This document provides information on caring for terminally ill and dying patients, including: - Assessing patient needs, maintaining communication, and meeting physical, psychological, and spiritual needs. - Common signs that a patient is approaching death like changes to breathing, circulation, skin, etc. - Providing symptomatic relief and care of the body after death like cleaning and positioning the body. - The importance of advance directives to ensure patient wishes are followed and ease the burden on families. - Other topics covered include euthanasia, organ donation, medico-legal issues, and post-death unit care.

1. CARE OF TERMINALLY ILL AND DYING PATIENTAND FAMILY
Presented By : Mrs Bemina JA
Assistant Professor
ESIC College of Nursing
Kalaburagi

2. INTRODUCTION
 Life begin with birth and ends with death. clients death is
often viewed as personal failure on the part of health
personnel. The family turns to the nurse for support and
assistance. To provide effective care nurse must have
reconciled his or her own feelings about death and must
understand the phases of grieving & dying and should be
able to recognize their manifestations.
 Death will come to all people at some time. caring allows
the patient to die with dignity. an important aspect of
patient care is to the patient sense of identity & self
esteem. every person has the right to die with dignity.

3. MEETING THE NEEDS OF DYING INDIVIDUAL
 Assessing needs
 Explaining the clients condition and treatment
 Maintaining good communication
 Promoting self care & Self Esteem
 Allowing family members to assists in care.
 Meeting clients needs.
 Physiological needs
 Psychological needs
 Spiritual needs

6. SIGNS OF APPROACHING DEATH
 Facial appearance.
 Changes in sight, speech, and hearing.
 Respiratory system.
 Circulatory system.
 Gastro intestinal system.
 Genito urinary system.
 Skin and musculo skeletal system.
 Central nervous system.

7.  FACIALAPPEARANCE.
Facial muscle relax, cheek becomes flaccid moving in and
out with each breath. Facial structure may change so the
dentures cannot be worn, mouth structure may collapse,
loss of muscles tone & prominent cheeks, pale, sunken
eyes.
 CHANGES IN SIGHT, SPEECH, AND HEARING.
Sight gradually fail.
The pupil’s fails to react to light.
Eyes are sunken and half closed.
Speech becomes increasingly difficult, confused.
Loss of Hearing.

8.  RESPIRATORY SYSTEM
Respiration becomes irregular, rapid and shallow breath
or very slow & Sertorius due to the presence of secretions.
 CIRCULATORY CHANGES cause alterations in the
temperature, pulse and respirations. Radial pulse gradually
fails. Once it stops, the apical pulse may continue for
some time. Usually the pulsations are seen even after the
patient has stopped breathing.
 GASTRO INTESTINAL SYSTEM.
Hiccoughs, Nausea, Vomiting, abdominal distensions are
seen. The gag reflux disappears; the patient feels the
inability to swallow,

9.  “DEATH RATTLE”
A rattling sound heard in throat caused by secretions that the
patient cannot cough longer.
 GENITO URINARY SYSTEM
Retention of urine, distention of the bladder, incontinence of
urine and stool due to loss of sphincter control.
 SKIN AND MUSCULO SKELETAL SYSTEM.
The skin may become pale, cool and sweats lot (cold
sweats).Ears and nose are cold to touch. Skin is pale & mottled
due to congestion of blood in the veins as a result of circulatory
failure.
 CENTRAL NERVOUS SYSTEM.
Reflexes and pain are gradually lost. Patient may be restless
due to lack of oxygen and due to raised body temperature,
although the body surface is cool

10. SIGNS OF CLINICAL DEATH
 Absence of pulse, heart beat and respirations
 Pupil becoming fixed and not reacting to light
 Absence of all refluxes.
 Rigor mortis: Stiffing of the body after death. The arms &
legs cannot be bent or straightened while rigor mortis is
present unless the tendons are torn.
 POSTMORTEM HYPOSTASIS-It is a dark red or bluish
discoloration due to the settling of the blood.

11. CARE OF THE DYING PATIENT
 Psychological support: The psychological need of a dying
person can be summarized as follows:
Relief from loneliness, fear and depression.
Maintenance of security, self confidence and dignity.
Maintenance of hope.
Meeting the spiritual needs according to his religious
customs.
The dying person may be shifted to privet room, or privacy is
maintained by putting the screen, so that other patients may not
be disturbed by the unpleasant sight, the crises and other
disturbances.

