2.04 residents nearing_end_of_life

Understanding the Understanding the dying dying processprocess and and needsneeds of the of the resident nearing the end resident nearing the end of life. of life.

Nursing Fundamentals 7243 12.04

Unit A Nurse Aide Workplace FundamentalsEssential Standard NA2.00 Apply communication and interpersonal skills and physical care that promote mental health and meet the social and special needs of residents in long-term care. Indicator 2.04 Understand the Dying Process and Needs of the Resident Nearing the End of Life.

Nursing Fundamentals 7243 2

2.04 Introduction2.04 Introduction

Death is defined as the final stage of Death is defined as the final stage of life. life. The nurse aide will need to The nurse aide will need to develop a realistic attitude toward develop a realistic attitude toward the topic of death to meet the the topic of death to meet the physical and psychological needs of physical and psychological needs of the resident and the family as they the resident and the family as they experience the dying process. experience the dying process. This This indicator also includes care of the indicator also includes care of the body following death.body following death.2.04


The s u n s e t t i n gThe s u n s e t t i n g i s n o l e s s b e a u t i f u l i s n o l e s s b e a u t i f u l th a n th e s u n r i s i n g . th a n th e s u n r i s i n g .

PSYCHOLOGICAL CHANGES OF PSYCHOLOGICAL CHANGES OF THE GRIEVING RESIDENTTHE GRIEVING RESIDENT


Five stages of grieving have been identified by

Elizabeth Kubler-Ross

ELIZABETH KUBLER-ROSS FIVE STAGESELIZABETH KUBLER-ROSS FIVE STAGES


Not all residents go through all the Not all residents go through all the stagesstages

Some residents may stay in one stage Some residents may stay in one stage until death occursuntil death occurs

Residents may move back and forth Residents may move back and forth between grieving stagesbetween grieving stages

Family and friends of the resident will Family and friends of the resident will experience the grief stagesexperience the grief stages



Understanding the Understanding the stages of griefstages of grief helps helps

the Nurse Aidethe Nurse Aide apply apply psychological psychological

support to resident, support to resident, family, and friendsfamily, and friends


Nursing Fundamentals 72437

2.04

DENIALDENIAL

• Defense mechanismDefense mechanism• Buffer against realityBuffer against reality• Emotional escape Emotional escape

hatchhatch• Resident may request Resident may request

another opinion another opinion



DENIAL (continued)

• Resident may Resident may avoid discussion avoid discussion of deathof death

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

Care PointCare Point


Nurse Aides must be Nurse Aides must be ready to listen if the ready to listen if the

resident expresses their resident expresses their feelingsfeelings



ANGER• Bitterness and turmoilBitterness and turmoil

• Sense of unfairnessSense of unfairness

• Blame of others such Blame of others such as health care workersas health care workers

• Feeling of, “Why me?”Feeling of, “Why me?”



Nurse Aide must not take the Nurse Aide must not take the accusations personallyaccusations personally

Do not follow the urge to leave the Do not follow the urge to leave the angry residentangry resident

Listen empathetically Listen empathetically



BARGAINING• Turn to religious Turn to religious

and spiritual and spiritual beliefsbeliefs

• Promises to God Promises to God and othersand others

• Comfort and Comfort and hope when all hope when all seems lostseems lost



BARGAINING (continued)

• Generally know Generally know this won’t workthis won’t work

• Frustration and Frustration and anger dissolve into anger dissolve into depressiondepression

• ““If only...I will”If only...I will”



Listen and reflect what is said, Listen and reflect what is said, express understandingexpress understanding

Be aware of when silence is Be aware of when silence is helpful and words are nothelpful and words are not



DEPRESSION Belief that hope is lostBelief that hope is lost

Overwhelming despairOverwhelming despair

Introverted and withdrawnIntroverted and withdrawn

Reminiscing and reviewing Reminiscing and reviewing lifelife

SleeplessnessSleeplessness

““I always wanted to”I always wanted to”



Your touch, Your touch, if acceptedif accepted, can be , can be very helpfulvery helpful

Understand the resident’s feeling Understand the resident’s feeling of lossof loss

Do not deny death is approachingDo not deny death is approaching



ACCEPTANCE• Calm and subdued interest Calm and subdued interest

in lifein life

• Strives to complete Strives to complete unfinished businessunfinished business

• Helps loved ones accept Helps loved ones accept deathdeath

• Needs others to validate Needs others to validate worth of lifeworth of life

• ““I’ve had a good life.”I’ve had a good life.”


