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1. PROGRAM TITLE: NURSING ASSISTANCE - III MODULE TITLE: Providing palliative care and maintain a mortuary service By Abera S. Abera S. keep social distance

2. Learning objectives At the end of this module the learner will be able to : Definition of palliative care Receive bodies at mortuary Perform after death care Prepare bodies for viewing Maintain the mortuary environment Release(discharge) bodies to Funeral Director/ Conveyors Follow security requirements Abera S. keep social distance

3. LO1:Receive body's at mortuary 1. I ntroduction to end –of-life care What Is Palliative Care? Palliative care is specialized medical care for people with serious illness . This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. a Abera S. keep social distance

4. Palliative care is provided by a specially-trained team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness, and it can be provided along with curative treatment. Abera S. keep social distance

5. human skull, widely used as a symbol of death and decomposition (break dawn, putrefaction, decay ) Abera S. keep social distance

6. What Is Death ? Death is the cessation of all biological functions that sustain an organism . phenomenima which commonly bring about death include biological aging (senescence), predation, malnutrition, disease, suicide, homicide, starvation, dehydration, and accidents or trauma resulting in terminal injury. Bodies of living organisms begin to decompose shortly after death. Abera S. keep social distance

7. Death has commonly been considered a sad or unpleasant(unlikable) occasion(events), particularly for humans, due to the affection for the being that has died and/or the termination of social and familial bonds with the decease d . Other concerns include fear of death, necrophobia , anxiety, sorrow, grief, emotional pain, depression, sympathy or compassion(empathy) . Abera S. keep social distance

8. The potential for an afterlife is of concern for humans and the possibility of reward or judgement and punishment for past sin with people of certain religions. When a person has died, it is also said they have passed away, passed on, expired, or are gone, among numerous other socially accepted, religiously specific, slang, and irreverent (disrespectful) terms . Abera S. keep social distance

9. The Principles of Palliative Care Affirms life and regards dying as a normal process. Neither hastens nor postpones death. Provides relief from pain and other distressing symptoms. Integrates the psychological and spiritual aspects of care. Offers a support system to help patients live as actively as possible until death. Abera S. keep social distance

10. Attitudes and principles required for successful palliative care 1. A caring attitude Involves sensitivity, empathy and compassion, and demonstrates concern for the individual There is concern for all aspects of a patient’s suffering, not just the medical, nursing or social work problems There is a non-judgmental approach in which personality, intellect, ethnic origin, religious belief or any other individual factors do not prejudice the delivery of optimal care Abera S. keep social distance

11. 2. Consideration of individuality The practice of categorizing patients by their underlying disease, based on the similarity of the medical problems encountered, fails to recognize the psychosocial features and problems that make every patient a unique individual. These unique characteristics can greatly influence suffering and need to be taken into account when planning the palliative care for individual patients. Abera S. keep social distance

12. 3. Cultural considerations Ethnic, racial, religious and other cultural factors may have a profound effect on a patient’s suffering. Cultural differences are to be respected and treatment planned in a culturally sensitive manner. Abera S. keep social distance

13. 4. Consent The consent of a patient, or those to whom the responsibility is delegated, is necessary before any treatment is given or withdrawn. The majority of patients want shared decision making although physicians tend to underestimate this. Having assessed what treatment is appropriate or inappropriate, this is discussed with the patient. In most instances, adequately informed patients will accept the recommendations made if they have been explained in non-medical jargon. Abera S. keep social distance

14. 5.Choice of site of care 6. Communication 7. Clinical context : Appropriate treatment All palliative treatment should be appropriate to the stage of the patient’s disease and the prognosis Over-enthusiastic investigations, therapy that is inappropriate and patient neglect are equally deplorable Abera S. keep social distance

