Care of terminally ill

1
CARE OF TERMINALLY ILL
PATIENT
Mr. Melvin Jacob
MSc Nursing
Mr. Melvin Jacob MSc (N)

CONCEPT OF LOSS, GRIEF
& GRIEVING PROCESS
2Mr. Melvin Jacob MSc (N)

CONCEPT OF LOSS
The fact or process of losing something or
someone.
oxford dictionary
Loss is an actual or potential situation in
which something that is valued is changed , no
longer available or gone.

• People can experience loss of body image ,a
job, sense of self etc.
• Death is an functional loss , both for dying
person and for those who survive .

Types of loss
1.Actual loss – can be recognized by others.
Eg – death
2.Perceived loss – It is experienced by one person ,
but cannot be verified by others (psychologic loss)
Eg:-a woman who leaves her job to care for child
may experience a loss of independence and
freedom.

3. Situational loss- loss of one’s job , death of a
child , loss of functional ability because of
injury.
4. Developmental loss – loss occur in the process
of normal development
Eg: departure of grown children from home ,
retirement , death of aged parents.

Sources of loss
1.Loss of an aspect of oneself
Eg: change in body image – burn in the face.
2. Loss of external objects
- loss of inanimate objects.eg: money, house
- loss of animate objects.eg : pets
3. Loss of familiar environment
Eg: 4-yr old child feel loss when leaving the home for the
first time for attending the school
4. Loss of loved ones
Eg: loss by illness, divorce , separation , death.

Concept of grief
• Grief is the total response to the emotional
experience related to loss
• Grief is manifested in thoughts , feelings and
behaviors associated with sorrows.
• Grieving is essential for mental and physical
health.
• It help the person to cope with the loss
gradually and to accept it as part of reality.

Factors influencing grief
Human development,
Personal relationship,
Nature of the loss,
Coping strategies,
Socioeconomic status,
Culture and ethnicity,
Spiritual and religious belief

STAGES OF GRIEVING /GRIEF
PROCESS
KUBLER-Ross's

1.Denial
Behavioral response: -refuses to believe the loss.
eg: unready to deal with practical problems such
as prosthesis after the loss of leg.
Nursing implications: - verbally support the
client

2.Anger
Behavioral response: - client / family may direct anger at
nurse / staff.
Nursing implications:
- Help client to understand that anger is a normal
response to feelings of loss / powerlessness.
- -Do not take anger personally
- - Deals with needs underlying any anger

3.Bargaining
Behavioral response:- seeks to bargain to avoid loss
- May express feelings of guilt / fear of
punishment for past sins.
- Listen attentively and encourage client to talk
to relieve guilt and fear
-If appropriate , provide spiritual support.

4.Depression
Behavioral response:
- Grieves over what has happened and what caanot be
- May talk freely or may withdraw.
-Allow to express sadness
- Communicate nonverbally by sitting quietly with out
conservation
- Convey caring by touch.

5. Acceptance
Behavioral response:
- Comes in terms with loss
- May have decreased interest in surroundings and
support people.
-Encourage client to participated as much as in
treatment and progress

SIGNS OF CLINICAL
DEATH

Death
Death can be defined as the cessation of all
vital functions of the body including the
heartbeat, brain activity (including the brain
stem) and breathing.

Incidence
More than 2.5 million people die in the United
States each year.
25% of all deaths take place at home, with
about 50% occurring in hospitals. Remaining
25% occur in nursing homes.

Indications of death
Total lack of response to external stimuli
No muscular movement, especially breathing
No reflexes
Flat encephalogram (brain waves)

Physical manifestations of approaching
death
SYSTEM MANIFESTATIONS
Sensory Decreased sensation, decreased perception, blurring
of vision, sinking and glazing of eyes, blink reflex
absent, eyelids remain half opened
Integumentary Mottling on hands,feet,arms and legs;cold,clammy
skin;cyanosis on nose,nail beds,knees;wax like skin
when very near to death
Respiratory Increased respiratory rate; Cheyne-stokes
respiration;inability to cough or clear secretions
resulting in granting,gurgling;irregular breathing

Urinary Decreased urinary output, urinary incontinence,
unable to urinate
Gastrointestinal Accumulation of gas, distension and nausea, loss of
sphincter control
Musculoskeletal Inability to move, sagging of jaw, difficulty
speaking, difficulty in swallowing, difficulty
maintaining body posture and allignment, loss of
gag reflex, jerking
Cardiovascular Increased heart rate , slower and weakening pulse,
irregular rhythm. Decreased in blood pressure,
delayed absorption of drugs 22Mr. Melvin Jacob MSc (N)

