The document discusses care of death and dying, including: 1. The stages of dying according to Kubler-Ross - denial, anger, bargaining, depression, and acceptance. 2. Assessing the physiological signs of approaching death such as slowed body functions and loss of reflexes. 3. Types of care for the dying person including physical, psychological, social, and spiritual care. This involves managing pain, allowing friends/family, and addressing religious/cultural needs. 4. Hospice care aims to provide compassionate, palliative care focused on comfort and quality of life for the terminally ill.

2. CONT ENT S
 Introduction to death and dying
 Stages of dying
 Care of death and dying
 Meeting the needs of dying individual
 Assessing the physiological signs of
approaching death
 Physical care
 Psychological care
 Social care
 Spiritual care

3. “As a well-spent day brings happy sleep, so a life well
used brings happy death”
- Leonardo Da Vinci

4. INTRODUCTION
ᴥ Birth and death are two aspects of life, which will
happen to everyone.
ᴥ Dying and death are painful and personal
experiences for those that are dying and their
loved ones caring for them.
ᴥ Death affects each person involved in multiple
ways, including physically, psychologically,
emotionally, spiritually, and financially.

5. DEFINITION
 Death is defined as “The irreversible
cessation of all vital functions especially
as indicated by permanent stoppage of the
heart, respiration, and higher brain
function”
 Dying means “approaching death”

6. ST AGES O F DEATH AND DYING
Although each person reacts to impending death or
loss in his or her own way, there are similarities in
the psychosocial responses to the situation
According to Kubler-Ross, there are 5 stages of dying
 Denial
 Anger
 Bargaining
 Depression
 Acceptance
“DABDA”

7. STAGE 1: DENIAL
 Refusing to believe a probable death will occur.
 There is initial reaction of shock
“No I donot belive it”
“An error has been made on the tests”
 You can help others face it by being available for
them to talk instead of forcing them to talk about it.
 Patient isolates self from source of accurate
information, not to seek treatment or assistance
 He never talks about dying and death. He refuses
hospital admission and treatment
 Patient appears to be superficially happy to deny the
truth of diagnosis

8. STAGE 2: ANGER
- Recognition of loss or death
- May become angry, frustrated and irritatble that
they are sick
- “Why me”
- Anger at God for not allowing them to see their kids
grow up
- Anger at the doctors, family, self, fate,
- Blame everybody for his misfortunes
- Try not to take it personally. They have a right to be
angry so allow them to express themselves so they
can move on in the grieving process.

9. STAGE 3: BARGAINING
 The patient attempts to make deal with someone or
something to prevent loss
 They may start to negotiate with God i.e. “I’ll live a healthier
life,” “I’ll be a nicer person,”
 They may negotiate with the doctor by saying, “How can I
get more time so I can live in my dream home, and so on.

10.  There is a deep sense of yearning at this stage to be
well again.
 This is the time when the wishes are so strong that it
seems actually to prolong his her life until his/her wish
is fulfilled
 “I know I am going to die, and I am ready to die bu not
just yet”
 “If I can live longer to attend my son’s wedding”

11. STAGE 4: DEPRESSION
 When reality sets in about their near death, bargaining
turns into depression.
 Realises the death
 Looks sad by thought,
relationship
withdraws from important
 Normal part of the process of preparing to die

12.  Guilt for demanding so much
depleting the family income occurs.
 Patient shows clinical signs
attention and
of depression-
withdrawal, psychomotor retardation, sleep
disturbances, hopelessness and possibly suicidal
ideation.
 Be available to listen instead of cheering them up
 Distraction is good but don’t ignore the situation.

13. STAGE 5: ACCEPTANCE
 When the dying have enough time and support, they
can often move into acceptance.
 Realises the death is inevitable and accepts
universality of experience
 Patient begins to make a plan fo his death. Eg. Write
a will, completes financial arrangements for family,
giving up personal possessions etc.

14.  The dying person will want someone caring, and
accepting by their side.
 People with strong religious beliefs and those
who are convinced of life after death can find
comfort in these belief

15. C ARE OF DYING
 To provide effective care of dying individual 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.
 Every person has the right to die with dignity.

16.  Caring allows the people to die with dignity.
 Nurse must understand the influence of
dignified death and the profound effect it has
on the family and those close to the person
who has died
Ensuring a good death for all is therefore a
major challenge not only for healthcare
professionals but also for society

17. CA R E O F D Y I N G …
1.Meeting the needs of dying individual
 Physical needs
 Psychological needs
 Spiritual needs
2. Assessing needs
3. Explaining the clients condition and treatment
4. Maintaining good communication
5. Promoting self care & self esteem
6. Allowing family members to assists in care.

