Stages of Dying

There are common psychosocial reactions to the situation, even if each person responds differently to the knowledge of approaching death or to loss. Five emotional stages were identified by Kubler-Ross (1969) as being present in the dying process. Similar to the phases of grieving, the stages of dying can overlap, and they can last anywhere from a few hours to several months. Each person goes through the process differently. Some people might only spend a brief period in a stage, giving the impression that they bypassed it. Occasionally, the participant goes back to a prior level.

According to Kubler- Ross, the five stages of dying are:

• Denial,
• Anger,
• Bargaining,
• Depression,
• Acceptance.

They are widely known in the acronym 'DABDA'.

Denial: The patient may repress what is said, distance themselves from reality, and deny that they will die during the denial stage. The patient can disagree with the diagnosis and believe it was incorrect. Some patients never progress past this point and may change doctors until they find one who agrees with them.

Patients experience frustration, irritability, and anger as a result of their illness. "Why me?" is a typical answer. They could grow enraged at God, their lot in life, a friend, or a relative. The hospital personnel or the doctors who are held accountable for the illness may receive the brunt of the ire.

Negotiation: During the negotiation phase, the patient tries to negotiate for more time. the like "I'll be happy if I can just make it to my son's graduation. Let me survive till then, please." The patient may try to bargain with doctors, friends, or even God, promising to keep one of several pledges in exchange for a cure, such as giving to charity or reaffirming a prior trust in God.

Depression: The patient experiences mourning before to passing away. Clinical depressive symptoms such as withdrawal, psychomotor impairment, sleep difficulties, hopelessness, and perhaps suicidal ideation are present in the patient. The depression may be a response to how the sickness has affected his or her life or it may be brought on by the impending death.

Acceptance: The patient understands that death is unavoidable and accepts the fact that everyone has experienced death. In the best case scenario, the patient is fearless and capable of discussing death as they confront the unknowable.

Breaking Bad News

• Six fundamental guidelines are suggested by an expert in "Breaking Bad News" to help patients achieve better results.
• Have the conversation when the patient is not distracted or in a lot of pain, while sitting face-to-face in a quiet area.
• To ensure that your discussion is at the right degree of information, ask the patient how much he or she already knows about the disease.
• Find out how much the patient wants to know.
• Give the information in manageable portions, pausing sometimes to ensure that it is absorbed.
• Recognize any emotional response from the patient and react to it truthfully and empathetically.
• Recap, ask questions, and know exactly when you will be meeting again.

Signs of Approaching Death

As a person approaches the very end of life, two types of changes occur. There are physical changes that take place as the body begins to shut down its regular functions. And there are changes on the emotional and spiritual level as well, in which the dying person lets go of the body and the material world. 

Change in the Respiration

• Respiration becomes irregular, chyne strokes.
• Noisy breathing as pharyngeal muscle relaxes.

Circulatory System

• Decreasing blood perfusion.
• Circulatory changes cause alterations in the temperature, pulse, respiration.
• Pulse becomes irregular, weak and fast.
• BP falls as the peripheral circulation decreases.
• The skin cyanoses as circulation decreases.
• Pitting edema develops, especially of the extremities and sacrum.

Nervous System

• Reflexes slowly go away.
• Restlessness may be a sign of stress or anxiety.
• increasing weariness or a feeling of weakness
• Throwing motions are made.
• Mental clarity varies.
• Sensation and movement eventually disappear.
• removing or charging for bedclothes.
• There is nonsensical crying and talking.
• Delirium and confusion: A person who is close to passing away may become agitated or bewildered. Less blood flow to the brain or other physical changes may cause this to happen. Uncertainty regarding the identification of loved ones, the time, and place; visions of absent persons and locations.
• dysfunction of the nervous system, such as delirium, sluggishness, and coma.

Genitourinary System

• Loss of bowel and bladder control: As muscles weaken, the person who is dying may no longer be able to control bowel and bladder functions.
• Urine decreases.

Gastrointestinal System

• Nausea, vomiting, abdominal distension is seen.
• Decreased peristalsis, anal sphincter may relax and the gag reflex disappears.
• Loss of appetite, inability to shallow.
• Decreased oral fluid intake and decreased thirst.

Facial Appearance

• Jaw and facial muscles relax with the expression becoming peaceful.
• Checks become flaccid, and sagging of the jaws, breathing takes place through mouth.

Changes in Sensory Organs

• Sight gradually falls; speech confused, hearing is dulled.
• Sleepiness and loss of consciousness: As death nears, people usually become very drowsy, sleeping more and becoming hard to wake.
• Cooling: Hands, arms, feet and legs begin to cool as the circulation of blood decreases. The skin may become pale, cool, sweat profusely.
• Loss of ability to close eyes.

Management of Dying Patient

Cassen (1991) suggests seven essential features in the management of the dying patient:

Concern: Empathy, compassion, and involvement are essential.

