3/3/14

Care After Death

Definition: - This is the care given to the body after death. It is also called post-mortem care.

Purpose
1. To show respect for the dead
2. To prepare the body for burial
3. To prevent spread of infection
4. To show kindness to the family

Equipment
• Basin for water, wash cloth and towel
• Cotton
• Gauze
• Dressings and tape if necessary
• Clean sheet
• Stretcher
• Forceps
• Name tag
• Gloves, if necessary

Procedure
• Note the exact time of death and chart it
• If the doctor is present call him to pronounce death
• If the family members are not present, send for them
• Wash hands and wear clean gloves according to agency policy
• Close doors of the room or pull curtain
• Raise bed to comfortable working level (when necessary)
• Arrange for privacy and prevent other patients from seeing in to room.
• Close patient's eyes and nose if necessary
• Remove N.G. tubes and other devices from patient's body
• Place patient in supine position
• Replace soiled dressing with clean ones when possible
• Bath patients as necessary
• Brush or comb hair
• Apply clean gown
• Care for valuable and personal belongings and document dispersement
• Allow family to view patient and remain in room
• Attach special level if patient had contagious disease
• Await arrival of ambulance or transfer to morgue
• Remove gloves and wash hands
• Document the procedure

Study Questions
1. Define death.
2. What are the stages experiences by dying person?
3. How do you confirm the occurrence of death?
4. What are the purposes of post mortem care?
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Assisting the dying client

Procedure
1. Minimize the client’s discomfort as much as possible.
a. Provide warmth.
b. Provide assistance in moving, and position client frequently.
c. Provide assistance in bathing and personal hygiene.
d. Administer the appropriate medications before the pain becomes severe.

2. Recognize the symptoms of urgency or emergency conditions and seek immediate assistance.
3. Notify the charge nurse if there is an impending crisis and perform emergency actions until help arrives.
4. Encourage dying clients to do as much as they can for themselves so that they do not just give up-a state that only reinforces low self-esteem.
5. Provide emotional nursing care for the client.

a. Form a relationship with the dying client. Be willing to be involved, to care, and to be committed to caring for a dying client.

b. Allocate time to spend with the client so that no only physical care is administered.

c. Recognize the grief pattern and support the client as he or she moves through it.

d. Recognize that your physical presence is comforting by staying physically close to the client if he or she is frightened. Use touch if appropriate and nonverbal communication.

e. Respect the client’s need for privacy and with draw if the client has a need to be alone or to disengage from personal relationships.

f. Be tuned into client’s cues that he or she wants to talk and express feelings, cry, or even intellectually discuss the dying process.

g. Accept the client at the level on which he or she is functioning without making judgments.

6. Provide the level of care that encourages the client to retain confidence in the health care team.

7. Assist the client through the experience of dying in whatever way you are able to do so.

8. Support the family of the dying client.
a. Understand that the family may be going through anticipatory grief before the actual event of dying.
b. Understand that different family members react differently to the impending death and support the different reactions.
c. Be aware that demonstrating your concern and caring assists the family to cope with the grief process.

9. Be aware of your own personal orientation toward the dying process.
a. Explore your own feelings about death and dying with the understanding that until you have faced the subject of death you will be inadequate to support the client or the family as they experience the dying process.
b. Share your feelings about dying with the staff and others; actively work through them so that negativity does not get transferred to the client.
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Died Nursing Process Assessment

Observe the physical symptoms.
• Evidence of circulatory collapse
• Variations in blood pressure and pulse
• Disequilibrium of body mechanisms
• Deterioration of physical and mental capabilities
• Absence of corneal reflex

Observe the client’s ability to fulfill basic needs without complete assistance.
• Assess the nature and degree of pain the client is experiencing.
• Observe for impending crisis or emergency situation.
• Observe for psychosocial condition.
• Need to establish a relationship for support
• Grief pattern and stage of grief the client is experiencing
• Need to express feelings and verbalize fears and concerns

Determine anxiety level, which may be expressed in physical or emotional behavior.
• Sleep disturbance
• Palpitations
• Digestive complaints
• Anger or hostility
• Withdrawal

Determine depression level that client may be experiencing.
• High fatigue level or lethargy
• Poor appetite, nausea, or vomiting
• Inability to concentrate
• Expressions of sadness, hopelessness, or uselessness