PSYCHOSOCIAL MANIFESTATIONS OF
APPROACHING DEATH
• Altered decision making
• Anxiety about unfinished
business
• Withdrawal
• Decreased socialization
• Fear of loneliness
• Fear of meaninglessness of one’s
life
• Fear of pain
• Helplessness
• Life review
• Peacefulness
• Restlessness
• Saying goodbyes
• Unusual
communication
• Vision like experiences

CARE OF DYING
PATIENTS

The major nursing responsibility for clients
who are dying is to assist the client to a
peaceful death.

1. Helping clients die with dignity
• Nurses need to ensure that the client is treated with
honor and respect.
• Help the client to consistent with their values ,
beliefs and culture.
• Allow the client to make some choices on the
location of care eg: hospital , home.
• Can help clients to determine their own physical ,
psychologic and social priorities.

2.Hospice and palliative care
• Hospice care focuses on “support and care of the dying
person and family” ,with the goal of facilitating a peaceful
and dignified death.
• It is based on “holistic care”.
• It emphasize care to improve quality of life rather than cure
• Supports the clients and family through the dying process
and supports the family through bereavement

Palliative care
Palliative care is any form of care or
treatment that focuses on reducing the severity of
disease symptoms , rather than trying to delay or
reverse the progression of the disease itself or
provide a cure.

3.Meeting the physiologic needs of
the dying client
- Personal hygiene measures
- Controlling pain
- Relieving respiratory difficulties
- Assisting with movement
- Nutrition , hydration and elimination

4.Providing spiritual support
Expressions of feeling , prayer , meditation
, reading , discussion with clergy or spiritual
advisor

5. Supporting the family
- Provide support to family members of a dying
client , using therapeutic communication , to
facilitate their expression of feelings.
- Encourage them to involve in patient care

ADVANCED DIRECTIVES

Euthanasia / mercy killing
- It is the act of painlessly putting to death persons
suffering from incurable or distressing disease.
- As of now, human euthanasia is legal in
Netherlands, Belgium, Colombia, Luxembourg and
Canada,
- Assisted suicide is legal in Switzerland, Germany,
Japan, and in the US states of Washington, Oregon,
Colorado, Vermont, Montana, Washington DC, and
California.

Living will

Specific instructions about
what medical treatment the client
choose to omit or refuse (eg:
ventilator support) in the event that
the client is unable to make those
decisions

Health care proxy / surrogate
It is a notarized or witnesses
statement appointing someone else ( e.g. a
relative / friend) to manage health care
treatment decisions when the client is unable
to do. it.

Declaration / certification of death
-The formal determination of death or
pronouncement , must be performed by
physician.
- The authority to pronounce the death for the
nurse, may be limited in long term care , home
health and hospice agencies or to an advanced
practice nurse.

- The death certificate is signed by the
physician and filed with a local health
or government office.
- A copy of certificate is given to the
family

Organ donation
- A person 18 years or older and of sound mind can
donate all or any part of their own body for the
following purposes:
- For medical or dental education
- Research
- Advancement of medical or dental science
- Therapy
- Transplantation

It is the process of removing tissues or
organs from a live, or recently dead, person
called Donor to be used in another living
person called Recipient.
• Heart, liver, kidneys, lung, Pancreas and
tissues such as corneas and bone marrow
• Organ donation should take place with in 2-
6hrs after the death.

• Live Donations- When the person making the
donation is alive
• Cadaver/ Deceased Donations- After the
donor dies

MEDICO LEGAL ISSUES

It can be defined as a case of injury or
aliment etc.. In which investigations by the
law enforcing agencies are essential to fix the
responsibility regarding the causation of the
said injury or aliment

• Abuse of children, elderly, and spouse
• Drug-related injury
• Unknown cause of death
• Suicide
• Violent death
• Poisoning
• Accidents
• Suspicion of criminal action

• Obtain death reports
• Do investigation -the natural death and infant/child death
• Conduct post mortem , sexual assault/child abuse
examinations
• Collaborate with organ/tissue procurement agencies
• Normally, only uniformed officers attend the natural
death scene

• Understand subtle signs of abuse and neglect
• Collaborate with pathologist to determine the
appropriate medical records
• Review medical records once received
• Obtain follow-up information
• Organize interagency meetings as necessary

Definition
An autopsy (post-mortem) is the surgical
dissection of a body after death to determine
the exact cause and circumstances of death or
discover the pathway of a disease.