Nursing Fundamentals 724318

2.04

Your presence lets them know Your presence lets them know you will not desert themyou will not desert them

Listen if they wish to discuss Listen if they wish to discuss their deaththeir death

BRAIN STORMThinkThink

Recall the conversation of a friend Recall the conversation of a friend who had a family member to die. who had a family member to die. Did you hear any of Kubler-Ross Did you hear any of Kubler-Ross stages of death (grieving)? stages of death (grieving)?

ActActRaise your hand and share your Raise your hand and share your thoughts.thoughts.

Unit A / Essential Standard NA2.00 / Indicator 2.01 / Letter B


Kubler-Ross – Five stages of griefKubler-Ross – Five stages of grief

Have we got it?Have we got it?Let’s check and seeLet’s check and see

20

Stick diagnostics

Student Name A

Student Name B

Nursing Fundamentals 72432.04

FACTORS INFLUENCING RESIDENTS/FAMILY FACTORS INFLUENCING RESIDENTS/FAMILY ATTITUDES TOWARD DEATHATTITUDES TOWARD DEATH


Personal experiencesPersonal experiences Culture; some fear Culture; some fear

death others look death others look forward to and accept forward to and accept death death



Religion Belief in life after death Belief in life after death Reunion with loved ones Reunion with loved ones ReincarnationReincarnation Punishment for sins Punishment for sins No afterlife No afterlife



Age: ChildrenChildren view death at view death at temporarytemporaryAdultsAdults may develop fears of may develop fears of pain and suffering, dying alone, pain and suffering, dying alone, separation from loved onesseparation from loved onesElderlyElderly generally have fewer generally have fewer fearsfears

Individual resident’s reaction to death


Accept or be resigned to deathAccept or be resigned to death

Open and receptiveOpen and receptive

Communicate about uncertaintiesCommunicate about uncertainties

Fearful or angryFearful or angry

Despairing or anxiousDespairing or anxious

HostileHostile

Thoughtful and meditativeThoughtful and meditative

COMMONCOMMON PHYSICAL SIGNSPHYSICAL SIGNS OFOF IMPENDING DEATHIMPENDING DEATH


Changes in SENSORY FUNCTIONSENSORY FUNCTION and the ability to speak

VISION Blurred and failing vision

Increased secretions in corner of eye

No eye movement / staring / unfocused eye


Reduce glareReduce glare and keep keep room lightening lowroom lightening low

COMMON COMMON PHYSICAL SIGNSPHYSICAL SIGNS OF OF IMPENDING DEATHIMPENDING DEATH



SPEECHSPEECH becomes difficultbecomes difficult hard to understandhard to understand may be unable to speakmay be unable to speak


Do not expect an answerDo not expect an answer

Observe body language of Observe body language of the residentthe resident

Anticipate needsAnticipate needs


HEARINGHEARING

last sensory last sensory function to be lost…function to be lost…




Be careful Be careful what you what you

say!say!


TOUCHTOUCH

SENSE OF TOUCH IS SENSE OF TOUCH IS

DEMINISHEDDEMINISHED




Resident can no longer Resident can no longer turn themselves, turn themselves,

SKIN CARE IS SKIN CARE IS PARAMOUNTPARAMOUNT



Changes in CIRCULATION AND MUSCLE TONECIRCULATION AND MUSCLE TONE and the ability to speak

LOSS OF MOVEMENT, LOSS OF MOVEMENT, MUSCLE TONE, AND FEELINGMUSCLE TONE, AND FEELING

Body is limpBody is limp Jaw may dropJaw may drop Mouth may stay partly Mouth may stay partly

openopen




CIRCULATION FAILSCIRCULATION FAILS Heat is lost from the body’Heat is lost from the body’ Mottling (bruised Mottling (bruised

appearance), spotting, or appearance), spotting, or blotching of skin caused by blotching of skin caused by poor circulationpoor circulation




CIRCULATION FAILSCIRCULATION FAILS Hands and feet cold to Hands and feet cold to

touchtouch Face becomes pale or gray Face becomes pale or gray

and mottledand mottled Perspiration may increase Perspiration may increase

(DIAPHORESIS)(DIAPHORESIS)



Changes in VITAL SIGNSVITAL SIGNS

BLOOD PRESSURE BLOOD PRESSURE DECREASESDECREASES




PULSE:PULSE:Abnormally slow, Abnormally slow, rapid, or irregularrapid, or irregular