Competence: Skill and knowledge can be as reassuring as warmth and concern.

Communication: Allow patients to speak their minds and get to know them.

Children: If children want to visit the dying, it is generally advisable; they bring consolation to dying patients.

Cohesion: Family cohesion reassures both the patient and family.

Cheerfulness: A gentle, appropriate sense of humor can be palliative; a somber or anxious demeanor should be avoided.

Consistency: Continuing, persistent attention is highly valued by patients who often fear that they are a burden and will abandoned; consistent physician involvement mitigates these fears.

Nursing care of dying patient and their families

• meeting physical requirements,
• keeping the airway open,
• Making personal hygiene available,
• supplying dietary needs,
• Providing care for elimination,
• addressing a sensory organ's need,
• controlling pain,
• Environmental stewardship Meeting psychological needs,
• addressing spiritual needs.

Physical Care of Dying Patient

• Provide a balanced diet. The patient should receive frequent little oral feedings or N/G feedings as tolerated.
• As long as the swallowing reflex is active, water should be given in little amounts.
• Fluids and nourishment should be given intravenously if the patient cannot tolerate oral feeding.
• To preserve the integrity of the skin, keep the patient dry and clean. Additionally, it fosters the confidence of the client.
• Frequently practice oral hygiene to keep your mouth clean.
• Nostrils ought to be lubricated and cleaned.
• Give a sponge bath and, when needed, change the linens.
• Use non-pharmacological pain management techniques.
• As directed by the doctor, administer prescription analgesics.
• Depending on the patient's condition, passive range of motion exercises should be given along with the administration of oxygen as needed.

Communicating With a Dying Patient

• Observe nonverbal cues while paying attention to what is being spoken.
• Utilize the right touch and eye contact to respond to nonverbal clues.
• Encourage and accept emotional expression.
• Assure the person that feeling angry, guilty, relieved, or any other emotions they may think are improper, is okay. The patient needs to hear you reassure them that their emotions are natural and not wrong or terrible.
• Even if a patient is in a coma, keep in contact with them. Encourage your family members to follow suit.

Helping Families of a Dying Patient

• See the family as a caregiving unit.
• Encourage family members to assist with care if they can by educating, supporting, and encouraging them to do so. Accept it if family members are incapable of providing care due to their mental or physical state.
• Encourage family members to engage in active listening to the patients' and families' concerns and to ask questions as necessary.
• If the family asks a question that is not within your area of expertise, swiftly follow up with other members of the healthcare team.
• To speak with a priest or their own spiritual advisor, the family should attend the hospital chapel.
• Educate the family in advance about the phases of sorrow and loss so they will understand what to expect when their loved one passes away.
• Remind family members and close friends to look for oneself. Being forced to see a loved one's death is incredibly traumatic.
• Assist the family members in exploring past coping strategies and reinforcing effective coping techniques.
• Explain to the family what to expect in terms of prescription drugs, medical procedures, and indicators of impending death. Family members will be less prone to freak out or worry the future if they are aware of what is typical.
• Inform the family as soon as any physical indicators of death appear. You may say something like, "Her blood pressure is rising and that is one symptom that she is very near to passing away."
• Ask family members directly if they want to be present while their loved one is dying when it is clear that death is imminent. If they are unsure, let them know what to expect.

Hospice and Palliative Care

Hospice: Hospice is a specialized program that addresses the needs of the catastrophically ill and their loved ones. A team approach is provided in hospice that may involve physicians, nurses, social workers, volunteers, therapists and family caregivers. Hospice workers can help a dying person manage pain, provide medical services and offer family support through every stage of the process, from diagnosis to bereavement.

Components of Hospice Care Programme Include the Following:

• The client and family are the caregiving unit.
• Coordinated home care that has access to inpatient and nursing home beds that are available.
• Management of symptoms (physical, sociological, psychological and spiritual).
• Medically supervised services.
• Offering an interdisciplinary care team made up of doctors, nurses, chaplains, therapists, and spiritual advisors
• Services for nursing and medicine are always available.
• After a client passes away, there is bereavement.
• Acceptance into the program based on medical necessity rather than financial capacity.

Palliative Care: Palliative care is the active total care of patients whose disease is not responsive to curative treatment (World Health Organization). It is taking care of whole person which affirms life and regards dying as a normal process, neither hastens nor postpones death, provides relief from pain and other distressing symptoms, integrates the psychological and spiritual aspects of patient care and offers a support system to help patients live as actively as possible until death and helps the family cope during the patient's illness and in their own bereavement.

Control of pain, of other symptoms and of psychological, social and spiritual problems is paramount. The goal of palliative care is to give patients with life threatening illness the best possible quality of life they can have by the aggressive management of symptoms.

