2. LEARNING OBJECTIVES
By the end of the lesson, students should be able to;
• Define the term death appropriately.
• Identify the fears/concerns experienced by patients
with their families regarding imminent death.
• Identify the 6 signs of approaching death
• Discuss ways of supporting the family
• Outline 7 signs that shows that death has occurred.
3. AIM
To empower the students with the knowledge and skills for addressing
issues involved in death and dying.
Introduction:
Even if it is obvious that one day we shall all die, we all never want to
experience death or see our loved one dying. Individuals react
differently when they realize they are soon dying especially with
terminal illnesses. Death remains a mystery throughout our lives.
• Students should be able to prepare the patient and family for imminent
death including the clinical management of the dying patient, and
better support them.
4. WHAT IS DEATH?
Death is the end of life of a person or an
organism.
Death is the termination of all biological
functions that sustain an
organism.(www.en.wikipedia.org/wiki/death)
5. A human skull, widely used as a
symbol of death and decomposition.
6. FEARS AND CONCERNS
The most helpful step in preparing patients and
their families for imminent death is to elicit their
fears and concerns. It is important, therefore, that
the patient and family understand the normal land
marks in the dying process and overcome the
common misconceptions regarding death. As
death approaches, the patient and the family
experience lots of fears and concerns.
7. Qn. Identify the fears and concerns experienced by patients
and their families regarding imminent death ( as an
individual, reflect on a dying patient and family you
recently attended to, list what fears and concerns you
identified).
Fears of:
• Not being able to cope with the process of dying and death
itself.
• Dying in pain and agony
• Being responsible for the illness in some way.
8. • Fear of how the others will survive when the
loved one is gone.
• Being alone in the house at the time of death.
• Fear of what will happen after death
• Fear of staying in the house when the loved
one is gone
9. Family concerns:
• Unfinished business or tasks which the patient
was undertaking.
• Wanting everything possible to be done to
sustain the patient’s life.
• Transportation of the body after death.
• Burial sites/costs.
10. Signs of approaching death
Certain signs are especially common at the end of
life, and the caregiver should be able to identify
them, prepare the family accordingly.
Identify the signs of a patient approaching death
and the appropriate care required.
• Decreasing social interaction: Many dying
patients remain aware of their surrounding until
the time of death.
11. -They may be confused about time, mumbling,
staring into space, plucking at bedclothes, odd
movements of hands, hallucinations and
agitation.
-It is thought that some of these behaviors are due
to failing blood circulation, electrolyte imbalance,
multi-organ dysfunction.
12. Clinical mgt
• Explain to the family what is happening and encourage
them to allow the patient to rest.
• Encourage the family to be present and be observant.
• Keep surroundings familiar.
• Encourage good nursing care with explanation to the
family.
• Encourage the family to continue talking to the patient.
• Encourage the family to use therapeutic touch i.e holding
hands with the patient.
13. • Pain: The patient’s pre-existing pains may worsen
and new ones may develop.
Clinical mgt:
• Monitor pain relief carefully. Do not stop analgesics
even if the patient is comatose, administer them
regularly using the most appropriate route preferably
by mouth or rectal.
• Drug dosages may need to be reviewed as side
effects may be more prominent at this stage.
14. • When there is reduced or no urine output, reduce morphine
routine dosing by ½, and break through dosing as needed.
• Stop most drugs as side effects accumulate.
Decreasing fluid and food intake: Often the family is
worried that the patient will get dehydrated and starve to
death. Facts that the family should know include;
-Food may be nauseating
-Eating and drinking become difficult as one must have
adequate strength to chew and maintain an upright
position.
15. -As energy requirements diminish, forcing fluids may
cause more problems than withholding i.e risk of
aspiration.
-Excess secretions may localize in the pharynx causing
a gurgling sound or death rattle.
Clinical mgt:
• Remind families , care givers that dehydration does
not cause distress but rather it is protective.
• Parenteral fluids may be harmful hence causing fluid
over load and breathlessness.
16. -Do not feed patient when in supine position for
fear of aspiration, instead patient must be
supported in an upright position.
-Keep the patient’s mouth clean and moist.
-It is important to respect the patients wishes.
Changes in elimination: Passing urine and stool
may decrease or even, but incontinence of the
two is possible.
17. Clinical mgt
• Reassure that this may be uncomfortable for the patient.
• Assist and educate the family on care of the skin and
pressure areas.
• Use urinals/bedpan or catheterize the patient if necessary.
Respiratory changes: there may be changes in the breathing
pattern.
• Death rattle; excess secretions may localize in the
hypopharynx associated with expiratory and inspiratory
phases of respiration, causing a gurgling sound
18. Clinical mgt
• Prepare the family before the death rattle occurs.
• Reassure the family that this is not uncomfortable or
a sign of pain to the patient.
• Reposition the patient to prevent aspiration.
• Give medications e.g Hyoscine Butylbromide to
reduce secretions.
Circulatory changes: the extremeties are cold and
sometimes appears greyish/bluish.
19. Mgt: Keep the patient covered and warm.
Gently ensure that the family is explained and
understands the cause of this.
SUPPORT THE FAMILY
Qn: Discuss the different ways of supporting the family.
Having explored the relatives understanding of the
situation and shared with them your assessment of the
patient’s approaching death, the following can be
useful in guiding your support of the family at this
difficult time.
20. • Recognition of the care they have given to the
patient so far.
• Encourage family to stay close as love and attention
are crucial to the comfort of the dying person.
• An explanation of how the patient’s condition is
likely to deteriorate, paying particular attention to
changes in the breathing pattern and circulation, and
explain that these are not uncomfortable to the
patient.
21. • Advice on all nursing aspects to maintain the patient’s privacy
and dignity e.g not leaving him/her exposed or in a soiled linen.
• Knowledge that the dying person, even when there is no
response, is aware of their presence and so they should:
-not encourage expression of anxiety/concerns
-inform them of your next visit
-ensure that they know how to get a message to you.
• Explanation about what to do when the patient has died. E.g
how to remove a urinary catheter can be very important for a
family.
22. • Encourage relatives to ask questions that they
may want to know but are reluctant to ask.
• Communication skills at such a time are vital
particularly in picking up and addressing
unspoken fears or qns they may have.
23. Signs that death has occurred
• Breathing ceases entirely
• Heart beat and pulse stop
• Patient is totally unresponsive to shaking, shouting.
• Eyes may be fixed in one direction, eyelids may be open or
closed.
• Eyeballs become soft.
• The skin tone changes
• Generalized stiffness of the body (rigor mortis) after several
hours.
24. Summary of key points
• It is important to identify the fears and concerns
experienced by patients and their families regarding
imminent death.
• Clinical mgt of the dying patient in the last hours of life is
very important both to the patient and family who have to
live after the patient dies. The family can be left with
particular difficult memories if pain and symptoms are not
controlled well.
• Communicate effectively to the patient and take them
through the signs of death and dying.
25. “Let us support the dying patient and their
family members as it is not easy to see a
loved one passing on”.
