THE DYING PATIENT AND THE DYING PATIENT AND LAST OFFICESLAST OFFICES

SHARON HARVEYSHARON HARVEY

9/6/059/6/05

LEARNING OUTCOMESLEARNING OUTCOMESthe student will be able to:-the student will be able to:-

Reflect on experiences of breaking bad Reflect on experiences of breaking bad news to patients and their relativesnews to patients and their relatives

Discuss factors that constitute a good deathDiscuss factors that constitute a good death Explore the signs of death in a patientExplore the signs of death in a patient Discuss the nurses’ role with regard to Discuss the nurses’ role with regard to

bereavementbereavement Identify the measures required in caring for Identify the measures required in caring for

a body after deatha body after death Discuss last rites and offices for patients of Discuss last rites and offices for patients of

different cultures and faithsdifferent cultures and faiths

THE CHANGING CUSTOMS OF THE CHANGING CUSTOMS OF DEATHDEATH

One hundred years ago, childhood death One hundred years ago, childhood death was common and the family units were was common and the family units were larger which meant that most young larger which meant that most young people had experienced the death of people had experienced the death of someone close to themsomeone close to them

Death was familiar and normalDeath was familiar and normal Last century the pattern of dying changed.Last century the pattern of dying changed. Most deaths are of older people in the Most deaths are of older people in the

hospital environment.hospital environment. Many dying patients require some form of Many dying patients require some form of

palliative care.palliative care.

PALLIATIVE CARE: WHAT IS IT?PALLIATIVE CARE: WHAT IS IT?

The World Health Organization (WHO) The World Health Organization (WHO) defines palliative care as "the active defines palliative care as "the active total care of patients whose disease is total care of patients whose disease is not responsive to curative treatment." not responsive to curative treatment." Palliative care seeks to improve Palliative care seeks to improve patients’ quality of life by relieving patients’ quality of life by relieving physical, emotional, and spiritual pain physical, emotional, and spiritual pain for patients and their caregivers.for patients and their caregivers.

HOW DO YOU KNOW IF A HOW DO YOU KNOW IF A PATIENT IS DYING?PATIENT IS DYING?

IT IS NOT NECESSARILY EASY TO DIAGNOSE DYING, BUT IT IS NOT NECESSARILY EASY TO DIAGNOSE DYING, BUT THERE ARE COMMON SIGNS THAT INDICATE THE PATIENT IS THERE ARE COMMON SIGNS THAT INDICATE THE PATIENT IS DETERIORATINGDETERIORATING

SYMPTOMS INCLUDE:SYMPTOMS INCLUDE: SEVERE WEAKNESSSEVERE WEAKNESS DECREASED ORAL INTAKEDECREASED ORAL INTAKE DIFFICULTY TAKING MEDICATIONDIFFICULTY TAKING MEDICATION DROWSINESSDROWSINESS SKIN MAY BE MOTTLED OR BLUESKIN MAY BE MOTTLED OR BLUE PATIENT MAY HAVE A GAUNT APPEARANCEPATIENT MAY HAVE A GAUNT APPEARANCE HANDS AND FEET MAY BE COLD TO TOUCHHANDS AND FEET MAY BE COLD TO TOUCH PATIENT MAY APPEAR DISORIENTATED AND MAY NOT BE PATIENT MAY APPEAR DISORIENTATED AND MAY NOT BE

ABLE TO CONCENTRATEABLE TO CONCENTRATE

FACTORS THAT MIGHT FACTORS THAT MIGHT CONSTITUTE A GOOD DEATHCONSTITUTE A GOOD DEATH

ACCEPTANCE OF IMPENDING DEATHACCEPTANCE OF IMPENDING DEATH EMOTIONAL SUPPORT FOR THE DYING EMOTIONAL SUPPORT FOR THE DYING

PATIENT AND SIGNIFICANT OTHERSPATIENT AND SIGNIFICANT OTHERS MINIMISING SUFFERING BY MANAGING MINIMISING SUFFERING BY MANAGING

SYMPTOMSSYMPTOMS NOT LEAVING THE DYING PATIENT NOT LEAVING THE DYING PATIENT

ISOLATED, ENABLING COMPLETION OF ISOLATED, ENABLING COMPLETION OF “UNFINISHED BUSINESS”“UNFINISHED BUSINESS”

COMMUNICATING WITH DYING COMMUNICATING WITH DYING PATIENTS AND THEIR FAMILYPATIENTS AND THEIR FAMILY

Traditionally telling the patient and Traditionally telling the patient and their family bad news has been the their family bad news has been the role of the doctor, however nursing role of the doctor, however nursing staff are now more involved in this staff are now more involved in this process.process.