15. Palliative care has been accused of the medicalisation of death, and care must be taken to balance technical interventions with a humanistic orientation to dying patients. This is where a team approach is essential, each member of the team being able to see different aspects of the patient’s suffering, personality and needs. The prescription of appropriate treatment is particularly important in palliative care because of the unnecessary additional suffering that may be caused by inappropriately active therapy or by lack of treatment. Abera S. keep social distance

16. 8. Comprehensive inter-professional care The provision of total or comprehensive care for all aspects of a patient’s suffering requires an interdisciplinary team 9. Care excellence Palliative care should deliver the best possible medical, nursing and allied health care that is available and appropriate Abera S. keep social distance

17. 10. Consistent medical care Consistent medical management requires that an overall plan of care be established, and regularly reviewed, for each patient This will reduce the likelihood of sudden or unexpected alterations, which can be distressing for the patient and family. It may lessen the chance of crises or medical emergencies which can frighten the patient and relatives. Abera S. keep social distance

18. 11. Coordinated care Involves the effective organization of the work of the members of the inter professional team, to provide maximal support and care to the patient and family. Care planning meetings, to which all members of the team can contribute, and at which the views of the patient and the family are presented, are essential to develop a plan of care for each individual patient. Abera S. keep social distance

19. 12.Continuity of care 13. Crisis prevention 14. Caregiver support 15. Continued reassessment Abera S. keep social distance

20. 1.2 The context for death and dying in Ethiopia Death is certain(sure) in human existence, though we do battle(conflict) with its inevitability. Despite its ubiquity, it is a phenomenon conceived differently, depending on cultural, ideological, or idiosyncratic orientation. These differences are apparent because of my multicultural exposure of death in both the African context. Abera S. keep social distance

21. One of the most difficult realities that nurse’s face is that, despite our very best efforts, some patients will die. Although we cannot change this fact, we can have a significant and lasting effect on the way in which patients live until they die, the manner( way,mode ) in which the death occurs, and the enduring(long-term) memories of that death for the families. Abera S. keep social distance

22. Theologically, death is defined as the separation of soul and body. But as Professor Philip Keane pointed out in a lecture, no one has seen the soul depart the body. This definition, according to German theologian Karl Rahner , fails to indicate “the specifically human element of human death.” faith( bilief ) Abera S. keep social distance

23. Philosophically, death is defined as the cessation of the integrated functioning of the human organism. This disintegration, of course, is like “the separation of body and soul” definition not an observable definition. Seemingly, there is no perfect answer to the meaning of death. We have no eyewitness testimony(proof): no one has died and come back to life and painted a clear picture of what death really is. From the Christian or religious perspective, death is not the end of life, but rather a transformation. Abera S. keep social distance

24. Ethiopians have an elaborate traditions associated with death and bereavement. Though death has become a part of everyday life just like war, famine and disease; people take it seriously, and almost personally. When someone dies in Ethiopia, in addition to the conventional signs of grief, there are specific characteristics unique to communities in rural region. Abera S. keep social distance

25. The universal grief responses may be the same but culturally sanctioned ritual vary tremendously among the various ethnic, religious, and cultural groups in the country. Approximately 887 deaths/100,000 populations die in Ethiopia each year. people with advanced life threatening illnesses and their families should expect good end of life care , whatever the cause of their condition. Abera S. keep social distance

26. In both urban and rural Ethiopia, a funeral is a significant event that involves the whole community. It is a big public affair which follows strict rules and religious customs. Abera S. keep social distance

27. For instance, in southern Ethiopia where various ethnic groups co-exist together, the celebration of the dead takes a longer process. Handling the body, managing the funeral process, and the commemoration of the death follows culturally prescribed ritual. The process of informing family members is handled with great sensitivity. Abera S. keep social distance

28. News of the death is orchestrate carefully, and done by a group of elderly or respected community members. As soon as the bad news is announce, people start gathering at the deceased’s home to comfort the grieving family. Families are expected to express their grief openly. Abera S. keep social distance

