Death & Dying
Assistant Professor Cindy Gross
Professor Margaret Huang- Saddleback College Thanatology
The study of death and dying Death
A universal experience A most difficult and painful realty to
accept The United Nations definition: Death is the permanent disappearance of
every vital sign Causes of Death and
Demographic/Social Trends
Medicine’s focus
Cause of death Early 1900’s
Comfort
Infectious, communicable
diseases Current
Cure
Chronic illnesses Age adjusted death rate 1720/100,000 (1900) 865/100,000 (1997) Average life expectancy 50 76 Number of persons > 65
years old
Site of death
Caregiver 3.1 million 35 million estimate for 2000 Home
Family Institutions
Strangers/ healthcare
providers Disease/ dying trajectory Relatively short prolonged Site of Death Hospital Nursing Home 17% Residences Other 57%
20%
6%
(CME Resources May 2002, vol. 89, No.3) Facts of Death in Elderly 73% of death in a given year are in the elderly 70% want to die at home, surrounded by love
ones and fe free of pain Reality- “most die alone and suffering in pain and
getting the treatment they don’t want”
( Dr Barry Baines, NCOA and ASA National Conference 2003) Changes in Death/Dying 2015 transitioning to end
of life care, death with dignity, palliative care. Facts of Death in Elderly Most people have minimal direct involvement
with dying individuals As direct experiences lessened Death becomes more impersonal and unusual event Resulting in difficulty to internalize and to
accept one’s own mortality (Charlotte Eliopoulos, Gerontologial Nursing, 5th edition, 2001)
) Personal Inventory An examination of one’s own feelings and
attitudes about death can be therapeutic
to the caregiver personally, as well as
helpful in the care of dying person When I think about death….
I face my own mortality
I face my own values/beliefs
I face my own fears/feelings Person’s Reactions to Dying Depends
on Previous experiences Age Health status Culture Religious and spiritual beliefs Philosophy of life Five Stages of Responses to Death
and Dying (Kubler-Ross, 1969) Denial Anger Bargaining Depression Acceptance General Principles Persons may not necessarily move
through the stages in order Not every person will experience all of
these stages. Hope permeates all stages of the dying
process. Hope is a Key in Coping It involves faith and trust, which may or
may not have a religious basis It may be related to a cure, the birth of
a grandchild, a graduation, or
reconciliation It will identify what the meaning of life
is to the individual.
(Ebersole & Hess, Geriatric Nursing & healthey Aging, 1st ed., 2001) General Principles All stages are adaptive…they are a way to
cope There is no specific time limit One may create a “safe place”… but are
powerless to move a person through the
loss/grieving process Family members/friends rarely use similar
coping mechanisms at the same time Denial Aware f impending death, react by denying the reality: “It is not true” “There Serves must be some mistake” as a shock absorber It allows for testing the information, to internalize the
information and to mobilize defenses Interventions To accept the individual’s reactions To provide an open door for communication Anger The person displaces the anger “Why me?” “What did I do to deserve this?” Expresses feeling that nothing is right “Food tastes awful” “Doctors and nurses do not know what they are doing.” Unfulfilled desires and unfinished business may cause outrage
Interventions To accept the individual’s reactions To let the person vent feelings To anticipate the person’s needs To guard against responding to the anger personnallly Bargaining An attempt to negotiate for a postponement of the
inevitable
Most bargains are made with God and usually kept a secret “I will do anything if….” Agree to be a better Christian if God lets me live Interventions To accept the individual’s reaction Listen, listen, listen To let the person vent and explore feelings Depression Occurs with realization that death is inevitable “yes…me.” An interest in prayer and a desire for visits from clergy are common This stage is necessary to approach the final stage of acceptance
Intervention To accept that depression is necessary to reach the final stage To respect the person’s silence To understand that cheerful words may be far less meaningful than
holding their hand or sit silently To help the person with religious needs, contact clergy when needed Acceptance Person has come to terms with death and has found a
sense of peace
Person says and does all the unfinished business of
life
The person may benefit more from nonverbal than
verbal communication
Intervention
Person is content with 1 or 2 close friends/family
To assist the family in learning to understand and
support the person Common Fears
Being alone
Loss of independence
Unrealized dreams/goals
Spiritual questions
Pain Physical Care Needs: Pain It is the 5th vital sign
It must be regularly reassed because it can increase or
decrease with time
Patients should be encouraged to report pain in a timely
manner
Use the pain scale of 0 to 10 ( 0 is no pain and 10 the most
severe pain)
Goals of pain management is to prevent pain from
developing rather than treating it once it occurs. Develop an analgesic schedule
“Narcotic addiction of a dying patient is not the issue: relief
of pain is paramount” (Ebersole & Hess, Geriatric Nursing & Healthy Aging, 1 ed., 2001)
st Alternative Interventions to Pain
Control Guided imagery Hypnosis Relaxation exercises Massage Acupressure Acupuncture Therapeutic touch Diversion Heat or cold application Pain Response Cultural background
Medical diagnosis
Psychological state
Social state Psychological Pain Pain induced by depression, anxiety, fear, and other unresolved
emotional concerns Unmet emotional needs can intensify the total pain experience Medication alone cannot give relief Allow the person to express feelings
“Patients over the age of 70 were at increased risk of under
treatment of pain because of the health professional’s fears of
causing addiction, hastening death, and incurring legal liability.”