12. SYMPTOMATIC MANAGEMENT
 PROBLEM ASSOCIATED WITH BREATHING:
The dying person who is restless, apprehensive and short of breath may be given-
Oxygen inhalation to remove his discomfort.
Elevation of the patient’s head and shoulders may make breathing easier.
Keep the room well ventilated and keep crowed away.
Periodic suctioning is necessary.
 PROBLEM ASSOCIATED WITH EATING AND DRINKING:
Anorexia, nausea, and vomiting are commonly seen in dying patient person.
They are unable to take any form of food and if they taken, they are unable to retain
the food.
The patient is unable to swallow even the sips of water poured in the mouth.
Most of them may require I.V fluids.
If they can tolerate the oral fluids, sips of water is given with teaspoon. That will
help the patient to keep the mouth moist. Give frequent oral hygiene.
Apply emollients to the dry lips.
The denture are removed and kept safely.

13.  PROBLEM ASSOCIATED WITH ELIMINATION:
Constipation, retention of urine and incontinence of urine
and stool are some of problem faced by the patient.
Catheterization has to be done
Through skin and Perineal care is to be given, to keep the
patient clean and to prevent skin breakdown.
 PROBLEM ASSOCIATED WITH IMMOBILITY:
Frequent skin care should be given with particular
attention to the pressure point.
Patient should be comfortably placed and their position
frequently changed in the bed.

14.  PROBLEM ASSOCIATED WITH SENSE ORGAN:
Since the patient loses sight, before given any care to the patient, the nurse
should touch the patient and say what she is going to do.
Since the hearing is retained longer, speak only what is appropriate. Avoid
whispering any think in patient room.
Speak distinctly so that patient may understand what is done for him.
Since the eyes are opened, protect the eyes from corneal ulceration with
protective ointment.
 PROBLEM ASSOCIATED WITH REST AND SLEEP:
Patient may distressing symptoms in these patients.
Patient should not be disturbed while sleeping.
The visitors should be instructed not to disturbed the patient during his
resting.
Maintain calm and quit environment.
 PROBLEM ASSOCIATED WITH CLEANLINESS AND GROOMING:
Cleanliness and appearance are important until the end.
Cleanliness of the skin, hair, mouth, and cloth has to be maintained.

15. CARING FOR THE BODY AFTER DEATH
 After the physician has pronounced death legally documented the death in the
medical record, care of the body is usually performed by the nurse.
 An autopsy consent may be requested & obtained if required.
 If the patient is to be an organ donor arrangements will be made immediately.
 The family often wishes to view the body before final preparations are made, they
may be allowed.
 If the patient had any valuables, they are handed over to the relatives
PURPOSES
 Make body look as natural & beautiful as possible.
 Perform his last duty tenderly.
 Protect other patients from unpleasant sights and sounds which could frighten them
ARTICLES REQUIRED
 Articles for bath
 Extra bandages and cotton swabs
 Perineal pads
 Sheets
 Restraints for jaw, hands and legs.
 Pair of gloves
 Thumb forceps
 Patients own set of clothes.

16. PROCEDURE
 Wash hands and put on gloves
 Soon the death is pronounced, remove the backrest, extra pillows and gently put the patient in
a supine position with the head elevated on the pillow.
 Positioning is important after death, because of rigor mortis. close the patients eyes and mouth.
 Remove all tubes and other devices from the patients body.
 Consult close relatives before preparing the body for removal from the ward to the mortuary
where the relatives will receive the body.
 If the relatives require, the nurse should help them to sponge the patient as necessary. brush
and comb hair.
 Replace soiled dressing with cleaned ones.
 Apply perineal pads and plug the rectum & vagina (in females) with cotton balls.
 Provide clean cloths(own).
 Take care of valuables and personal belongings by handing over to members of family.
 Allow members of family to see the patient & remain in the room & remember that the body is
still dear to someone.
 Close the body from side to side and head to foot with the sheet.
 Prepare the identification slip and attach it to the patients pack sheet.
 Attach a special label if the patient had a contagious disease.
 Transfer the body to the mortuary. Remove contaminated articles from room.
 IDENTIFICATION TAG SHOULD CONTAIN Patient name Age Registration number
Relatives name (specify) Address Ward number Bed number Date and time of
death Cause of death