Palliative care is based on five major principles (Foley and Carver, 2001):

• It respects the goals, likes and choices of the dying person.
• It looks after the medical emotional, social and spiritual needs of the dying person.
• It supports the needs of the family members.
• It helps gain access to needed health care providers and appropriate care settings.
• It builds ways to provide excellent care at the end of life.

Verification of Expected Death

It is essential that the nurse takes time to observe the patient for any spontaneous movement or any reaction to the environment e.g. chest movement, swallowing, coughing, nasal flaring and eye movement, whilst in the process of verifying death. Death will be verified using the criteria below (Winter-bates, 2014). These observations should be repeated after 5 minutes.

• Absence of carotid pulses over 1 minute,
• Absence of heart sounds over 1 minute,
• Absence of respiratory movements and breath sounds over 1 minute,
• Pupils not reacting to light,
• No response to painful stimuli e.g. trapezium squeeze.

Along with the above criteria, no cardiac activity in electrocardiogram (ECG) and brain activity in electroencephalogram (EEG) should be observed.

Changes in Body after Death

After death, a sequence of changes naturally occurs in the human body. Although these changes proceed in a relatively orderly fashion, a variety of external factors and intrinsic characteristics may accelerate or retard decomposition.

• Pulse, heartbeat, and breathing are absent.
• Pupils that are unresponsive to light and fixed.
• Reduced urine production, peripheral cyanosis, and chilly extremities are symptoms of declining blood perfusion.
• Complete lack of reactions.
• Methanogenesis halts.
• Fixed jaws and a somewhat open mouth.
• Pallor Mortis: The paleness of the face and other parts of a corpse is the first change to appear. The capillary circulation has stopped, which is the cause of this. Within 15 to 30 minutes of death, this is the very first indicator and it happens very quickly.
• Algor Mortis: The steady drop in body temperature that occurs after death. Each hour, the temperature drops a few degrees. Body temperature drops when the hypothalamus stops working and blood flow stops.
• Rigor mortis is the term used to describe the stiffening of the body that begins within two hours of the time of death and is typically complete eight hours later as a result of decreased ATP generation. Muscles remain pliable and smooth because to adenosine triphosphate (ATP). The heart and bladder are the first involuntary muscles affected, followed by the head, neck, trunk, and extremities.
• Livor Mortis: The blood is now subject to gravity's whims after the heart stops beating. It frequently gathers in the bodily component that is dependent on it. Dependent body components start to look discolored. As the hemoglobin degrades, blood pools, which causes the colour. These portions would change based on the body's location. For instance, if the victim died while lying flat on their back, the blood would concentrate in the areas closest to the base. It would gather in their fingertips, toes, and earlobes if they were hanging. The bluish color of the skin is caused by this blood.
• The term "tache noire," which translates to "black spot," refers to a dark, reddish-brown band that develops across the eyeball. Individuals with open eyelids after death will experience tache noire.
• Computer faction/autolysis: After death, tissue is softened and eventually turned into liquid by bacterial fermentation. Changes emerge at varying rates, depending on the surroundings. Putrefaction is slowed down by cold, dry conditions whereas it is accelerated by heat and moisture.
• Purge Fluid: This reddish-brown, putrid fluid with a very offensive odor can come from the nasal and oral cavities. It appears as a result of the body's various gases producing. The abdomen may feel tight and swollen when gas is formed in the stomach and intestines. The result is an expulsion of unpleasant, blood-tinged fluid from the mouth, vagina, and nose as a result of the rise in abdominal pressure. Purge fluid can be helpful in figuring out when someone passed away. In a hotter environment, the purge fluid can be observed in less time than a day after death.

Care of the Body after Death

Death body care means care of body in 30 to 45 minutes following declaration of death by the physician to prevent disfiguration of body part. Care of the body after death is an important nursing function that occurs in a wide variety of contexts. After a patient dies, nursing care continues as physical care of the body as well as care of the family members. Nurse should know the religious faith of patient. 

Purpose

• To maintain normal body alignment before rigor mortis sets in.
• To ensure proper identification of the patient.
• To maintain hygiene and prevent from spread of infection
• To reduce mental distress of family.
• To maintain vital organs, if is planned.
• To facilitate transportation to mortuary/residence.

Articles

• Tray/trolley counselors
• Identification levels, tape, comb
• Bandage, cotton
• Patient's cloth, trolley
• Gloves
• Plastic apron
• Soap, towels, bowel, water
• Mortuary sheet
• Dust bin
• Articles for cleaning or bathing the body

Steps in Procedure

Legal Responsibility

• The physician attending the patient should certify the death including time pronounced pallog of abus death, therapy used, action taken and cause of death. In some areas a nurse may also perform this task.
• The person who pronounces death must sign the death certificate. In some agencies a on a no nurse is responsible for checking to see that it has been signed.
• If the person's eye or bodies are donated, review and make any necessary arrangements.