18. Assess the following:
 Gather complete set of data regarding state of awareness
manifested by client and family members.
 In cases of terminal illnesses, the state of awareness
shared by the client and family affects the nurse’s ability to
communicate freely with the client and other health care
team members and to assist the family in grieving
process.
Care of Dying….

19. C ONT…
Assessment of the
approaching death:
physiological signs of
 Slowed body function
 Drowsiness, mental confusion become apparent
 Withdrawal and decreased socialisation, sleep
more

20.  Loss of bowel and bladder control
 Cold skin
 Secretions collect in the back of throat and rattle
or gurgle as the patient breathes
 Breathing may become irregular with periods of
no breathing

21. C ONT…
 Involuntary movements called myoclonus, change in
heart rate, loss of reflexes
 The patient become restless
 He maynot be responsive, vision and hearing may
become somewhat impaired and speech become
difficult to understand
 As death nears, the pulse become rapid and weaker,
pale skin, eye stare and pupil donot respond to light

22. PHYSICAL C ARE
 Providing comfort to the patient and relieving pain.
 As patients become weaker they find it increasingly
difficult to take oral drugs
 Discontinue drugs that no longer contribute to
patient comfort like withdrawing blood,
measurement of vital signs, continuing Iv fluids,
tube feeding

23.  Regular observations should be made and good
symptom control maintained, including control of
pain and agitation
 Attention to mouth care is essential in the dying
patient, and the family can be encouraged to give
sips of water or moisten the patient's mouth with
a sponge
 Turning the patient, eye care, positioning to
facilitate drainage of secretions

24. PSYCHOLOG ICAL C A R E
 Patients' insight into their condition should be
assessed. Issues relating to dying and death
should be explored appropriately and sensitively
 Talk with the dying person and hear them.
 Use your mind, eyes and ears to listen them

25.  Respond to his concerns
 Appreciate the patients.
communication
Never force
 Honour their wishes even if u don’t agree with
them
 Need for privacy
 Acknowledge them and provide a caring touch or
hand holding that offer a comforting message

26. S O C IAL C A R E
o The family's insight into the patient's condition should be
assessed and issues relating to dying and death explored
appropriately and sensitively.
o Prepare the family for the normal, expected change.
o If they have been prepared for death, families are less
likely to be panic and and better able to be with their
loved ones in a meaningful way

27. o Use therapeutic communication to facilitate
their expression of feeling.
o Allow presence of loved ones and allow time to
share with spouse and children his feeling.
o Allow him to complete his unfinished work

28. o Showing empathetic and caring presence conveys
positive message to the grieving family.
o The nurse must have a calm and patient manner.
o Repeated information may need as the family members
are going through the grieving process. They may not
absorb what they are told

29. SPIRITUAL C A R E
 Religion is a prime source of strength to many people
when they are dealing with the death
 Different religious theories explain the inevitability
and even necessity of death from different perspective.

30.  Cultural influences can significantly impact the
patient’s reaction to the dying process and the
decision the family and patient make.
 The nurse has a responsibility to ensure that the
client’s spiritual needs are attended to, either
through direct intervention or by arranging
access to individual who can provide spiritual
care.

31. SPIRITUAL…
 Specific interventions include facilitating expressions of
feelings, prayer, meditation, reading and discussion with
an appropriate clergy or a spiritual advisor.
 It can also be helpful, where possible, to ask the dying
person where they want to die, who they want to be
present at the time of death, and how their
cultural/spiritual/individual needs can be met.

32. Many faces of
death
Death is a biological fact; but it also has social, cultural, historical, religious, legal,
psychological, developmental, medical, and ethical aspects, and often these are closely
intertwined.
Although death and loss are universal experiences, they have a cultural and historical
context. The ways people face death, as well as its meaning and impact, are profoundly
influenced by what people feel and do, and people’s feelings and behavior are shaped
by the time and place in which they live.
Cultural and religious attitudes toward death and dying affect how people deal with
their own death and the deaths of those close to them.
Death used to come early and frequently in the life of a family and community and was a
constant household companion. Today, people in most countries live longer, and death
is a less frequent and less visible occurrence.