17. Advance Directive
 Advance Directive is a Scottish term, but in other parts of the UK these documents are also
called Advance Decisions.
 An advance directive tells the health care team what kind of care the patient would like to
have if he is unable to make medical decisions (e.g., if in coma)
 A good advance directive describes the kind of treatment the patient would want depending on
the sickness
 An Advance Directive allows you to make a refusal of treatment in advance of a time when
you can’t communicate your wishes, or don’t have the capacity to make a decision.
 It only comes into effect if either of these situations occur.
 You can use an Advance Directive to refuse any treatment, including life-sustaining treatment
such as resuscitation, artificial nutrition and hydration, or breathing machines.
 An Advance Directive enables healthcare professionals to know what your wishes are even if
you cannot tell them yourself, e.g. if you had severe dementia or were in a coma.
 If you change your mind you can change your Advance Directive to reflect this. If you have
mental capacity and can communicate your wishes then your Advance Directive will not apply.

18. An Advance Health Care Directive
 An Advance Health Care Directive (AHCD) is a generic term for a document that
instructs others about your medical care should you be unable to make decisions on
your own. It only becomes effective under the circumstances delineated in the
document, and allows you to do either or both of the following:
 Appoint a health care agent. The AHCD allows you to appoint a health care agent
(also known as “Durable Power of Attorney for Health Care,” “Health Care Proxy,”
or “attorney-in-fact”), who will have the legal authority to make health care
decisions for you if you are no longer able to speak for yourself.
 This is typically a spouse, but can be another family member, close friend, or anyone
else you feel will see that your wishes and expectations are met.
 The individual named will have authority to make decisions regarding artificial
nutrition and hydration and any other measures that prolong life—or not.
 Prepare instructions for health care. The AHCD allows you to make specific written
instructions for your future health care in the event of any situation in which you can
no longer speak for yourself. Otherwise known as a “Living Will,” it outlines your
wishes about life-sustaining medical treatment if you are terminally ill or
permanently unconscious, for example.

19.  The Advance Health Care Directive provides a clear statement of
wishes about your choice to prolong your life or to withhold or
withdraw treatment.
 You can also choose to request relief from pain even if doing so
hastens death.
 A standard advance directive form provides room to state additional
wishes and directions and allows you to leave instructions about
organ donations.
 While most people would prefer to die in their own homes, the norm
is still for terminally-ill patients to die in the hospital, often receiving
ineffective treatments that they may not really want.
 Their friends and family members can become embroiled in bitter
arguments about the best way to care for the patient and
consequently miss sharing the final stage of life with their loved one.
 Also, the opinions and wishes of the dying person are often lost in
all the chaos.

20.  It’s almost impossible to know what a dying person’s wishes
truly are unless the issues have been discussed ahead of time.
 Planning ahead with an Advance Health Care Directive can
give your principal caregiver, family members, and other loved
ones peace of mind when it comes to making decisions about
your future health care.
 It lets everyone know what is important to you, and what is not.
 Talking about death with those close to us is not about being
ghoulish or giving up on life, but a way to ensure greater
quality of life, even when faced with a life- limiting illness or
tragic accident.
 When your loved ones are clear about your preferences for
treatment, they’re free to devote their energy to care and
compassion

21. Euthanasia
 Euthanasia literally means “good death”. It is basically to bring about the death of a
terminally ill patient or a disabled. Generally, the word euthanasia is defined as the
act or practice of painlessly putting to death or withdrawing treatment from a person
suffering an incurable disease.
Euthanasia can be classified in different ways, including:
 ACTIVE EUTHANASIA (action)– where a person deliberately intervenes to end
someone’s life – for example, by injecting them with a large dose of sedatives
 PASSIVE EUTHANASIA (ommission) – where a person causes death
by withholding or withdrawing treatment that is necessary to maintain life, such as
withholding antibiotics from someone withpneumonia
 VOLUNTARY EUTHANASIA – where a person makes a conscious decision to die
and asks for help to do this
 NON-VOLUNTARY EUTHANASIA – where a person is unable to give
their consent (for example, because they are in a coma or are severely brain
damaged) and another person takes the decision on their behalf, often because the ill
person previously expressed a wish for their life to be ended in such circumstances
 INVOLUNTARY EUTHANASIA – where a person is killed against their expressed
wishes

22. A WILL/DYING DECLARATION
 A will is a document by which a person regulates the
rights of others over his property or family after death.
 A statement by a person who is conscious and knows that
death is imminent concerning what he or
she believes to be the cause or circumstances of death that
can be introduced into evidence during
a trial in certain cases
 A person who makes a dying declaration must,
however, be competent at the time he or she makes a state
ment, otherwise, it is inadmissible.