29. Usually they cry, wail loudly, call out the name of the deceased, and beat their foreheads and chests. Female relatives may scratch their face and tear out their hair, throw themselves to the ground, faint, or attempt to harm themselves as a manifestation of intense grief. Abera S. keep social distance

30. Men often chant songs, praise and tell stories about the deceased one. Young men help with setting up rooms, looking after the arriving guests, digging the burial site and preparing the casket. Three days of mourning is the norm, and families are under social pressure to do so even if their circumstances do not allow that. Abera S. keep social distance

31. Unlike in many parts of the country where the dead is buried on the same day, in southern regions such as in Kemabta , Hadiya , Sidama , and Wolayita the burial takes place on the third day, sometimes even longer. Abera S. keep social distance

32. In developed countries dying has become increasingly hospitalized and medical and place of death has been an issue of interest to public heath policy and to palliative care in particular. In contrast, dying at home is highly prevalent in Africa partly due to lack of accessibility of modern health services. Abera S. keep social distance

33. In turn, limited infrastructure and health care deliveries in Africa complicate access to health services. communicable diseases are the primary illnesses in Ethiopia. Acute respiratory infections such as tuberculosis, upper respiratory infections, and malaria are the Ministry of Health's priority health problems. Abera S. keep social distance

34. Ethiopia is a country of diverse cultures, traditions and histories with poor health outcomes even by sub- saharan Africa's standards. Poverty, backwardness, malnutrition, limited access to health services and unbalanced population growth coupled with harmful traditional practices are blamed for the poor health outcome of the country. Abera S. keep social distance

35. Despite extensive poverty and limited resources, in the last decade Ethiopia has made impressive progress in improving its health care system. The improvement is especially on training of health extension workers, expansion of health center and improved staffing, proper provision of equipment, essential medicines and other supplies that led to a marked increase in the uses of primary health services. Abera S. keep social distance

36. 1.2 socio-cultural context Although each individual experiences terminally illness uniquely, such illness is also shaped substantially by the social and cultural contexts in which it occurs. In Ethiopia life threatening illness, life- sustaing treatment decisions, dying, and death occur in a social environment where illness is largely considered a foe/enemy and where battles are either lost or won. Abera S. keep social distance

37. Clinicians reluctance to discuss disease and death openly with patient stems from there anxieties about death as well as misconceptions about what and how much patients want to now about their illnesses. In an early study of care of the dying in hospital setting, sociologist glaser and strauss (1965) discovered that health care professionals in hospital setting avoided direct communication about dying in hope that the patient would discover it on his or her own. Abera S. keep social distance

38. They identified four awareness context, described as the patients physicians, family's and other health care professionals awareness of the patient status and their recognition of teach others awareness: 1. closed awareness: the patient is unaware of his or her terminal state while others are aware. Abera S. keep social distance

39. Closed awareness may be characterized by families and health care professionals conspiring to guard the secret fearing that the patient would not be able to cope with full disclosure about his or his status, and the patient acceptance of others accounts his or her future biography as long as they give him or her no reason to be suspicious. Abera S. keep social distance

40. 2. suspected awareness: The patient suspects what other know and attempts to find out. Suspected awareness may be triggered by inconsistencies in families and clinicians communication and behavior, discrepancies between clinicians accounts of the seriousness of the patient illness , or a decline in the patients condition or other environmental cues. Abera S. keep social distance

41. 3. Mutual pretense awareness: the patient , the family and the health care professionals are aware that the patient is dying but all pretend otherwise. 4. open awareness: All are aware that the patient is dying and are able to openly acknowledge that reality. Abera S. keep social distance

42. The key terms in socio-cultural context: Attitude : a state of mind or a feeling, disposition: an attitude of open mindedness. value : a principle, standard or quality considered worthwhile or desirable. Belief : something believed or accepted as true, especially a particular tenet or a body of tenets accepted by a group of persons. Abera S. keep social distance