33. Care of the
dying
Hospice care is personal, patient- and family-centered, compassionate care for the
terminally ill.
Its focus is on palliative care (also called comfort care): relief of pain and suffering,
control of symptoms, maintaining a satisfactory quality of life, and allowing the patient
to die in peace and dignity.
Hospice care usually takes place at home: but such care can be given in a hospital or
another institution, at a hospice center, or through a combination of home and
institutional care. Family members often take an active part. Palliative care also can be
introduced earlier in an illness that is not yet terminal.
What does it mean to preserve the dignity of a patient who is dying?
Dignity-conserving care depends, not only on how patients are treated, but on how they
are regarded: “When dying patients are seen, and know that they are seen, as being
worthy of honor and esteem by those who care for them, dignity is more likely to be
maintained”

34. Patterns of
grieving
Bereavement—the loss of someone to whom a person feels close and the process of adjusting to it—can affect
practically all aspects of a survivor’s life. Bereavement often brings a change in status and role (for example,
from a wife to a widow or from a son or daughter to an orphan).
It may have social and economic consequences—a loss of friends and sometimes of income. But first there is
grief—the emotional response experienced in the early phases of bereavement.
The Classic Grief Work Model - A classic pattern of grief is three-stages in which the bereaved person accepts
the painful reality of the loss, gradually lets go of the bond with the dead person, and readjusts to life by
developing new interests and relationships. This process of grief work, the working out of psychological issues
connected with grief, often takes the following path—though, as with Kubler-Ross’s stages, it may vary.
1. Shock and disbelief. Immediately following a death, survivors often feel lost and confused. As awareness of
the loss sinks in, the initial numbness gives way to overwhelming feelings of sadness and frequent crying.
This first stage may last several weeks, especially after a sudden or unexpected death.
2. Preoccupation with the memory of the dead person. In the second stage, which may last six months to two
years or so, the survivor tries to come to terms with the death but cannot yet accept it. A widow may relive
her husband’s death and their entire relationship. From time to time, she may be seized by a feeling that
her dead husband is present. These experiences diminish with time, though they may recur—perhaps for
years—on such occasions as the anniversary of the marriage or of the death.
3. Resolution. The final stage has arrived when the bereaved person renews interest in everyday activities.
Memories of the dead person bring fond feelings mingled with sadness, rather than sharp pain and
longing.

35. Death and
bereavement
across
lifespan
Childhood and Adolescence According to early neo-Piagetian research, sometime between ages 5 and 7 most children come to
understand that death is irreversible—that a dead person, animal, or flower cannot come to life again. At about the same age,
children realize two other important concepts about death: first, that it is universal (all living things die) and therefore
inevitable; and second, that a dead person is nonfunctional (all life functions end at death).
Before then, children may believe that certain groups of people (say, teachers, parents, and children) do not die, that a person
who is smart enough or lucky enough can avoid death, and that they themselves will be able to live forever. They also may
believe that a dead person still can think and feel.
The concepts of irreversibility, universality, and cessation of functions, these studies suggest, usually develop during the shift
from preoperational to concrete operational thinking, when concepts of causation become more mature.
Like their understanding of death, the way children show grief depends on cognitive and emotional development. Children
sometimes express grief through anger, acting out, or refusal to acknowledge a death, as if the pretense that a person is still
alive will make it so. They may be confused by adults’ euphemisms: that someone “expired” or that the family “lost” someone or
that someone is “asleep” and will never awaken.
Adjusting to loss is more difficult if a child had a troubled relationship with the person who died; if a surviving parent depends
too much on the child; if the death was unexpected, especially if it was a murder or suicide; if the child has had previous
behavioral or emotional problems; or if family and community support are lacking.
For adolescents, death is not something they normally think much about unless they are directly faced with it. Many of them
take unnecessary risks. They hitchhike, drive recklessly, or experiment with drugs and sex often with tragic results.
In their urge to discover and express their identity, they tend to focus more on how they live than on how long they are likely to
live.