TEMPERATURE:TEMPERATURE:Rising or below-Rising or below-normalnormal




RESPIRATIONS:RESPIRATIONS:Slow, irregular Slow, irregular alternating with alternating with

rapid, shallowrapid, shallowakaaka Cheyne-StokesCheyne-Stokes




RESPIRATIONS:RESPIRATIONS:““fish out of water fish out of water

breathing” breathing” akaaka

Agonal BreathingAgonal Breathing




RESPIRATIONS:RESPIRATIONS:Rattling or gurgling Rattling or gurgling sound referred to as sound referred to as

Death RattleDeath Rattle


Elevate HOB Elevate HOB to facilitate to facilitate breathingbreathing


Why do you think the vital Why do you think the vital signs change as they do when signs change as they do when a resident is dying?a resident is dying?

ActActRaise your hand and share Raise your hand and share your thoughts.your thoughts.

Unit A / Essential Standard NA2.00 / Indicator 2.01 / Letter B




Changes in BOWEL AND BLADDER ELIMINATIONBOWEL AND BLADDER ELIMINATION

URINARYURINARY ANDAND ANALANAL

INCONTINENCEINCONTINENCE



Changes in BOWEL AND BLADDER ELIMINATIONBOWEL AND BLADDER ELIMINATION

DECREASED DECREASED PERISTALSISPERISTALSISABDOMINAL ABDOMINAL DISTENTIONDISTENTIONRELEASE OF RELEASE OF FLATUSFLATUS


Why do you think the changes Why do you think the changes in bowel and bladder in bowel and bladder elimination occur?elimination occur?

ActActRaise your hand and share Raise your hand and share your thoughts.your thoughts.




DECREASED PAIN



DECREASED DECREASED INTAKE INTAKE OF FOOD OF FOOD AND FLUID AND FLUID


• Modify diet.Modify diet.• Do not force feed.Do not force feed.• Fluids most Fluids most

important.important.



Disorientation and

Disorientation and

confusion, loss of

confusion, loss of

consciousness

consciousness

Physical Signs of impending DeathPhysical Signs of impending Death

Have we got it?Have we got it?Let’s check and seeLet’s check and see

51

Stick diagnosticsStick diagnostics

Student Name A

Student Name B


NURSE AIDE CARE NURSE AIDE CARE FOR THE DYING RESIDENTFOR THE DYING RESIDENT


Observe Observe ““Care Care PointsPoints”” in previous in previous slides related to slides related to sensory function sensory function



Care of Care of NoseNose and and MouthMouth::

Give mouth care often; if resident Give mouth care often; if resident unconscious, every two hoursunconscious, every two hours

Apply lubricant such as a lip balm, to lips Apply lubricant such as a lip balm, to lips and noseand nose

Olive oil is a good lubricant for lipsOlive oil is a good lubricant for lips



Care of SKIN:Give bed baths and incontinence care as needed

Bathe perspiring patients often

Keep skin clean and dry

Change sheets and clothes for comfort

Keep sheet wrinkle free



Care of Care of SKINSKIN::Reposition resident often, Reposition resident often, use supportive devices as use supportive devices as neededneeded

At least every 2 hours or At least every 2 hours or prnprn



Promote Promote COMFORTCOMFORT::Observe for signs of pain and report Observe for signs of pain and report them!them!

Frequent changes of position, back Frequent changes of position, back massage, and body alignmentmassage, and body alignment

Elevate head of bed (HOB) to facilitate Elevate head of bed (HOB) to facilitate breathingbreathing



Control Control ENVIRONMENTENVIRONMENT::Place resident’s favorite objects and Place resident’s favorite objects and photographs where resident can see themphotographs where resident can see them

Provide appropriately lit and well-ventilated Provide appropriately lit and well-ventilated room without odorroom without odor

Place call bell in reach, even if resident Place call bell in reach, even if resident unresponsiveunresponsive


Control Environment

Features of resident’s room:Features of resident’s room:–Contains personal items which Contains personal items which

provide comfort and provide comfort and reassurancereassurance• PicturesPictures• MementosMementos• CardsCards• FlowersFlowers• Religious objectsReligious objects

2.04


Nurse Aide Role - RespectNurse Aide Role - Respect

• Treat religious objects Treat religious objects with care and respect:with care and respect:–medalsmedals–picturespictures–statuesstatues–BiblesBibles

• Encourage family and Encourage family and friends to be includedfriends to be included

2.04


Nurse Aide’s Role - SupportNurse Aide’s Role - Support

• Source of strength and Source of strength and comfortcomfort

• Open and receptiveOpen and receptive• Know own feelings Know own feelings

about death and do not about death and do not project those feelings project those feelings onto resident.onto resident.

