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.