(Ebersole & Hess, Geriatric Nurisng & Healthy Aging, 1st ed., 2001) Pain Response Respiratory Distress
Elevate the head of the bed
Administer oxygen
Narcotics may be used for heir ability to control respiratory
symptoms by blunting the medullary response.
(Charlotte Eliopouls, Gerontological Nursing, 5th ed., 2001) Constipation Causes of constipation Reduced food & fluid intake,
Inactivity
Side effects of medication Take intervention to promote regular elimination
Fecal impaction can appear as diarrhea Pain Response Nutrition
Causes of poor appetite Anorexia Nausea, vomiting Fatigue weakness Assist with oral hygiene
Stimulate appetite with appealing & favorite meals
Use antiemetics Psychological Care Needs
An individual is living until he or she has died No one wants to die alone The dying older adult is a living person with all
the same needs for good relationships Dying is a multifaceted active process which
involves the dying person, the family and the
professional caregivers Individuals need to be in control Human contact is vital Family members need to remain involved with the
patient Spiritual Care Needs America has a diversity of religious beliefs
Each religion has its own practices related to death
We need to respect these practices to meet the individual’s
spiritual needs
Assess individual’s religious affiliation and practices
Religion and spirituality are no synonymous
Spirituality
It is two-dimensional Between the person and God
Between the person and others It may be met through religious acts and/or through human
caring relationships
A person’s internal beliefs, personal experiences, and religion
ae expressions of spirituality Hospice It is a philosophy of care that is offered through a rande of
organizational settings-hospital, nursing home, home health
agencies, primarily in the home It provides physical, medical, emotional, and spiritual care to
patients and his or her support system Its focus is palliative care It is dedicated to help people who are beyond cure to remain in
a familiar surrounding where pain (physical, psychological,
social, and spiritual) is reduced and personal dignity and
control over the dying process maintained First Hospice is America was developed in Connecticut in 1974 Now over 4,100 exist Hospice Majority provide in-home services for cancer, HIV/AIDS,
chronic terminal patients with a prognosis of 6 months or
less Only 17% of dying American of all ages participate in
Hospice
(Cloud, 2000) “The population over 75 years of age is generally
underserved by hospice compared to other age groups
with terminal illnesses.
(Hooyman & Kiyak, Social Gerontology, 7 ed., 2005)
th Hospice Team Patient’s attending physician Medical director RN case manager Social worker Home health aide Spiritual counselor/chaplain Volunteer Other Services Included Medications related to the Hospice diagnosis Durable medical equipment Nutritional consultation 24-hour availability Other therapies as warranted Bereavement services Palliative Care “ … a comprehensive, interdisciplinary care, focusing
primarily on promoting quality of life for patients living
with a (serious, chronic, or) terminal illness and for their
families…assuring physical comfort (and) psychosocial
support.
Billings, J Pall Med, 1999;1:73-81. The World Health Organization defines Palliative care as: “ The active total care of patient s whose disease is not
responsive to curative treatment, control of pain, other
symptoms, and psychological, social and spiritual
problems is paramount. The goal of palliative care is
achievement of the best quality of life for patients and
their families” (World Health Organization, 1990). Palliative Care Team Focus is the patient in control of making decisions U.S. Supreme Court ruled in 1997 that Americans have a right to
palliative care
The Palliative Care Team Geriatricians Nurse practitioners Nurses Licensed clinical social workers Spiritual leaders Dietician Activates coordinators Primary physician Loss Loss, Dying and Death are Universal Cannot be stopped or controlled (Ebersole & Hess, Geriatric Nursing & Healthy Aging, 1 Losses of the Aged Loss of Relationships st ed., 2001) Significant others Social contacts through illness, death, distance, decreased mobility Life transitions Significant roles, financial security Independence Physical health Mental stability Life-death (Ebersole & Hess, Geriatric Nursing & Healthy Aging, 1st ed., 2001) Loss With increase in life expectancy, more older adults are
seeing their adult children go before them, which is a
heartbreaking loss “losing a spouse is like losing an arm, losing a child is like
losing your heart.” Older adults have gone through series of losses. They develop resiliency (tough) and coping skills from pain
and loss experiences. Social connection and spirituality increase survival
(Living with Grief, Loss Later in Life”, video Hospice Foundation, 2002) Loss: Bereavement and Grief Bereavement, Grief, mourning are manifested with physical,
psychological, and behavioral responses.