43. Societal : of or relating to the structure, organization, or functioning of society, relating to human society and its members; social institutions ,societal evolution, societal forces, social legislation. Culture : the totality of socially transmitted behavior patterns, arts beliefs, institutions, and all other products of human work and thought. Abera S. keep social distance

44. 2. Setting for end –of-life care : palliative care programs and hospice 2.1 palliative care : is an area of healthcare that focuses on relieving and preventing the suffering of patients, that improves the quality of life patient their families facing problems associated with life- threating illness. Abera S. keep social distance

45. Central to this type of care is an interdisciplinary team approach that typically encompasses pain and symptom management, spiritual and psychological care for the patient, and support for family caregivers during the patient's illness and the bereavement period. Abera S. keep social distance

46. Terminally ill patients have a wide variety of advanced diseases, often with multiple symptoms demanding relief, and require noninvasive therapeutic regimens to be delivered in flexible care settings. Abera S. keep social distance

47. Fundamental to ensuring quality palliative and end-of-life care is a focus on four broad domains: (1) physical symptoms; (2) psychological symptoms; (3) social needs that include interpersonal relationships, care giving, and economic concerns; and (4) existential or spiritual needs. Abera S. keep social distance

48. 1. physical symptoms; Pain Fatigue and weakness Dyspnea Insomnia Dry mouth Anorexia Nausea and vomiting Constipation Abera S. keep social distance

49. ` Cough Swelling of arms or legs  Itching   Diarrhea Dysphagia   Dizziness   Fecal and urinary incontinence   Numbness/tingling in hands/feet Abera S. keep social distance

50. 2 . psychological symptoms; Anxiety Depression Hopelessness Meaninglessness Irritability Impaired concentration Confusion Delirium Loss of libido Abera S. keep social distance

51. A comprehensive assessment screens for and evaluates needs in each of these four domains. Goals for care are established in discussion with the patient and/or family based on the assessment in each of these domains. Interventions are then aimed at improving or managing symptoms and needs. Abera S. keep social distance

52. Palliative medicine is appropriate for patients in all disease stages, including Those undergoing treatment for curable illness. Those living with chronic diseases. As well as patients who are nearing the end of life. Abera S. keep social distance

53. Palliative medicine utilizes a multidisciplinary approach to patient care, relying on input from physicians, pharmacists , nurses, social workers, psychologists, and other allied health professionals in formulating a plan of care to relieve suffering in all areas of a patient's life. This multidisciplinary approach allows the palliative care team to address physical, emotional, spiritual, and social concerns that arise with advanced illness. Abera S. keep social distance

54. Medications and treatments are said to have a palliative effect if they relieve symptoms without having a curative effect on the underlying disease or cause. For example treating nausea related to chemotherapy. Abera S. keep social distance

55. Palliative care: provides relief from pain and other distressing symptoms affirms life and regards dying as a normal process intends neither to hasten or postpone death integrates the psychological and spiritual aspects of patient care offers a support system to help patients live as actively as possible until death offers a support system to help the family cope during the patients illness and in their own bereavement Abera S. keep social distance

56. uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated will enhance quality of life, and may also positively influence the course of illness Abera S. keep social distance

57. is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications Abera S. keep social distance

58. Where palliative care GIVEN ? In the home In a hospital In an aged care home In a hospice. Abera S. keep social distance

59. Most people prefer to receive palliative care in the home, but this will depend on many factors including: The nature of the illness. How much support is available from the patient’s family and community? Whether the patient has someone who can care for them. Abera S. keep social distance

60. Ethical consideration in palliative care Four basic principles Respect for patient’s autonomy Beneficence (prevent harm and do good) Non- maleficence (no deliberate harm) Justice (fairness) Abera S. keep social distance

61. Palliative care services require skills in Communication Decision-making Management of pain and symptom Management of complication of treatment and the disease Psychosocial care for the patient and family Spiritual understanding and approaches Care of the dying Bereavement care Abera S. keep social distance