2.04


Nurse Aide’s Role - SupportNurse Aide’s Role - Support

• EmpatheticEmpathetic• Calm and efficient Calm and efficient • Normal tone of voiceNormal tone of voice• Good listening skillsGood listening skills• Non-judgmentalNon-judgmental

2.04


Nurse Aide Role Support to Family & Friends

• Offer comfort measures such as Offer comfort measures such as drinks, food, chairs, blankets etc. drinks, food, chairs, blankets etc. within facility policy.within facility policy.

• Use good communication skillsUse good communication skills

• Listen and provide understanding Listen and provide understanding throughout the grief/loss stagesthroughout the grief/loss stages

• Answer questions or refer to Answer questions or refer to supervisorsupervisor

2.04


Nurse Aide Role Support to Family & Friends

• Available for supportAvailable for support

• Use touch as appropriateUse touch as appropriate

• Courteous and Courteous and considerateconsiderate

• Respect right to privacyRespect right to privacy

• Let family assist with care, Let family assist with care, if they desire, where if they desire, where appropriateappropriate

2.04


Nurse Aide Role – Spiritual Support

• Priest, rabbi, minister or Priest, rabbi, minister or other clergy may be other clergy may be contacted at request of contacted at request of resident or familyresident or family

• Privacy to be provided Privacy to be provided when clergy with when clergy with residentresident

2.04


Nurse Aide Role – Spiritual Support

• Support resident’s Support resident’s religious/spiritual practices even if religious/spiritual practices even if different from that of nurse aidedifferent from that of nurse aide

• Listen respectfully to Listen respectfully to religious/spiritual beliefs religious/spiritual beliefs

• Participate in religious practices if Participate in religious practices if asked and acceptableasked and acceptable

2.04


Hospice CareHospice Care

• Hospice Care offered:Hospice Care offered:– in hospitals and extended care in hospitals and extended care

facilitiesfacilities–by special facilitiesby special facilities–usually in the individual’s homeusually in the individual’s home

• Continuing care provided by team Continuing care provided by team of health professionalsof health professionals

• Designed for residents with Designed for residents with terminal illnessterminal illness

2.04



• Acceptance of death as imminent (6 months or Acceptance of death as imminent (6 months or less)less)

• Assures that individual dies with dignity and Assures that individual dies with dignity and comfortcomfort

• Not concerned with cure or life-saving Not concerned with cure or life-saving proceduresprocedures

• Emphasis on pain reliefEmphasis on pain relief

• Trained volunteers and professionals make Trained volunteers and professionals make regular visits.regular visits.

2.04



• Provides counseling for individual and Provides counseling for individual and family:family:– EmotionalEmotional– PsychologicalPsychological– SpiritualSpiritual– FinancialFinancial– Bereavement Bereavement

• Family included in all aspects of care as Family included in all aspects of care as desireddesired

2.04


Reasons for Postmortem Care Reasons for Postmortem Care

• Prevent discoloration and skin Prevent discoloration and skin damagedamage

• Maintain good appearance of bodyMaintain good appearance of body

• Identify body and prepare for Identify body and prepare for transportationtransportation

• Position body in normal alignmentPosition body in normal alignment

• Arrange time family to view the bodyArrange time family to view the body

2.04


Postmortem Care – Genenral GuidelinesPostmortem Care – Genenral Guidelines

• Begin care when instructed by Begin care when instructed by supervisorsupervisor

• Treat body to privacy, respect Treat body to privacy, respect and gentlenessand gentleness

• Give care before rigor mortis Give care before rigor mortis sets insets in

2.04

2.04 Nursing Fundamentals 7243 73

SKILLSKILL 2.042.04Postmortem CarePostmortem Care

Training Lab AssignmentTraining Lab AssignmentEngage in the Skill Engage in the Skill EXPLORATIONEXPLORATION Process for: Process for:

Understanding the dying process and Understanding the dying process and needs of the resident near the end of needs of the resident near the end of life. life.

74

ENDEND 2.042.04

2.04 Nursing Fundamentals 7243

2.04 residents nearing_end_of_life

Education