Communication is more than just Communication is more than just verbal interaction but also involves verbal interaction but also involves non verbal communication.non verbal communication.

COMMUNICATING WITH DYING COMMUNICATING WITH DYING PATIENTS AND THEIR FAMILYPATIENTS AND THEIR FAMILY

Some nurses apply “blocking” tactics Some nurses apply “blocking” tactics when a patient begins to discuss when a patient begins to discuss sensitive topics.sensitive topics.

Nurses worry about not knowing Nurses worry about not knowing what to say or saying the wrong what to say or saying the wrong thing.thing.

All of which creates barriers to All of which creates barriers to communication.communication.

WHAT QUALITIES DOES THE NURSE WHAT QUALITIES DOES THE NURSE NEED TO HAVE IN ORDER TO DEAL NEED TO HAVE IN ORDER TO DEAL WITH PATIENT’S AND THEIR FAMILY WITH PATIENT’S AND THEIR FAMILY

WHO HAVE RECEIVED BAD NEWS.WHO HAVE RECEIVED BAD NEWS. SSensitiveensitive UUnderstandingnderstanding PPositiveositive PPracticalractical OOpenpen RRespectfulespectful TTruthfulruthful IIn a position to offer skilled approach to communicationn a position to offer skilled approach to communication VValuingaluing EEmpatheticmpathetic

BREAKING BAD NEWSBREAKING BAD NEWS

PREPARE YOURSELFPREPARE YOURSELF WHAT DOES THE PATIENT/FAMILY KNOW?WHAT DOES THE PATIENT/FAMILY KNOW? IS MORE INFORMATION WANTED?IS MORE INFORMATION WANTED? GIVE WARNING SHOT, FOR EXAMPLE “I AM AFRAID ITS GIVE WARNING SHOT, FOR EXAMPLE “I AM AFRAID ITS

RATHER SERIOUS” ALLOW A PAUSE FOR PATIENT RATHER SERIOUS” ALLOW A PAUSE FOR PATIENT RESPONSERESPONSE

ALLOW DENIALALLOW DENIAL EXPLAIN – IF REQUESTEDEXPLAIN – IF REQUESTED LISTEN TO CONCERNSLISTEN TO CONCERNS ENCOURAGE EXPRESSION OF FEELINGSENCOURAGE EXPRESSION OF FEELINGS SUMMARY AND PLANSUMMARY AND PLAN OFFER AVAILABILITY (YOURSELF, RELIGIOUS LEADERS, OFFER AVAILABILITY (YOURSELF, RELIGIOUS LEADERS,

BEREAVEMENT COUNSELLORS)BEREAVEMENT COUNSELLORS)

DIAGNOSIS OF DEATHDIAGNOSIS OF DEATH

ABSENCE OF THE MAJOR PULSES – CAROTID ABSENCE OF THE MAJOR PULSES – CAROTID AND FEMORALAND FEMORAL

ABSENCE OF HEART AND LUNG SOUNDS ABSENCE OF HEART AND LUNG SOUNDS AFTER AUSCULATION CONTINUALLY FOR 1 AFTER AUSCULATION CONTINUALLY FOR 1 MINUTE AND INTERMITTENTLY FOR 5 MINUTE AND INTERMITTENTLY FOR 5 MINUTESMINUTES

ABSENCE OF RESPIRATORY EFFORTABSENCE OF RESPIRATORY EFFORT FIXED AND DILATED PUPILSFIXED AND DILATED PUPILS ABSENCE OF CORNEAL REFLEXABSENCE OF CORNEAL REFLEX

SHOULD WE LET THE SHOULD WE LET THE BEREAVED RELATIVES SEE BEREAVED RELATIVES SEE THEIR LOVED ONE’S BODY?THEIR LOVED ONE’S BODY?