62. Scope of the term Palliative care is specialized medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness whatever the prognosis. The goal is to improve quality of life for both the patient and the family as they are the central system for care. Abera S. keep social distance

63. World Health Organization describes palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Abera S. keep social distance

64. ." More generally, however, the term "palliative care" may refer to any care that alleviates symptoms, whether or not there is hope of a cure by other means; thus, palliative treatments may be used to alleviate the side effects of curative treatments, such as relieving the nausea associated with chemotherapy Abera S. keep social distance

65. Components of palliative care Symptom management Preventive care Psychosocial and spiritual support End-of-life care Abera S. keep social distance

66. Guideline for the management of palliative care Problems 1. End-of-life decision making and care planning Goal Resident’s advance directives will be followed. In the event of no advance directives, direction for care will be sought from Medical Durable Power of Attorney (MDPOA). If no MDPOA, interested persons will select a proxy and selection will be documented in chart. Abera S. keep social distance

67. Intervention Meet with resident and/or resident’s agent (MDPOA) to ascertain the level of aggressive intervention the resident should receive. Review previously documented advance directives. Provide education/information on interventions such as: hospitalization, IVs, artificial nourishment, mechanical ventilation, dialysis, blood transfusions, antibiotics, diagnostic testing, and pain medication. Abera S. keep social distance

68. Interv …. Document in advance directives or Medical Orders for Scope of Treatment (MOST). Instruct on hospice care benefit and provide resources. Determine if family consents to hospice care. Abera S. keep social distance

69. 2. Knowledge deficit Goal Resident/family will have understanding of the plan of care. Resident/family will verbalize their wishes and desires to be incorporated into plan of care. Intervention Identify resident/family readiness to learn about trajectory of illness/prognosis including attitudes toward death and dying. Abera S. keep social distance

70. Ensure they understand prognosis and have declined more aggressive treatment options. Discuss and document funeral arrangements. Discuss process on disposition of the body, coroner involvement, and disposition of belongings. Discuss need for spiritual care and provide support as requested. Abera S. keep social distance

71. 3. Pain or discomfort Goal Pain scale will be used. Resident will achieve and maintain tolerable level of physical comfort. Intervention Assess pain every shift (or more frequently if pain is greater than goal) until under control. Change or titrate pain meds per doctor’s orders. Offer different routes for pain meds. Provide comfort measures such as positioning, turning, calm/quiet atmosphere, relaxation, music, massage. Educate resident/family on pain and pain relief. Abera S. keep social distance

72. 4. Dyspnea and shortness of breath Goal Resident denies dyspnea or reports it as tolerable. Intervention Promote maximal inspiration (elevate head of bed, increase air circulation, use fan, allow for rest periods). Titrate oxygen as ordered. Medicate as ordered with opioids . Manage secretions including suctioning and medication. Abera S. keep social distance

73. 5. Decreased cardiovascular circulation Goal Alleviate distressing symptoms such as edema, cold, or heat. Intervention Monitor resident for comfort. Respect patient/MDPOA or proxy requests for nonintervention. Assess activity tolerance, ranging from frequent rest periods to complete bed rest. Elevate lower extremities to prevent edema. Compression hose if ordered. Environmental control. Abera S. keep social distance

74. 6. Anorexia and decreased food and fluid intake related to nausea, fatigue, opioids , underlying disease, fasting Goal Maintain nutritional status within disease limitations. Awareness that anorexia, weight loss are typical natural trajectories of the underlying illness. Abera S. keep social distance

75. Intervention Assess resident’s dietary preferences and tolerance. Lift dietary restrictions. Offer small frequent meals, snacks, and fluids as resident will tolerate. Offer assistance to eat and drink. Honor resident’s wishes to not eat. Medicate with anti-emetics as ordered. Abera S. keep social distance

