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Dying and death

HAIVN

Havard Medical School AIDS Initiative in Vietnam

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By the end of this session, participants should be able to:Review the five (5) emotional stages of death and dying Discuss five (5) things that can help ease the dying processDescribe the course of physical death Provide physical care for dying patientsSupport patient’s family members and others to complete 4 specific tasks at the funeral

Learning objectives

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The stages might not occur in exact order• Patients can move back and forth

between stages Patient’s family might experience

similar stages Patient and his/her family members

may be in different stages, which can make interactions difficult

5 stages of dying

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Patients:DON’T believe that they are dyingDON’T want to hear the prognosis about their remaining timeFor Example: • “Not me” • “Not now”

Denial stage

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Patients will be very angry and feel that it’s not fair for them to die before other people

It’s very difficulte to communicate with patients at this stage

For example:• “Why me?” • “I am not ready for this yet”

Anger stage

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Patients will try their best to bargain For example:• “I will be nice, very nice if you let me live

until my son grows up”• “I will never use drugs again if you give

me a chance to fix this”

Bargaining stage

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Sense death is impending Think about everyone and everything

that will happen after:• Loss of control: cannot take care of

themselves• Loss of mental competency: cannot work

much longer• Loss of family and friends

Might isolate themselves and avoid seeing people

Feel hopeless / depressed

Depression stage

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Not all patients go through this stage Patients are sad but accept that their

life will end Sort out assets and clarify remaining

tasks for the person who will accepted fiscal responsibility

Say “goodbye” to their family and close friends

Acceptance stage

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Avoid mentioning death when communicating with patients and their families• Don’t make patient’s family upset

Prepare to answer patient’s questions:• What will happen to my body when I die? • What are some signs of dying? • Will it hurt?

Taking care of dying patients (1)

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Support patients and their families: • Comfort, encourage them to reduce /

alleviate their concerns Patients might be concerned about what will

happen to their families after they die

• Help patients select desired / appropriate setting:

At home or at hospital

Determine who will be at patient’s bedside during dying process

Taking care of dying patients (2)

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Patients often desire to: 1. Apologize for what they have done wrong in their lives 2. Ask for forgiveness from their family & friends3. Forgive other people for what those people have done wrong to patient4. Thank their family and friends5. Say their goodbyes

Resting in peace: 5 things that help patients reconcile and obtain closure

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Nurses need to be aware that it’s not easy for patients to complete the 5 tasks listed previously

Nurses can help them to have a peaceful death by:• Encouraging them to think about life• Helping them communicate with their

family and friends: Directly Via mail / email Via videos

Support from nurses to help patients have a peaceful death

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Death due to illness is a process, in which physical changes will happen over a period of time

Usually, the body will become weaker and weaker and then stop functioning

Process of physical death of patients (1)

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Reduce their food and drink intake• Don’t feel hungry or thirsty much

Become weaker and reduce their physical movement

Might not be able to voluntarily control urination and defecation

Experience changes in resting and sleeping habits • Wake up at midnight and sleep during the

day

Process of physical death of patients (2)

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Pay less attention to surrounding, environment May describe odd feelings / sensations /

visions• Visits from relative(s) who are deceased

May experience alterations in senses:• Reduced vision, sensation in feet• Retained sounds in ears for longer periods

May experience changes in breathing:• Breathing might become more rapid and shallow• Occurrence of cessations during breathing

(apneas) increases

Process of physical death of patients (3)

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More difficult to arouse/ wake patient up• Might need a few seconds

When awakened, patient might not talk

Patients “stare blankly into space” Patients experience visual

hallucinations

Signs that death is near…(1)

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Hands & feet are cold to touch and become pale in color

Eyes and mouth remain ajar Heart rate can be rapid and

peripheral veins are weak Lower jaw drops down Increased frequency of apneas

Signs that death is near…(2)

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Dying cannot be stopped Goal of care during this time is to

help patients and their families feel more comfortable and at ease with process

Treatment process during dying stage is not acute treatment but more palliative in nature

Discuss with family what will occur

Physical care for dying patients (1)

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Do not try to force food or drink on the patient• Losing appetite is common for dying

patients• Keep mouth wet / moist

Evaluate frequency of pain and provide pain medications regularly

Physical care for dying patients (2)

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Continue taking good care:• Keep patients clean and dry• Change bed sheets regularly• Change posture for patients regularly• Oral care• Keep eyes wet

Create personal space for patients and their families

Physical care for dying patients (3)

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Taking care of dying patients and their families is an emotional challenge:• Nurses can feel loss and sadness when

patients die Expressing feelings is important,

therefore it is necessary to provide:• Support for nurses and have group

discussion(s)• Personal counseling

When taking care of dying patients…

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Completion of 4 missions of the farewell is a part of caring

These missions:• Need to happen in order• Can be applied for any loss or grief

Four missions of the “farewell” (1)

Four missions of the “farewell” (2)

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Taking good care of dying patients physically and mentally is very helpful for patients and their families

Nurses, when taking care of dying patients and suffering from loss, need to have emotional support

Providers can assist patients’ families to complete 4 missions of the farewell

Key points

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Thank you!

Questions?