Bereavement refers to both the situation and the long-term process of
adjusting to the death of someone close
Grief process is the complex emotional response to bereavement can
include: Shock and disbelief
Guilt
Anxiety
Depression
Anorexia and insomnia Mourning signifies culturally patterned expectations about the
expression of grief. Loss: Bereavement and Grief Current concepts about grief recognize
that it is not rigidly structured and is
without a predictable pattern of responses.
Some responses to grief occur internally
and are not visible, whereas other aspects
of grief may not occur at all.”
“ (Ebersole & Hess, Geriatric Nursing & Healthy Aging, 1st ed., 2001) Tasks of Grieving Accepting the reality of the loss
Working through the pain (physical, emotional, behavioral) the
intensity will vary with the individual
Adjusting to a change in environment
Emotionally relocating the deceased and moving on with life
To rebuild fait and philosophical systems
Working through pain is an individual process and needs a
support network
Accepting the reality can be measured by the use of present or
past references to the dead
Adjusting to a changed environment takes time, especially if
the relationship is close
The emotional relocation ( a letting go) may produce anxiety
(Ebersole & Hess, Geriatric Nursing & Healthy Aging, 1st ed., 2001) Interventions for Grieving Listen, listen, listen-Active listening allows the griever to
express feelings and to feel supported Reminiscing allows working through the loss Allow the griever to remain in control which is crucial to
recovery Sometimes the most helpful response is simply “to be there”. Listen carefully to the silences Identify concrete tasks by which to help, such as cooking meals,
child care, and house cleaning, so the breaved has time and
space to grieve “Healthcare providers now recognize the importance of grief
work and counseling, and view grieving as a natural healing
process. Assistance in grief resolution, perhaps through life
review and new risk-taking, is especially important for older
adults”. (Hooyman & Kiyak, Social Gerontology, 7 ed., 2005)
th Current Issues Decision making regarding life-prolonging procedures when
death is inevitable have become legal, ethical, medical, and
professional issues, resulting from the technological
advances.
(Ebersole & Hess, Geriatric Nursing & Healthy Aging, 1 ed., 2001)
st Legal aspects of end of life care Patient Self-determination act is a federal law, requires that
healthcare facilities (hospitals, skilled nursing facilities,
hospice, home health care agencies, and HMOs) that receive
medicare and Medicaid funsd o inform patient sin writing of
their rights to execute advanced directives regarding how they
want to live or die.
(Hooyman & Kiyak, Social Gerontology, 7 ed., 2005)
th Advance Directives Only 9% under age 30 have Only 35% over age 75 have Types Durable power of attorney Durable power of attorney for health care Living will Healthcare professional’s responsibilities Serve as a resource person for people to learn about it and
make one
Must be sure of proper disposition when completed
When a new client enters a facility with an advanced directive,
make sure it is current and reflective of person’s choices
All residents should be given the opportunity to execute one
Be aware of the types of directives that are legally recognized
in the state
Be aware of the forms used by the employed institution
Recognize the barriers to completion of the directives, i.e.
memory, language difficulty, fear of being untreated
Elders in long-term care facilities usually ned tow witnesses,
one being the ombudsman from Department of Aging Suicide As longevity increases and risk of long term degenerative
illnesses, a growing number of people consider a mature adult’s
choice of suicide a rational decision
Incidence 1998-29,000 people
Most prevalent among older men
Highest rate is among white men, over age 85 Causes Depression, Alcohol, Abuse, Social isolation
Sense of hope or purpose is life enhancing i.e. love, work
9 of 10 people who kill themselves have depression or another
mental or substance use disorder (NIMH, 1999a)
Older adults who attempt are more likely to complete it with the
use of more lethal methods Euthanasia Active euthanasia (sometimes called mercy killing) Intervention taken deliberately to shorten a life in order to
end suffering or allow a terminally ill person to die with
dignity It is illegal Passive euthanasia Is deliberately withholding or discontinuing treatment that
might extend the life of a terminally ill patient, such as
medication, life support systems or feeding tube

Attachments:

• 1505130485-Death and Dying.pdf