23. 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
 The request for organ donation should be done by patent in the presence of a physician or a nurse
 Organs removed from the body following the death cannot be sold.
 All organ donation are voluntary and there should not be any compulsion for the patient / family members
 Organs usually donated :- kidney, heart, lungs, liver, bone, cornea
 Organ donation should take place with in 2-6hrs after the death.
COUNCELLING FOR ORGAN DONATION
 Organ transplantation is truly one of the miracles of modern medicine, saving the lives of many patients and
improving the quality of life for many more.
 Given the ever-increasing gap between the number of organs needed and the supply, nurses have an ethical
obligation to help ensure that the desires of people who want to donate organs are respected.
 Nurses have to ensure that the consent process is informed and voluntary.
 Information to the patient should consist of a balanced discussion of the available options and counseling to
help patients or their families reach the choice that is best for them, including the provision of information
about the urgent need for organs and the consolation that many families derive from knowing that their loved
one was able to help others.

24. MEDICO LEGAL ISSUES
 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
Provide link between pathologists and lay investigative staff
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

25. CARE OF UNIT AFTER DEATH
 Inform the nurse in charge and inform the medical staff of the patient’s death
 In the case of an expected adult death, a registered nurse deemed competent by the
Trust may confirm death
 Confirmation of death must be recorded in the patient’s healthcare record
 An unexpected death must be confirmed by the attending medical officer and if
confirmed the service manager should be contacted or duty manager out of hours.
Incident form to be completed
 Inform the patient’s relatives/next of kin of the patient’s death. Ensure that this is
handled in a sensitive and appropriate manner with as much privacy as possible.
 Ask if the relatives wish to see the chaplain or an appropriate religious leader or
other appropriate person to the person’s faith or ethnic origins that need to be
attended to immediately
 If relatives are in the hospital ask if they wish to assist with the last offices and/or if
they have any particular wishes regarding the procedure
 If the relatives are not in the hospital ask if they wish to view the body on the ward
or at a later date
 Assemble required equipment
 Wash hands and put on disposable gloves and apron
 Any injuries sustained whilst carrying out the procedures on the deceased must be
reported through the Trust risk system and follow the Trust Sharps and Inoculation

26. Management Procedure
 Lay the patient on their back with one pillow in place (adhere to the Moving and Handling
Policy)
 Straighten the patient’s limbs (if possible) and place their arms by their sides
 Gently close the patient’s eyes if open by applying light pressure for 30 seconds.
 If corneal or eye donation to take place, close the eye with gauze moistened with normal
saline
 Do not apply tape
 If syringe driver in situ, disconnect and remove battery
 In cases where there is no referral to the coroner required infusions can be discontinued and
infusion lines, cannulae, drainage and other tubes can be removed If referred to the coroner
endo-tracheal tubes, catheters and infusion lines should remain in site.
 Discard all sharps into a sharps bin as per Trust Sharps and Inoculation Management
Procedure
 Place a receiver between the patient’s legs and drain the bladder by pressing on the lower
abdomen.
 Pads and pants can be used to absorb any leakage
 Exuding wounds should be covered with absorbent gauze and secured with an occlusive
dressing
 Wash the patient if necessary, unless requested not to do so for religious/cultural reasons or
patient has died in suspicious circumstances

27.  It may be important to the family and carers to assist with washing,
thereby continuing the care given to the patient in the period before death
 Clean the patient’s teeth and gums using a moistened, soft small headed
nylon toothbrush and or suction to remove any debris and secretions
 Clean any dentures and replace them in the mouth – a small pillow or rolled
up towel placed under the patient’s chin may help to keep the jaw closed
and teeth in situ
 Tidy the hair as soon as possible after death and arrange into the preferred
style (if known)
 Patients should not be shaved; usually a funeral director will do this.
Some faiths prohibit shaving
 Remove all jewellery, in the presence of another nurse, unless requested
by the family to do otherwise.
 Any jewellery removed must be documented on a property form and placed
in the hospital safe until collected by the family. Wedding rings may be left
in situ and taped in place.
 Any jewellery remaining on the body should be documented on the
identification card accompanying the patient to the mortuary or undertakers