Planning/Objectives
• To assist the dying client to cope with the dying process
• To handle own feelings of loss and sadness that arise when caring for a client who is dying
• To provide support for the client and the client’s family during the dying process
• To complete the actions necessary to care for the client who has died

Implementation /Procedure (See this under procedure part)
Assisting the Dying Client

Evaluation/Expected Outcomes
Client finds internal resources to accept death.
Client is able to verbalize feelings and needs.
Physical discomfort is minimized.
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Stages of Dying

Elisabeth Kubler-Ross (1969) has beautifully described the phases of dying, which mirror those of the grieving process. As a person learns of his or her own impending death, he or she experiences grief in relation to his or her own loss.

The first stage, as Dr. Ross views this process, is that of denial. The denial may be partial or complete and may occur not only during the first stages of illness or confrontation but later on from time to time. This initial denial is usually a temporary defense and is used as a buffer until such time as the person is able to collect him or herself, mobilize his or her defenses, and face the inevitability of death.

The second stage is often anger. The person feels violent anger at having to give up life. This emotion may be directed toward persons in the environment or even projected into the environment at random. Dr. Ross discusses this reaction and the difficulty in handling it for those close to the person by explaining that we should
put ourselves in the client’s position and consider how we might feel intense anger at having our life interrupted abruptly.

The third stage is bargaining. The person attempts to strike a bargain for more time to live or more time to be without pain in return for doing something for God. Often during this stage the person turns or returns to religion.

Depression is the fourth stage. Usually, when people have completed the processes of denial, anger, and bargaining, they move into depression. Dr. Ross writes about two kinds of depression. One is preparatory depression; this is a tool for dealing with the impending loss. The second type is reactive depression. In this form of depression, the person is reacting against the impending loss of life and grieves for him or herself.

The final stage of dying is that of acceptance. This occurs when the person has worked through the previous stages and accepts his or her own inevitable death. With full acceptance of impending death comes the preparation for it; however, even with acceptance, hope is still present and needs to be supported realistically.

Many factors influence how individuals accept death. Personal values and beliefs about life; views of personal successes, both financial and emotional; the way they look physically when experiencing the dying process; their family and friends and their families’ attitudes and reactions; their past experiences in coping with difficult or traumatic situations; and, finally, the health care staff who are caring for them during this process – all affect an individual’s attitude toward dying.
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Care of the dying and postmotremcare

Learning Objectives
At completion of the chapter the learner will be able:
• Mention stages experienced by dying person
• Define death
• Identify sing of death.
• Confirm death in collaboration with physician.
• Reassure relatives of the dying patient.
• Provide care fore the dead body with respect.
• Transferee the dead body to morgue or his house.

Key terminology
Autopsy                          Cheyne-Stkes respiration
postmortum examination     Brain death
Kussmal’s breathing

Care of the Dying
Death:-Is a natural part of life and comes to all beings. Is the end of life and all the vital processes. Legal death is the total absence of brain activities as assessed and pronounced by the physician.
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2/10/14

Accounting for valuables

• Be aware of local policy.
• All valuables should be identified, accounted for and sent for safe-keeping as soon as is reasonably practical, in keeping with local policy.
• Any jewellery left on the deceased should be taped, and details noted on the appropriate documentation.
• A second responsible person should always be called on as witness when accounting for client property whether the client is deceased or otherwise.
• No valuables or other client property should be given to relatives prior to full documentation and a signature of receipt should be obtained.
• It is usual to ask relatives to collect the deceased’s belongings when they come to collect the Medical Certificate of Death. This allows time to parcel the property more appropriately and thus reduce the potential for further distress.
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Confirming death

Clients are usually pronounced dead by a doctor; however, some senior nurses may undertake this task as part of their expanded role if the death was expected and there are no suspicious circumstances. The procedure is usually performed when relatives are present though on occasions circumstances may prevent this.
Nurses and others may recognize classic signs, which are:
• no evidence of pulse, respirations or blood pressure
• pupils fixed and dilated.

Post-mortems may only be carried out with written consent of relatives unless the death occurs in suspicious circumstances or occurred without prior medical intervention. In these cases permission – whilst desirable – is not required in law. A booklet produced by the Royal College of Pathologists (2000), Examination of the Body after Death, offers useful information about post-mortem examination for relatives, and copies are readily available from http://www.rcpath.org.uk.