Supporting the Family

• When the patient's death is announced, check to see if any family members or close friends are present, and if not, if they have been informed of the patient's passing or not.
• Expressing condolences to the family as soon as possible is crucial. Say something brief like, "I'm sorry for your loss." Avoid saying things such, "It will get better in time," "You still have your son," or "It will go al gainison."
• If the family requests viewing, cover the body with a sheet or light blanket so that only the head and upper shoulders are visible, and allow them to remain alone with the patient. If they decline viewing, ask if they would like to see the body, observe their response, and give them the chance to ask questions. It aids in their acceptance of death and confirmation of death.
• Regardless of how bizarre a family member's behavior may seem to you at the moment, try to be understanding.
• Make arrangements for each family member to have some alone time with the deceased after confirming their desires. Never take a body away until the family is prepared.
• Examine the patient's cultural or religious background. Find out whether the family would like a priest or minister to visit the patient at their bedside.
• Tell the family that the nurse would first take care of the body before giving it to them. Ask the family member whether they want to help prepare the body, such as by donning particular attire.

Care of the Body

• Cover the patient's face with a sheet once the family members have left the bedside and begin preparing the body.
• As care must be made to stop the spread of the infectious disease to others, find out if the patient was undergoing isolation therapy.
• hand washing Gather articles.
• Put on disposable gloves, a gown, and other necessary safety equipment.
• Draw the bedside curtains or shut the door to the room.
• Lie on your back with just a little pillow under your head, or raise the head of the bed by 10 to 15 inches. It aids in preventing facial discolouration brought on by blood pooling in the area.
• Remove all jewelry, give the family possession of all valuables, and have a wod signature taken in a register.
• Holding the eyes closed for a short while requires gentle pressure.
• Place the dentures in your mouth after positioning the body in a natural posture. Shut your mouth. If the mouth won't shut, put a cloth rolled up under the chin.
• The patient's NG tube, urine catheter, oxygen tube, IV line, and drainage tube should all be removed.
• Swap out the dirty dressing for a fresh piece of gauze.
• Use absorbent cotton first to cover body orifices such the nose, mouth, vagina, and rectum before switching to non-absorbent cotton. The packing of the nose must make the cotton invisible.
• Body parts covered in blood, urine, feces, or other discharge should be washed before donning a clean robe. Subsequently, place a soft pad beneath the patient's buttocks.
• Straighten your legs, splay your feet, and knot your big toes. Avoid stacking your hands since the bottom hand will turn discolored.
• Cleanly comb the person's hair. Take off any rubber bands, hairpins, or clips.
• Put on the patient's own, tidy clothes.
• Places a finished identifying tag on the patient's ankle. After the body is covered, the remaining tag should be preserved to sew to the outside of the sheet. Name, age, sex, address, ward, bed number, date of death, diagnosis, certified by, and patient taken by relative's entire name and address should all be included on these tags, as well as the relative's full signature.
• Send the account part the patient's chart together with a death certificate.
• After the bill has been paid, turn the body back to the relatives and have them sign the mortuary record.
• Make arrangements for the body's delivery to the morgue, along with one copy of the death certificate, or just turn the body over to the family.
• Maintaining proper alignment while transferring the corpse to a stretcher. Wrap in a fresh sheet. Lock the doors to the rooms of the other patients and make plans to move the body.
• Gloves should be taken off, any leftovers and linen from the patient's room removed, and they should be disposed of properly.
• hand washing
• When releasing the patient, treat the bed and the unit as such.
• Complete the patient's chart and the hospital record with all the necessary information on the cause of death, then send them to the record section for filing.

Things to Keep in Mind

• Respect the deceased person's body. Steer clear of pointless interactions and chats.
• You must adhere to hospital policies and procedures.
• It is important to correctly identify the body.
• Clothing, jewelry, and other assets or possessions need to be carefully stored and taken care of.

Bill of Rights for Dying People

• Until I pass away, I have the right to be regarded like a living person.
• I have the right to hold onto my optimism, no matter how divergent it may be.
• I deserve to be taken care of by people who can hold onto hope, no matter how difficult it may be to do so.
• I am entitled to use any means I see fit to convey my thoughts and feelings over my impending death.
• I am entitled to take part in selecting my medical care.
• Even when "cure" aims must be adjusted to "comfort" goals, I have the right to continue receiving medical care and nursing care.
• I'm entitled to not pass away by myself.
• I am entitled to pain relief.
• I have a right to truthful responses to my inquiries.
• I have the right to maintain my individuality and to avoid criticism for my choices, even if they go against what other people might think.
• I am entitled to assume that the human body's sacredness will be upheld after death.
• I have the right to get care from kind, sensitive, educated individuals who will make an effort to understand my needs and who will be able to derive some satisfaction from assisting me in accepting my demise.