28.  Record all property in the patient property book and pack in a labelled
property bag, keeping secure until collected by the family. Pack personal
property showing consideration for the feelings of those receiving it.
 Discuss the issues of soiled clothes sensitively with the family and ask
whether they wish them to be disposed of or returned
 Unless a specific request has been made by the family for alternative
clothes the patient should be dressed in a hospital gown
 If relatives are present at the time of death, or attend the hospital shortly
after, staff should ensure that they are given the Trust Bereavement
information copies of which are available on the ward.
 Relatives should be told to contact the relevant Trust officer who supports
bereavement or the patient’s GP to collect the death certificate
 Label one wrist and one ankle with an identification band containing the
following information: Full name NHS Number Date of Birth
Complete patient identification cards and notification of death book clearly
in capitals
 If the patient has an implant device such as a pacemaker or an infectious
disease is known or suspected – record this fact on both patient
identification cards

29. AUTOPSY
 An autopsy or postmortem examination is an examination of the body after death.
 It is performed in certain cases such as:
Committed suicide
Unknown cause of death
Unknown dead bodies
Homicide (The killing of one human being by another )
 The organs and tissues of the body are examined to establish the exact cause of death , to learn
more about a disease
 A consent should be obtain from the immediate relative :surviving spouse, adult children,
parents, siblings.
 After an autopsy , hospitals cannot retain any tissues/ organs without the permission of the
person who signed the consent form
 it is also known as a post-mortem examination,
 It is a highly specialized surgical procedure that consists of a thorough examination of
a corpse to determine the cause and manner of death and to evaluate any disease or injury that
may be present.
 It is usually performed by a specialized medical doctor called a pathologist.
 Autopsies are performed for either legal or medical purposes.
 Autopsies are divided into 2 categories:
 Medical, authorized by the decedent, decedent's family or healthcare surrogate
 forensic, authorized by statute.

30.  Tape one identification card to clothing or hospital gown Wrap the body
in a sheet, ensuring that face to feet are covered and that all limbs are held
securely in position
 If the body may be infectious or there is a risk of leakage of body fluids
place the body in a body bag and put the second identification card into the
pocket of the body bag
 If the deceased person has a known infectious disease Category 3 & 4
they must be placed in a heavy duty body bag and you must inform anyone
else who comes in contact with this patient e.g. funeral directors, porters.
 Remove gloves and aprons. Dispose of equipment according to local
policy and wash hands
 If mortuary on site request porters to remove body from the ward to the
mortuary
 If no on site mortuary, contact local funeral directors or the funeral
directors according to the relatives wishes Screen off the area where
removal of the body will occur
 Screen off the area where removal of the body will occur
 Record all the details and actions in the nursing records Any property
retained on the ward out of hours must be stored in a secure area and any
valuables stored in the ward or hospital safe

31. EMBALMING
 It is the art and science of preserving human remains by treating them (in
its modern form with chemicals) to forestall decomposition.
 The intention is to keep them suitable for public display at a funeral, for
religious reasons, or for medical and scientific purposes such as their use as
anatomical specimens.
 The three goals of embalming are sanitization, presentation and
preservation (or restoration).
 Embalming has a very long and cross cultural history, with many cultures
giving the embalming processes a greater religious meaning.
 Embalming prevents the process through injection of chemicals into the
body to destroy the bacteria
 It is the process of preserving dead body from decay
 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

32.  Make sure the body is face up
 Remove any clothing that the person is wearing.
 Disinfect the mouth, eyes, nose, and other orifices
 Shave the body.
 Break the rigor mortis by massaging the body.
 Setting the Features 1. Close the eyes. 2. Close the mouth
and set it naturally 3. Moisturize the features. A small
amount of creme should be used on the eyelids and lips 4.
Casketing the Body

33. PROCESS OF EMBALMING
 Embalming fluid is injected into the arteries of the deceased during
embalming.
 Many other body fluids may be drained or aspirated and replaced with the
fluid as well.
 The process of embalming is designed to slow decomposition of the body.
 The actual embalming process usually involves 4 parts:
Arterial embalming: which involves the injection of embalming chemicals
into the blood vessels, usually via the right common carotid artery. Blood is
drained from the right jugular vein.
Cavity embalming: The suction of the internal fluids of the corpse and the
injection of embalming chemicals into the body cavities, using an aspirator
and trocar.
Hypodermic embalming: The injection of embalming chemicals under the
skin as needed.
Surface embalming: Which supplements the other methods especially for
visible, injured body parts.

34.  CONCLUSION When death cannot be prevented it
becomes imperative that the doctor and nurse do all
whatever is necessary to make dating less difficult for the
patient. 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 grieving family.
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