If a post-mortem is to be carried out, under no circumstances should any tubes, catheters or other invasive equipment be removed from the body. If unsure then you must check with the medical officer or senior nurse before performing Last Offices and adhere strictly to their guidance.
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Signs of approaching death

It is not uncommon for novice health care professionals to be anxious about their first encounters with death. The following points may help to allay some of the anxieties you might have arising from a limited knowledge base, and reduce some of the fear stemming from the ‘unknown’.

• As the client’s bodily systems begin to shut down, motion and sensation are gradually lost.
• Whilst the client’s temperature may be elevated they often feel cold and clammy to touch. This can be disconcerting for both relatives and staff and can be eased by regular cleansing with moist wipes.
• Respirations may be noisy due to the build-up of secretions in the lungs. This can be distressing for relatives and inexperienced staff. Administering an antimuscarine such as hyoscine butylbromide sublingually or intramuscularly, if prescribed, can sometimes reduce this.
• Cheyne-Stokes respirations are common and again can be disconcerting if not expected or understood.
• Circulation fails and the blood pressure falls. It is therefore best to remove any monitoring devices, which tend to alarm when pulse, blood pressure and/or respirations fall outside the parameters set.
• Pain, if it has been present, may subside. Unfortunately this can sometimes lure relatives into a false sense of security.
• The client’s mental condition usually deteriorates though it is thought by many that hearing remains acute and indeed may be accentuated immediately prior to death.

Informing relatives
If relatives are not present the identified next of kin should be informed of the client’s deteriorating condition. Only in exceptional circumstances should relatives be informed of a death over the telephone. An alternative solution, particularly for those next of kin who are immobile or live a considerable distance away, is to inform their local police force, who will usually deliver a ‘death warning’ in person and can thus assess the situation and provide support if necessary.

It is the responsibility of the senior nurse to contact relatives and ask them if they wish to attend. If you are asked to deputize and feel confident, knowledgeable and competent to do so you should:

• give name, title and where you are calling from
• determine the identity of the person to whom you are speaking
• explain that the client’s condition has worsened
• stay calm and speak in a controlled manner
• use short sentences offering small pieces of information
• pause to allow the receiver of the call time to comprehend
• urge the individual to come to the hospital and reassure that care is being given. Ask if they require you to contact any other persons on their behalf such as a priest or other religious leader
• document time and nature of information given and the name of the recipient(s).

Helping arriving relatives
To avoid confusion, ideally the nurse who made the call should meet the relatives on arrival to provide continuity of care. They should not be left alone but shown to a private place.

Grief reactions may differ:
• be prepared and avoid being judgemental
• words of comfort are often difficult to find; sincerity is generally the best course of action
• active listening is often the best approach as this allows for reminiscing and/or expression of emotions.

Those receiving notification of a sudden unexpected death may show severe emotional reactions. Encouraging survivors to view the deceased can seem quite brutal; however, this can help to reinforce the reality of the event and assist subsequent grieving. Consider the likely effect of showing personal emotion. It may or may not be appropriate depending upon the circumstances surrounding the actual/impending death.
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Communicating with dying clients and their relatives

Dying clients and their relatives often have preconceived ideas and sometimes misconceptions about death and dying. Whilst some individuals seek answers and reassurance from religious sources regarding the where, when, why and how death might befall them, many clients and their loved ones look to health care professionals. Unfortunately we are not always able to give an unequivocal response and often fear that anything we do say will create even greater anxiety and distress. Often we feel too uncomfortable with the topic ourselves to believe we can be of any help to others. Rather than admit these facts, all too frequently we adopt the tactic of self-preservation whereby we use a variety of strategies, consciously and sometimes unconsciously, in the hope of avoiding these difficult questions. The commonest strategy in busy health care environments is to focus on clients’ physical needs and appear ‘too busy to chat’. The consequence of such actions is that clients and their families are frequently left with unmet needs. The following section is therefore designed to offer some pointers for novice health care professionals when communicating with dying clients and their significant others.

Always remember, dying clients are, in fact, still very much alive and may not necessarily wish to be surrounded by those they perceive to be doom and gloom ‘experts’, nor wish any encounter to be planned like a military operation. They very often welcome the approach of bright-eyed,effervescent, naive neophytes so never be afraid to stop and talk to a client who is known to be dying: it can make such a difference to their last days, hours or moments of life. The greatest skill is recognizing when they wish to be left alone.