• It is performed in certain cases such as:
- When death is sudden or occurs within 48hrs of
admission to the hospital
- Committed suicide
- Unknown cause of death
- Unknown dead bodies
- Homicide (The killing of one human being by
another )

EMBALMING

Definition
Embalming is the art and science of
preserving human body by treating them
with chemicals to prevent
decomposition.
• It is temporary in nature

Purpose
• To keep the body suitable for public display at
a funeral.
• For medical and scientific purposes such as
their use as anatomical specimens

• Injection of chemicals into the body to destroy
the bacteria ; thereby prevents rapid
decomposition of tissues.
• Embalming fluid contains a mixture of
formaldehyde, methanol, ethanol and other
solvents

Process
Embalming fluid is injected into the
arteries of the deceased during embalming.
Many other bodily fluids may be drained or
aspirated and replaced with the fluid as well.

CARE OF DEAD BODY

After death the body undergoes many
physical changes .so care must be provided –as
early-to prevent tissue damage /disfigurement
of body parts.

Physiological changes after death
1.Rigor mortis
- Stiffening of the body that occurs about 2-4hrs after
death.
- Results from a lack of ATP , which causes the
muscles to contract , which in turn immobilize the
joints
- It starts in the involuntary muscles( heart, bladder)
then progress to head, neck, trunk , extremities. 67Mr. Melvin Jacob MSc (N)

2.Algor mortis
- Gradual decrease of the body temperature after
death.
- When blood circulation terminates and
hypothalamus ceases to function , body temperature
falls down.

3.Livor mortis
- Discoloration of body after death.
- After blood circulation has ceased , the RBC
broken down , - leads to discoloration of
surrounding tissues

4. Decomposition
-Tissues after death become soft and eventually
liquefied by bacterial fermentation .
- The hotter the temperature , the more rapid the
change.
- So bodies are stored in cool places / embalming

Care after death
• Physician must certify the death
• Consent form for autopsy
• Provide options for organ donation
• If death due to any accident, suicide , poisoning
etc., it should be informed to legal authorities .
• The body should not be handed over without any
legal written permission.

• Care of dead body ,often depends upon the
customs and religious beliefs. Also consider
any injury or scaring or accidents which can
cause threat to others.
• Nurses provide dignity and sensitivity to the
client and family
• Check orders for any specimens

• Ask for special requests to family (eg: shaving
, a special gown , Bible in hand , rosary at the
bedside)
• Remove al equipments , tubes , supplies and
dirty linens.
• Cleanse the body thoroughly , apply clean
sheets
• Brush and comb the hairs

• The eyelids are closed and held in place for a
few seconds , so they remain closed.
• Dentures should be in the mouth to maintain
facial alignment.
• Mouth should be closed.
• Remove all the ornaments , except wedding
bands ( in some instances)

• Absorbent pads are placed under the buttocks to
take up any feces and urine released because of
muscle sphincter relaxation
• All the orifices should be closed.
• Cover with a clean sheet up to the chin.
• Spray a deodorizer to remove unpleasant odor.
• Apply name tag ( wrist , right big toe)
• Allow the family members to view the dead body

• The body is wrapped in a “ shroud” a large piece
or plastic or cotton material used to enclose a
body after death. Identification is then applied
outside of the shroud.
• Hand over all the belongings to the relatives.
• Handed over the dead body to the relatives / sent
to the mortuary.

• Do complete documentation in the nursing notes.
- Time of death and actions taken to prevent the death.
- Who pronounced the death.
- Any organ donation
- Personal articles left on the body
- Personal items given to family
- Time of discharge and destination of the body
- Location of name tags on the body
- Special request by family

Conclusion
The dying patient has a variety of needs
ranging from the need for open communication to
physiological and spiritual needs. They should
maintain self care as long as possible. Families of
the dying patient may like to assist in providing
care. The nurse should provide emotional support
for the grievingfamily.

83
Before leaving let me ask
Do you need any clarification?
Mr. Melvin Jacob MSc (N)

Thank
you

Care of terminally ill

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