When death is imminent

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Introduction

Death is defined as the final stage of life. Develop a realistic attitude toward the topic of death to meet the physical and psychological and spiritual needs of the sister, the family and the community, as they experience the dying process.

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Death trajectories. Lunney JR, et al. Profiles of older Medicare decedents. J Am Geriatr

Soc 2002;50:1108-1112.

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Murray, S. A et al. BMJ 2008;336:958-959

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Murray, S. A et al. BMJ 2008;336:958-959

SYMPTOM PATIENTS (%) SYMPTOM PATIENTS (%)

Pain 84 Edema 28

Easy fatigue 69 Taste change 28

Weakness 66 Hoarseness 24

Anorexia 66 Anxiety 24

Lack of energy 61 Vomiting 23

Dry mouth 57 Confusion 21

Constipation 52 Dizziness 19

Early satiety 51 Dyspepsia 19

Dyspnea 50 Dysphagia 18

Weight loss 50 Belching 18

Sleep problems 49 Bloating 18

Depression 41 Wheezing 13

Cough 38 Memory problems 12

Nausea 36 Headache 11

Most Common Symptoms of Patients with Advanced Cancer

Walsh D, Donnelly S, Rybicki L. Support Care Cancer 2000;8:175-179.

SYMPTOM HOSPICE NURSES SELECTING THE SYMPTOM (%)

Agitation 45

Pain 40

Shortness of breath

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Confusion 33

Pressure ulcers 27

Nausea 26

Fatigue 25

Constipation 24

Depression 22

Anxiety 21

From Johnson DC, Kassner CT, Houser J, Kutner JS. Barriers to effective symptom management in hospice. J Pain Symptom Manage 2005;29:69-79.

Symptoms difficult to manage

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1. Personal experiences 2. Culture Some fear death Others look forward to and accept death 

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3. Faith Belief in life after death Reunion with loved ones Punishment for sins 

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4. Age

-Adults may develop fears of: pain and suffering, dying alone, separation from loved ones

-Elderly generally have fewer fears

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1. Visits of family members/batch mates, certain sisters

2. Features of resident’s room:pleasant as possiblelighting that meets resident’s preferences

well ventilatedodor free

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Room contains personal items which provide comfort and reassurancePicturesMementosCardsFlowersReligious objects

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1. Attention to skin care2. Hygiene: Good

personal hygiene, Oral hygiene - denture care

3. Bedding changed as needed

4. Back massages

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5. Frequent position changesevery two hoursP.R.N. (= as it is needed)

6. Good body alignmentsupportive devicesprevention of deformities and pressure ulcers

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7. Head of bed elevated to facilitate breathing

8. Modified diet

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Source of strength and comfort

Open and receptiveKnow own feelings about death and do not project those feelings onto the sister.

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EmpatheticCalm and efficient Normal tone of voiceGood listening skillsNon-judgmental

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Accept or be resigned to death

Open and receptiveCommunicate about uncertainties

Fearful or angryDespairing and anxiousHostileThoughtful and meditative

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DENIALDefense mechanismBuffer against realityEmotional escape hatch

Resident may request another opinion

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DENIAL (continued)

Resident may avoid discussion of death

Feeling of, “This can’t be happening to me.”

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ANGERBitterness and turmoilSense of unfairnessBlame of others such as health care workers

Feeling of, “Why me?”

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BARGAININGTurn to religious and spiritual beliefs

Promises to God and others

Comfort and hope when all seems lost

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BARGAINING (continued)Generally know this won’t work

Frustration and anger dissolve into depression

“If only...I will”

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DEPRESSIONBelief that hope is lostOverwhelming despairIntroverted and withdrawnReminiscing and reviewing lifeSleeplessness“I always wanted to”

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ACCEPTANCECalm and subdued interest in lifeStrives to complete unfinished business

Helps loved ones accept deathNeeds others to validate worth of life

“I’ve had a good life.”

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Changes in sensory functions and ability to speakVision

increased secretions in corner of eyes

blurred visionfailing visionno eye movement/staring

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Changes in sensory functions and ability to speak (continued)

Speechbecomes difficulthard to understandmay be unable to speak

Hearing - last function to be lost

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Changes in circulation and muscle toneCirculation

failsheat gradually lost from bodyhands and feet cold to touch and mottled

face becomes pale or gray and mottled

perspiration may increase (diaphoresis)

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Changes in circulation and muscle tone (continued)Muscle tone

body limpjaw may dropmouth may stay partly open

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Changes in Vital SignsRespirations

slowershallowlaboredmay experience dyspnea, apnea, Cheyne-Stokes

mucous collects in the throat and bronchial tubes (death rattle)

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Changes in Vital Signs (continued)

Pulserapidweak and irregular

Blood pressure dropsTemperature

elevatedsubnormal

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Urinary and anal incontinence

Decreased peristalsis, abdominal distention

Release of flatus

Decreased pain

Loss of consciousness

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Calling a priestConfessionLast SacramentWord of God AudioPraying nuns

DHSR Approved Curriculum-Unit 12 41

Support sister’s beloved religious/spiritual practices

Listen respectfully to the beliefsParticipate in religious practices in the place of the sister and share it with her

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Provide religious objects which are dear to the sister:medalspicturesstatuesBibles

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Make them available for support

Use touch as appropriateCourteous and considerate

Respect right to privacyLet family assist with care, if they desire, where appropriate

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Use good communication skills

Listen and provide understanding throughout the grief

Answer questions or refer to the superior

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Health care service offered:in hospitals and extended care facilities

by special facilitiesusually in the sister’s convent

Continuing care provided by team of health professionals

Designed for sisters with terminal illness

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Acceptance of death as imminent (6 months or less)

Assures that individual dies with dignity and comfort

Not concerned with cure or life-saving procedures

Emphasis on pain reliefTrained volunteers and professionals make regular visits.

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Provides counseling for individual and family:EmotionalPsychologicalSpiritual

Family included in all aspects of care as desired

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