DEATH AND DYINGDefinition of Terms Bereavement period during which mourning for a loss takes place Brain death irreversible loss of all brain functions, including those of the brainstem Cheyne-Stokes respiration pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing Death cessation of heart function, lung function or of whole brain function or of higher brain function Death rattle noisy, wet-sounding respirations which are caused by mouth breathing and accumulation of mucus in the airways Grief personal feeling that accompany an anticipated or actual loss Mourning individual, family, group, and cultural expression of grief and associated behaviors Spirituality personal belief systems that focus on a search for meaning and purpose in life, intangible elements that impart meaning and vitality to life, and a connectedness to a higher or transcendent dimension

PHYSICAL MANIFESTATIONS AT END OF LIFESYSTEMMANIFESTATIONS

Sensory system Hearing Touch

Taste Usually the last sense to disappear Decreased sensation Decreased perception of pain and touch Decreased with disease progression Blurring of vision Sinking and glazing of eyes Blink reflex absent Eyelids remain half-open

Cardiovascular system Increased heart rate; later slowing and weakening of pulse Irregular rhythm Decreased blood pressure Delayed absorption of drugs administered intramuscularly or subcutaneously

Respiratory system Increased respiratory rate Cheyne-Stokes respiration (pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing) Inability to cough or clear secretions resulting in grunting, gurgling, or noisy congested breathing (death rattle) Irregular breathing, gradually slowing down to terminal gasps (may be described as guppy breathing)

Urinary system Gradual decrease in urine output Incontinence of urine Inability to urinate

Gastrointestinal system Slowing or cessation of GI function (may be enhanced by pain-relieving drugs) Accumulation of gas Distention and nausea Loss of sphincter control, producing incontinence Bowel movement before imminent death or at time of death

Musculoskeletal system Gradual loss of ability to move Sagging of jaw resulting from loss of facial muscle tone Difficulty speaking Swallowing becoming more difficult Difficulty maintaining body posture and alignment Loss of gag reflex Jerking seen in patients on large amounts of opioids

Integumentary system Mottling on hands, feet, arms, and legs Cold, clammy skin Cyanosis of nose, nail beds, knees Waxlike skin when very near death

Changes in body after death:1. Rigor Mortis: body becomes stiff within 4 hours after death as a result of decreased ATP production. ATP keeps muscles soft and supple.2. Algor Mortis: Temperature decreases by a few degrees each hour. The skin loses its elasticity and will tear easily.3. Livor Mortis: Dependant parts of body become discolored. The patient will likely be lying on their back, their backside being the 'dependant' body part. The discoloration is a result of blood pooling, as the hemoglobin breaks down.

PSYCHOSOCIAL MANIFESTATIONS AT END OF LIFE Altered decision making Anxiety about unfinished business Decreased socialization Fear of loneliness Fear of meaninglessness of ones life Fear of pain Helplessness Life review Peacefulness Restlessness Saying goodbyes Unusual communication Vision-like experiences WithdrawalKUBLER-ROSS MODEL OF GRIEFSTAGECHARACTERISTICSNURSING IMPLICATION

DenialDenies the loss has taken place and may withdraw. This response may last minutes to months.Provide a buffer after bad news. Assess the patients and familys coping style, information needs, and understanding of the illness and treatment to establish a bases for empathetic listening.

AngerMay be angry at the person who inflicted the hurt (even after death) or at the world for letting it happen. May be angry with self for letting an event take place, even if nothing could have stopped it.Allow the patient and the family to express anger, treating them with understanding, respect, and knowledge that the root of the anger is grief over impending loss.

BargainingMay make bargains with God, askingIf I do this, will you take away the loss?Nurses should be patient, allow expression of feelings, and support realistic and positive hope.

DepressionFeels numb, although anger and sadness may remain underneath.Nurses should encourage the patient and the family to fully express their sadness.

AcceptanceAnger, sadness, and mourning have tapered off. Accepts the reality of the loss.Family may be rejected by the patient so the nurses need to support the familys expression of emotions and encourage them to continue to be present for the patient.

Sources:Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins.Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2011). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Canada.

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