Before the interaction:
• Be clear about your own attitudes, values and beliefs about death and dying.
• Learn about and endeavour to be accepting of others’ differing values and beliefs.
• Do not underestimate the importance of spirituality to some clients.
• Do not assume that because it is OK for you and your nearest and dearest that it will be OK for others.
• Be aware of the support mechanisms you can draw upon if you feel you are getting ‘out of your depth’, such as the Macmillan nurse, palliative care team, chaplaincy and specialist counselling services.
• Establish what has or has not been said by the doctors and other health care professionals.
• Establish whom the client wishes to be present during the interaction, taking care not to be drawn into any collusion or secrecy.
• For some clients tape-recording the interaction can be helpful to refer back to. They may then also share it with others if they so wish.
• If possible prepare the environment to ensure privacy and no disturbances.

At the commencement of the interaction:
• Try not to have any preconceived ideas: each client and relative is a unique individual and may respond very differently to similar sets of circumstances.
• Think before you open your mouth to speak.
• Establish the most important source of information to the client/family.
• Establish the client and family’s level of awareness of the situation.
• Establish trust and confidence.
• Try not to be judgemental.
• Do not be afraid to stop and listen.
• Be accessible; show that you have time and are willing to listen.
• Don’t be afraid to say ‘I don’t know’.
• Don’t agree to collude or keep secrets.
• Be prepared for the vast array of reactions that can occur, such as anger, guilt, fear, denial, acceptance or loss of control.
• Sometimes anger can be directed at you; try not to appear defensive unless truly warranted. Don’t take it personally. Try and stay calm and kind. Try to understand and to see the situation from their perspective. for guidance as to what to do should the situation become particularly aggressive or violent.
• Empathy in this situation is almost impossible, but sympathy and compassion can be equally important.
• Give time to grieve, talk, and reminisce, to express fears and anxieties, to express wishes and dreams.
• Offer to contact a priest or other religious leader if the client wishes.

At the end of the interaction:
• Ensure that the client and/or their relatives are clear about the key points of the interaction.
• If appropriate write down the key points for them to keep, refer back to and/or, if desired, share with others.
• If necessary arrange a day/time for a follow-up consultation.
• Make it clear that either you or a colleague are available at any time should the client require any further help or support.

Following the interaction:
• Document any key points that will facilitate continuity of care.
• If you have indicated that you will contact another person, health professional or agency, be sure to do so promptly before you become involved with other tasks that mean you might forget later.
• Endeavour to promote a positive atmosphere.
• Always convey the impression that you have time, and pay attention to the little things, as they often mean the most to clients and those they love.

Communicating with dying patients and their significant others is probably one of the hardest tasks facing health care professionals, but it can be one of the most rewarding. Do not be disheartened if you are left thinking you didn’t get it quite right. It takes time to develop the skills. Instead analyse the interaction and discuss your thoughts and feelings with your mentor or other members of the health care team.
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Assessing the dying client

Remember that assessment of the activity of dying is only part of a holistic nursing assessment and should not be undertaken in isolation without reference to or consideration of the client’s other activities of living. The specific points to consider when assessing the dying client are:

• Physical
Is the client in any physical distress, for example nauseous, vomiting, dehydrated, breathless, constipated, unable to sleep, immobile, in pain?
Is everything possible being done to promote the client’s comfort?
Could anything else be done?
Do they have a ‘Do not resuscitate’ order and has this been discussed with the client and their next of kin?
Can any other members of the multidisciplinary team offer help or guidance?
Could any alternative therapies be of help?
Are there any physical effects on family/friends?
Is the client an actual or potential organ donor and are the family aware?
Do the client/family wish sustained treatment?
Remember, good symptom control is not just for clients but also for relatives, as they have to live with their memories.

• Psychological
Are the client/family aware of the diagnosis/prognosis?
What are the client/family’s beliefs about death and dying?
Are the client/relatives frightened, anxious, depressed?
Do they have any concerns that can be addressed by you or others, for example a Macmillan nurse, the palliative care team?
Is everything possible being done to promote the client’s autonomy, privacy and dignity?
Have they any outstanding or unfinished business they wish to address?
Do they require you to contact any outside agencies on their behalf?
What effect will the death have on family members?