ALL EVIDENCE SUGGESTS THAT SEEING THE ALL EVIDENCE SUGGESTS THAT SEEING THE BODY OF A DEAD PERSON IS AN IMPORTANT BODY OF A DEAD PERSON IS AN IMPORTANT PART OF THE ADJUSTMENT PROCESS.PART OF THE ADJUSTMENT PROCESS.

IT PROVIDES AN OPPORTUNITY TO SEE AND IT PROVIDES AN OPPORTUNITY TO SEE AND BECOME FAMILIAR WITH THE REALITIES OF BECOME FAMILIAR WITH THE REALITIES OF DEATH.DEATH.

IT IS AN OPPORTUNITY TO SEE AND TOUCH, IT IS AN OPPORTUNITY TO SEE AND TOUCH, FOR THE LAST TENDERNESS, FOR THE LAST FOR THE LAST TENDERNESS, FOR THE LAST GOODBYE; PERHAPS HOLD THE DEARLY GOODBYE; PERHAPS HOLD THE DEARLY LOVED ONE FOR THE LAST TIME….LOVED ONE FOR THE LAST TIME….

(RAPHAEL, 1984)(RAPHAEL, 1984)

PHASES OF BEREAVEMENTPHASES OF BEREAVEMENT

ACCEPTANCE THAT THE PERSON IS ACCEPTANCE THAT THE PERSON IS GOING TO DIEGOING TO DIE

EXPERIENCING GRIEFEXPERIENCING GRIEF ADAPTING TO LIFE WITHOUT A ADAPTING TO LIFE WITHOUT A

LOVED ONELOVED ONE RELOCATING THE DECEASED RELOCATING THE DECEASED

INTERNALLYINTERNALLY

SCENARIO WORKSCENARIO WORK

WORK IN GROUPS OF 4 OR 5WORK IN GROUPS OF 4 OR 5

GUIDELINES FOLLOWING A GUIDELINES FOLLOWING A DEATH IN HOSPITALDEATH IN HOSPITAL

INFORM DOCTOR WHO SHOULD EXAMINE INFORM DOCTOR WHO SHOULD EXAMINE PATIENT AND CERTIFY DEATHPATIENT AND CERTIFY DEATH

INFORM RELATIVES (IF THEY HAVE NOT INFORM RELATIVES (IF THEY HAVE NOT ALREADY BEEN INFORMED)ALREADY BEEN INFORMED)

PERFORM LAST OFFICES FOR PATIENTPERFORM LAST OFFICES FOR PATIENT RELATIVES CAN SEE THEIR LOVED ONE AT RELATIVES CAN SEE THEIR LOVED ONE AT

THIS POINTTHIS POINT PATIENT PROPERTY TO BE ACCOUNTED PATIENT PROPERTY TO BE ACCOUNTED

FOR AND GIVEN TO RELATIVES IF FOR AND GIVEN TO RELATIVES IF POSSIBLEPOSSIBLE

GUIDELINES (CONTINUED)GUIDELINES (CONTINUED)

THE PATIENT’S BODY NEEDS TO BE TAGGEDTHE PATIENT’S BODY NEEDS TO BE TAGGED THEY SHOULD BE DRESSED IN A SHROUD THEY SHOULD BE DRESSED IN A SHROUD

WHICH SHOULD BE TAGGEDWHICH SHOULD BE TAGGED THE PATIENT SHOULD THEN BE WRAPPED IN THE PATIENT SHOULD THEN BE WRAPPED IN

A SHEETA SHEET THE PATIENT SHOULD THEN BE PLACED IN A THE PATIENT SHOULD THEN BE PLACED IN A

BODY BAG WHICH AGAIN SHOULD BE BODY BAG WHICH AGAIN SHOULD BE TAGGEDTAGGED

THE PORTERS SHOULD BE ASKED TO THE PORTERS SHOULD BE ASKED TO REMOVE THE BODY TO THE MORTUARYREMOVE THE BODY TO THE MORTUARY