36. Adulthood - Young adults who have finished their education and have embarked on careers, marriage, or parenthood are
generally eager to live the lives they have been preparing for. If they are suddenly struck by a potentially fatal illness or injury,
they are likely to be extremely frustrated and angry.
People who develop terminal illnesses in their twenties or thirties must face issues of death and dying at an age when they
normally would be dealing with such issues of young adulthood as establishing an intimate relationship. Rather than having a
long lifetime of losses as gradual preparation for the final loss of life, they find their entire world collapsing at once.
In middle age, most adults understand that they are indeed going to die. Their bodies send them signals that they are not as
young, agile, and hearty as they once were. More and more they think about how many years they may have left and how to
make the most of those Years. Often—especially after the death of both parents—there Is a new awareness of being the older
generation or the next in line to die.
Middle-aged and older adults may prepare for death emotionally as well as in practical ways by making a will, planning their
funerals, and discussing their wishes with family and friends.
Older adults may have mixed feelings about the prospect of dying. Physical losses and other problems and losses of old age may
diminish their pleasure in living and their will to live. Some older adults, especially after age 70, give up on achieving unfulfilled
goals. Others push harder to do what they can with lifc in the time they have left. Many try to extend their remaining time by
adopting healthier lifestyles or struggle to live even when they are profoundly ill
When they think or talk of their impending death, some older adults express fear. Others, especially the devoutly religious,
compare death to falling asleep, an easy and painless transition to an afterlife. They do not talk about the process of dying itself
or the declines that may precede it. For them, this approach may mute fear of dying.
According to Erikson, older adults who resolve the final critical alternative of integrity versus despair achieve acceptance both of
what they have done with their lives and of their impending death. One way to accomplish this resolution is through a life
review. People who feel that their lives have been meaningful and who have adjusted to their losses may be better able to face
death.

37. Medical, Legal,
and Ethical
Issues:
The “Right to
Die”
Although suicide is no longer illegal in modern societies, there is still a stigma attached to it.
Some people ‘maintain a “right to die,” especially for people with long-term degenerative
iliness.
Suicide rates tend to rise with age and are more common among men than among women,
though women are more likely to attempt suicide. It is often related to depression, isolation,
family conflict, financial troubles, and debilitating ailments.
Euthanasia and assisted suicide involve controversial ethical, medical, and legal issues.
To avoid unnecessary suffering through artificial prolongation of life, passive euthanasia is
generally permitted with the patient's consent or with advance directives. However, such
directives are not consistently followed. Most hospitals now have ethics committees to deal
with decisions about end-of-iife care.
Active euthanasia and assisted suicide are generally illegal, but public support for physician
aid in dying has increased.
The Forgoing or withdrawing treatment of newborns who cannot survive or who can do so
only with extremely poor quality of life is becoming a more widely accepted practice than in
the past.
The aid-in-dying controversy has focused more attention on the need for better palliative care
and understanding of patients' state of mind. Issues of social and cultural diversity need to be
considered.

38. Finding
meaning in
life and death
Life review is a process of reminiscence that enables a person to see the significance of his or her
life.
Life review can, of course, occur at any time. However, it may have special meaning in old age, when
it can foster ego integrity according to Erikson, the final critical task of the life span.
As the end of their journey approaches, people may look back over their accomplishments and
failures and ask them- selves what their lives have meant.
Awareness of mortality may be an impetus for reexamining values and seeing one’s experiences and
actions in a new light. Some people find the will to complete unfinished tasks, such as reconciling
with estranged family members or friends, and thus to achieve a satisfying sense of closure.
Not all memories are equally conducive to mental health and growth. Older people who use
reminiscence for self-understanding show the strongest ego integrity, while those who entertain
only pleasurable memories show less. Most poorly adjusted are those who keep recalling negative
events and are obsessed with regret, hopelessness, and fear of death; their cgo integrity has given
way to despair,
Within a limited life span, no person can realize all capabilities, gratify all desires, explore all
interests, or experience all the richness that life has to offer. The tension between possibilities for
growth and a finite time in which to do the growing defines human life.
By choosing which possibilities to pursue and by continuing to follow them as far as possible, even
up to the very end, each person contributes to the unfinished story of human development.

39. RE F E R E N C E S
 Berman, J., A., Snyder, S., (2014), Kozier and Erb’ s
Fundamentals of Nursing, 9th Edition, Pearson
 Potter, A., P., & Perry, G., N., (2011), Fundamentals of
Nursing, 7th Edition, Elsevier
 Nursing Reviews [Online] Available from:
http://currentnursing.com/reviews/care_of_dying_and_death.ht
ml [Accessed: 17th November 2015].
 Henry, C, Wilson, J . (2012) Personal care at the end of life and
after death. Nursing Times; 108: online issue. Available from
http://www.nursingtimes.net [Accessed: 17th November 2015].
 Wilson, J., White, C. (2012). Guidance for staff responsible for
care after death (last offices) Developed by the National End of
Life Care Program and National Nurse Consultant Group
(Palliative Care). RCN. Available from
 http://www.nhsiq.nhs.uk/media/2426968/care_after_death_gui
dance.pdf [Accessed: 17th November 2015].


40. THANK YOU