• Sociocultural
Do you have full contact details of next of kin/religious leaders?
Do they wish to see a minister, priest or other religious leader?
Do the client/family wish anyone else to be contacted?
Do the client/family feel isolated?
Does the client wish restricted or unrestricted visiting?
Are family and significant others aware of the visiting agreement?
Are there any other specific spiritual, religious or cultural wishes to be addressed before, during or following death?
Do the client’s family wish to be participants or observers of care?
If they wish to participate how can this be facilitated?
Are there any barriers preventing their involvement that can be overcome, for example lack of skill or knowledge?
Do relatives wish to be informed immediately if their loved one dies and they are not present? This is particularly important if the death occurs during the night, if the relatives live a long distance away, or the next of kin is ill or disabled. Who should be informed of the death first?

• Environmental
Does the client wish to die in a clinical environment, hospice or at home?
Can this be facilitated?
What support mechanisms are required/available?
Is the environment of care conducive to the client/visitors?
Could it be improved?
Are there any concerns about necessary environmental changes that might be incurred for spouse/family following death?

• Politico-economic
Have the client/relatives any financial worries or concerns?
Could referral to other agencies help?
Are there any other health or support services available for the dying or bereaved?
Have they made a will? If not, how can this be facilitated, if desired?
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Common terminology of Dying

Cadaver = Corpse, dead body

Cheyne-Stokes respirations = Periodic breathing characterized by a gradual increase in respiration followed by a decrease in respiration resulting in apnoea

Coroner = A person appointed by the Home Office who is required by law to investigate deaths due to unnatural, suspicious or unknown causes

Inquest = An investigation held by the Coroner when death is known or suspected to be due to any other cause than natural death

Medical Certificate of Death = Sometimes referred to as the Death Certificate, it is a legal document required by the Registrar of Births, Deaths and Marriages before they can issue a form permitting disposal of the body

Palliative = Something which relieves discomfort or distress but does not cure

Pathologist = A doctor trained in the detection and diagnosis of disease

Post-mortem = Involves the examination of the brain and other internal organs by a pathologist, usually undertaken when the cause of death is uncertain or suspicious

Prognosis = Course of the disease including expected outcome

Rigor mortis = The term given to the stiffening of the body following death

Rose Cottage = A term commonly used for the mortuary when speaking in a public area
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Dying

From the moment we are born the only predictable event in life is that one day we will die. Dying is thus an inevitable part of life, yet it remains surrounded in mystery to a large extent, provoking fear and anxiety in most individuals, particularly in Western society. However, when explored, it is not usually the thought of death that creates anxiety but the where, the when, the why and the how. Other issues of concern often include: what will happen to my body; how will those left behind manage, financially and emotionally; and who will help them through this difficult time? It is also not unusual for dying clients to feel guilty about the distress they perceive they are causing to their loved ones.

Addressing such issues with clients and their relatives can be daunting for even the most seasoned health care professional, let alone the novice. Consequently, whilst this chapter aims to offer guidance for those with little or no experience of death and dying, the reader is reminded that it is important for us all to recognize and acknowledge our limitations and not be afraid to seek assistance if we are unsure or worried about any particular aspects of care delivery.

Factors affecting dying may be:
• physical arising from the nature of the terminal illness or cause of death such as pain, nausea, breathlessness
• psychological such as fear and anxiety about death itself or the effects on those left to grieve
• sociocultural including personal beliefs about death and attitude towards death and dying
• environmental, for example preferred place of death, quiet/noisy, private/open
• politico-economic such as lack of finances for funeral, outstanding debts.

This chapter outlines some of the principles and practices surrounding care of the dying and the performance of last offices. The need for respect of clients’ and relatives’ beliefs, values, culture and customs when initiating and carrying out these final acts of nursing care is emphasized throughout. The chapter includes sections on common terminology; communicating with dying clients; the signs of approaching death; informing relatives; confirmation of death; the equipment required to perform last offices; and the procedure for cleansing, dressing and positioning of the deceased, paying due regard to issues surrounding infection control,
labelling of the body and care of the deceased’s property and valuables. The reader is reminded of the need to refer to local policy and procedures throughout but particularly in relation to infection management and removal of the body from the clinical area. The chapter concludes with references and direction to enable further reading.
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