GUIDELINES (CONTINUED)GUIDELINES (CONTINUED) THE DOCTOR WILL CONTACT THE CORONER TO THE DOCTOR WILL CONTACT THE CORONER TO

DECIDE WHETHER A POST MORTEM IS DECIDE WHETHER A POST MORTEM IS REQUIREDREQUIRED

IF A POST MORTEM IS NOT REQUIRED THEN A IF A POST MORTEM IS NOT REQUIRED THEN A MEDICAL CERTIFICATE OF CAUSE OF DEATH MEDICAL CERTIFICATE OF CAUSE OF DEATH WILL BE ISSUED (IF THE PATIENT IS TO BE WILL BE ISSUED (IF THE PATIENT IS TO BE CREMATED AN ADDITIONAL FORM WILL NEED CREMATED AN ADDITIONAL FORM WILL NEED TO BE FILLED IN BY THE DOCTOR)TO BE FILLED IN BY THE DOCTOR)

THE FAMILY SHOULD BE INFORMED THAT THE FAMILY SHOULD BE INFORMED THAT REGISTRATION OF THE DEATH SHOULD BE REGISTRATION OF THE DEATH SHOULD BE MADE WITHIN 5 DAYS OF DEATH AND IN THE MADE WITHIN 5 DAYS OF DEATH AND IN THE LOCAL REGISTRAR’S OFFICE (NOT THE LOCAL REGISTRAR’S OFFICE (NOT THE NEAREST ONE TO THEIR HOME)NEAREST ONE TO THEIR HOME)

GUIDELINES (CONTINUED)GUIDELINES (CONTINUED)

IF A POST MORTEM IS REQUIRED THE IF A POST MORTEM IS REQUIRED THE DOCTOR WILL NOT BE ABLE TO DOCTOR WILL NOT BE ABLE TO ISSUE A MEDICAL CERTIFICATE OF ISSUE A MEDICAL CERTIFICATE OF CAUSE OF DEATH AND IT IS IN THE CAUSE OF DEATH AND IT IS IN THE HANDS OF THE CORONERHANDS OF THE CORONER

REASONS WHY A DEATH IS REASONS WHY A DEATH IS REPORTED TO THE CORONERREPORTED TO THE CORONER

IF THE CAUSE OF DEATH IS UNCERTAINIF THE CAUSE OF DEATH IS UNCERTAIN IF THE DEATH WAS SUDDEN, VIOLENT OR IF THE DEATH WAS SUDDEN, VIOLENT OR

CAUSED BY AN ACCIDENTCAUSED BY AN ACCIDENT IF A DEATH WAS CAUSE BY AN INDUSTRIAL IF A DEATH WAS CAUSE BY AN INDUSTRIAL

DISEASEDISEASE IF DEATH HAPPENED DURING AN OPERATION OR IF DEATH HAPPENED DURING AN OPERATION OR

UNDER ANAESTHETICUNDER ANAESTHETIC WHERE THE PATIENT HAS NOT BEEN SEEN BY A WHERE THE PATIENT HAS NOT BEEN SEEN BY A

DOCTOR FOR 14 DAYS BEFORE DEATHDOCTOR FOR 14 DAYS BEFORE DEATH IF DEATH OCCURS WITHIN 24 HOURS OF IF DEATH OCCURS WITHIN 24 HOURS OF

ADMISSION TO HOSPITALADMISSION TO HOSPITAL

WHAT IS LAST OFFICES?WHAT IS LAST OFFICES?

LAST OFFICES IS THE FINAL SERVICE LAST OFFICES IS THE FINAL SERVICE OFFERED AS A MARK OF RESPECT TO OFFERED AS A MARK OF RESPECT TO THE DEAD PERSON BEFORE BURIAL THE DEAD PERSON BEFORE BURIAL OR CREMATION.OR CREMATION.

