Pallia notes: death and dying


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Pallia notes: death and dying

  1. 1. Death & DyingM. Guimalan- Dec10, 11Dying- accident, injury, pathologic crisis such as a heart attack, or after a prolonged experience ofdebilitating disease, cancer, AIDS, multiple sclerosisDeath- irreversible cessation of circulatory and respiratory functions - Irreversible cessation of all functions of brain and brain stemClinical signs that must be present at least 24 hours: - Lack of receptivity and responsiveness - Lack of movement/breathing - Lack of reflexes - Flat encephalogram (confirmatory dx exam)3 definitions of death in the US: 1. Heart-lung death- irreversible cessation of spontaneous respiration to circulation o Until 1960s: flow of body is essential 2. Whole-brain death- irreversible cessation of entire brain function and brainstem o 1960s: neocortical function is key to definition of human being o Clinical exams include induction of painful stimuli, pupillary responses to light, oculovestibular testing and apnea testing. o To enhance accuracy, do not perform brain death testing while patient is hypothermic/hypotensive or when under neuromuscular blocking agents with barbiturates 3. Higher- brain death- irreversible loss of “higher” brain functions o Irreversible loss of “higher” brain functions o 1970s: from belief that brain is more important than the spinal cord and that the critical functions are individual’s personality, conscious life, uniqueness, memory, judging, reasoning, actingTheories of death and DyingStages of death and dying - The stages of dying, much like the stages of grief, may overlap, and the duration of any stage may range from as little as a few hours to as long as months. The process varies from person-
  2. 2. person some people may be in one stage for such a short time that it seems as if they skipped that stage. Sometimes a person returns to a previous stage.Five stages of dying (Kubler Ross): 1. Denial and isolation stage - The patient denies that he or she will die, “may repress what is discussed and may isolate self from reality - The patient may thins, “they made a mistake in the diagnosis. Maybe they mixed up my records with someone else’s” - May consult another doctor 2. Anger - Patient expresses rage and hostility and adopts a “why me?” attitude: “why me? I quit smoking, and I watched what I ate. Why did this happen to me?” - 3. Bargaining - Trying to barter for more time - Many put their personal affairs in order, make wills, fulfil last wishes - Important to fulfil wishes because it will help them more to later stage 4. Depression- period of grief burying /not speaking much 5. Acceptance - Patient feels tranquil, accepted death, and prepared to die - “I’ve tied up all loose ends: made the will, made arrangements for my daughter to live with her grandparents, now can i go in peace knowing you’ll be okay.Signs and symptoms of impending death: - As each person is unique, all of these s/sx will not occur with everyone, nor will they occur in this particular sequence. These are few common sx that often occur: 1. Decreased food and fluids and related effects- as the body no longer desires or tolerates foods and fluids. The person normally eats and drinks less o Person loses weight and skin becomes thin and tears easily o Dec urine outputs and more concentrated o Proper positioning to prevent choking o Do not force foods/fluids o Use glycerine swabs to keep the mouth and lips moist 2. Increased sleeping and withdrawal- do not assume person can’t hear what is said in the room o Sit with person, hold hands gently o Orient: time, place, and person 3. Incontinence- people with end-stage dementia lose control of the bladder and of bowels o Reposition and change pads frequently to avoid use of dispersible undergarments o To prevent skin breakdown: keep clean and dry, change pads, straighten linens
  3. 3. 4. Breathing pattern change and congestion- breathing may become shallow, irregular, fast or abnormally slow. o Moaning-like sound when exhaling o Elevating person’s head and turn head to side5. Changes in temperature and skin color- the person’s arms and legs may become cold, hot, or discoloured o Hot water bag on sole of feet o Keep warm if cold but don’t use electronic blankets o Start with the extremities6. Restlessness and disorientation- he or she may groan, scream, or mumble loudly. o Hold person’s hand/gently massage forehead o Talk reassuringly, read to the person, repeat favourite prayers/music7. At time of death- breathing ceases, heartbeat ceases, the person cannot be aroused. o Eyelids may be half open with eyes in a fixed stare o Supine position, HOB elevated o Post-mortem before Rigor mortis o Name tag: name, doctor, time of death