OTHERWISE KNOWN AS LAYING OUTOTHERWISE KNOWN AS LAYING OUT THERE MUST BE SENSITIVITY TO THE THERE MUST BE SENSITIVITY TO THE

BELIEFS OF THE FAMILY AS TO HOW BELIEFS OF THE FAMILY AS TO HOW LAS OFFICES ARE CARRIED OUT.LAS OFFICES ARE CARRIED OUT.

LAST OFFICES INVOLVES:-LAST OFFICES INVOLVES:-

WASHING THE BODYWASHING THE BODY CLOSING THE EYELIDSCLOSING THE EYELIDS ENSURING THE JAW REMAINS CLOSEDENSURING THE JAW REMAINS CLOSED WASHING HAIR(IF NECESSARY)WASHING HAIR(IF NECESSARY) STRAIGHTENING OF ARMS AND LEGSSTRAIGHTENING OF ARMS AND LEGS PACKING OF BODY ORRIFICES (NOT PACKING OF BODY ORRIFICES (NOT

ALWAYS NECESSARY)ALWAYS NECESSARY) SHAVING MENSHAVING MEN

RIGOR MORTISRIGOR MORTIS

IS A STIFFENING OF THE MUSCLES, WHICH IS A STIFFENING OF THE MUSCLES, WHICH USUALLY BEGINS WITHIN ABOUT 2 TO 4HOURS USUALLY BEGINS WITHIN ABOUT 2 TO 4HOURS AFTER DEATH AND GRADUALLY EXTENDS OVER AFTER DEATH AND GRADUALLY EXTENDS OVER THE WHOLE BODY IN ABOUT 48 HOURS AFTER THE WHOLE BODY IN ABOUT 48 HOURS AFTER THIS IT USUALLY BEGINS TO WEAR OFF.THIS IT USUALLY BEGINS TO WEAR OFF.

RIGOR MORTIS CAN BE LESS PRONOUNCED IN RIGOR MORTIS CAN BE LESS PRONOUNCED IN THE BODY OF AN ELDERLY PATIENTTHE BODY OF AN ELDERLY PATIENT

WHEN SOMEONE HAS BEEN DEAD FOR HALF AND WHEN SOMEONE HAS BEEN DEAD FOR HALF AND HOUR OR MORE, PARTS OF THE SKIN DISCOLOUR HOUR OR MORE, PARTS OF THE SKIN DISCOLOUR WITH PURPLE/BLACK PATCHES. THIS IS CALLED WITH PURPLE/BLACK PATCHES. THIS IS CALLED HYPOSTASIS AND IS DUE TO BLOOD SETTLING IN HYPOSTASIS AND IS DUE TO BLOOD SETTLING IN THE BODY DUE TO GRAVITYTHE BODY DUE TO GRAVITY

POST MORTEMPOST MORTEM

THERE ARE TWO TYPES:THERE ARE TWO TYPES: POST MORTEM WHICH THE DOCTOR POST MORTEM WHICH THE DOCTOR

REQUESTS (HOSPITAL POST MORTEM) REQUESTS (HOSPITAL POST MORTEM) MUST HAVE THE CONSENT OF THE NEXT MUST HAVE THE CONSENT OF THE NEXT OF KINOF KIN

POST MORTEM WHICH THE CORONER POST MORTEM WHICH THE CORONER REQUIRES (NO CONSENT REQUIRED)REQUIRES (NO CONSENT REQUIRED)

RELATIVES WILL NOT AUTOMATICALLY BE RELATIVES WILL NOT AUTOMATICALLY BE TOLD THE RESULTS OF A POST MORTEMTOLD THE RESULTS OF A POST MORTEM

AFTER REGISTRATIONAFTER REGISTRATION

A DEATH CERTIFICATE WILL BE A DEATH CERTIFICATE WILL BE ISSUEDISSUED

USUALLY MORE THAN ONE USUALLY MORE THAN ONE CERTIFICATE IS REQUIREDCERTIFICATE IS REQUIRED

THE REGISTRAR WILL ISSUE A GREEN THE REGISTRAR WILL ISSUE A GREEN CERTIFICATE TO SAY THAT THE CERTIFICATE TO SAY THAT THE DEATH HAS BEEN REGISTERED AND DEATH HAS BEEN REGISTERED AND THAT A FUNERAL MAY TAKE PLACETHAT A FUNERAL MAY TAKE PLACE

FUNERAL ARRANGEMENTSFUNERAL ARRANGEMENTS

THE RESPONSIBILITY OF FAMILY OR THE RESPONSIBILITY OF FAMILY OR FRIENDSFRIENDS

OR THE HEALTH AUTHORITY WHERE OR THE HEALTH AUTHORITY WHERE THERE ARE NO FAMILY OR FRIENDSTHERE ARE NO FAMILY OR FRIENDS

LAST OFFICES FOR DIFFERENT LAST OFFICES FOR DIFFERENT RELIGIONS AND CULTURESRELIGIONS AND CULTURES

United Kingdom is a multicultural, multiracial United Kingdom is a multicultural, multiracial and multireligious society.and multireligious society.

All wards, units, hospices, etc. should have All wards, units, hospices, etc. should have some form of reference material with regard some form of reference material with regard to managing patients of different religions to managing patients of different religions and cultures.and cultures.

The Royal Marsden “Manual of Clinical The Royal Marsden “Manual of Clinical Nursing Procedures” looks at the last offices Nursing Procedures” looks at the last offices of patients from different religions and of patients from different religions and cultures.cultures.

CHRISTIANITYCHRISTIANITY

Customary last offices are Customary last offices are acceptableacceptable

Family may ask for hospital Family may ask for hospital chaplain, minister or priest to chaplain, minister or priest to perform last rites.perform last rites.

Some Roman Catholic families Some Roman Catholic families may wish to place a rosary in the may wish to place a rosary in the deceased hands or a crucifix at deceased hands or a crucifix at the patient’s head.the patient’s head.

Some orthodox families may wish Some orthodox families may wish to place an icon (holy picture) at to place an icon (holy picture) at either side of the patient’s head.either side of the patient’s head.

HINDUISMHINDUISM

If available relatives may wish to If available relatives may wish to read from the Bhagavad Gita or read from the Bhagavad Gita or make a request that staff read make a request that staff read extracts during the last officesextracts during the last offices

Relatives of the same sex as the Relatives of the same sex as the patient may wish to wash his or her patient may wish to wash his or her body preferably in water mixed with body preferably in water mixed with water from the river Gangeswater from the river Ganges

The patient’s family may request The patient’s family may request that the patient be placed on the that the patient be placed on the floor and they may wish to burn floor and they may wish to burn incenseincense

Post mortems are viewed as Post mortems are viewed as disrespectful to the deceased disrespectful to the deceased person, so are only carried out when person, so are only carried out when strictly necessarystrictly necessary

MUSLIMMUSLIM

The family will want to stay with the dying patient and perform The family will want to stay with the dying patient and perform last rites. last rites.

The patient’s head should point towards Mecca, which in the The patient’s head should point towards Mecca, which in the U.K. is south east or alternatively turn the patient on their right U.K. is south east or alternatively turn the patient on their right side so that the deceased face is facing towards Meccaside so that the deceased face is facing towards Mecca

The body should be untouched by non-muslims but if they are The body should be untouched by non-muslims but if they are to be touched gloves should be wornto be touched gloves should be worn

The patients eyes should be closed and the body straightened. The patients eyes should be closed and the body straightened. The head should be turned to the right shoulder and the body The head should be turned to the right shoulder and the body covered with a plain white sheet. The body and hair should covered with a plain white sheet. The body and hair should not be washed nor the nails cut.not be washed nor the nails cut.

The patients body is normally taken home or to a mosque as The patients body is normally taken home or to a mosque as soon as possible to be washed by another muslim of the same soon as possible to be washed by another muslim of the same sex. A wife may wash her husband but the reverse is not sex. A wife may wash her husband but the reverse is not permittedpermitted

Burial never cremation is preferred within 24 hours of death Burial never cremation is preferred within 24 hours of death