76. 7. Risk for skin breakdown related to poor intake, hydration, mobility Goal Maintain skin integrity without signs and symptoms of infection. Intervention Turn and position for comfort PRN and as resident tolerates. Assess for skin integrity with turning and positioning with supports. Abera S. keep social distance

77. Teach family that effects of poor nutrition and compromised circulation may result in impaired skin integrity despite vigorous intervention. Keep skin clean and dry; keep linens smooth and wrinkle free. Use pressure-reducing devices if resident appears at risk. Abera S. keep social distance

78. 8. Need for frequent mouth care related to thirst, dry mouth, dehydration, reduced oral intake, opioids , and mouth breathing Goal Resident will maintain intact mucosa. Intervention Assess oral mucosa every shift or PRN. Provide mouth care BID and PRN to include cleansing, swabbing, and lip moisteners. Offer ice chips, hard candy when appropriate. Abera S. keep social distance

79. 9. Urinary elimination Goal Maintain urine output within disease limits. Intervention Assess for signs and symptoms of urinary retention. Assess for need for catheter during end-of-life care. Perinial care BID and PRN. Assess for signs of renal shutdown. Instruct family on relevance. Abera S. keep social distance

80. 10. Risk for constipation related to decreased food intake and use of analgesics Goal Maintain bowel elimination within limits of disease process. Intervention Use bowel protocol PRN. Encourage fluids/activity within limits of disease process. Assess for signs and symptoms of discomfort related to constipation. Abera S. keep social distance

81. Hospice care Hospice care is a type and philosophy of care that focuses on the palliative care of a terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs. The focus of hospice care is on palliation of the patient's pain and symptoms. These symptoms may be physical, emotional, or psychosocial in nature. Patients’ symptoms and pain are controlled. Abera S. keep social distance

82. Hospice believes that the end of life is not a medical experience; it is a human experience that benefits from expert medical and holistic support that hospice offers. Provides support and care for those in the last phases of life-limiting illness. Recognizes dying as part of the normal process of living. Abera S. keep social distance

83. Hospice Admission Criteria Life-limiting illness, prognosis is 6 months or less if disease takes normal course Patient wants hospice (consents to accept services) Seeking palliative (pain and symptom relief) rather than curative treatment. Abera S. keep social distance

84. Benefits of hospice: By selecting hospice, resident has clearly asked that his/her care be focused on palliation. Added attention to pain management and other symptoms related to life-ending illness. One-on-one emotional support for the resident and the family. May have financial relief due to Hospice paying for medication, supplies, and equipment related to the terminal illness. Volunteers visit residents and provide interaction with the resident and/or family. Abera S. keep social distance

85. NB:- All of hospice is palliative care, but not all of palliative care is hospice Abera S. keep social distance

86. LO2. NURSING CARE OF THE PATIENT WHO IS CLOSE TO DEATH Providing care to the patient who is close to death and being present at the time of death can be one of the most satisfying experiences a nurse can have. Abera S. keep social distance

87. 2.1 Expected physiologic changes when the patient is close to death Observable, expected changes in the body take place as the patient approaches death and organ systems begin to fail. Nursing care measures aimed at patient comfort should be continued: pain medications(administered rectally or sublingually), mouth care, eye care, positioning to facilitate draining of secretions, and measures to protect the skin from incontinence Abera S. keep social distance

88. The nurse should consult with the physician about discontinuing measures that no longer contribute to patient comfort such as drawing blood administering tube feedings suctioning (in most cases) and invasive monitoring Abera S. keep social distance

89. The nurse should prepare the family for the normal, expected changes that accompany the period immediately preceding death. Although the exact time of death cannot be predicted, it is often possible to identify when a patient is very close to death. Abera S. keep social distance

90. 2.2 Signs of Approaching Death 1. Anorexia / The person will show less interest in eating and drinking. For many patients, refusal of food is an indication that they are ready to die. Fluid intake may be limited to that which will keep their mouths from feeling too dry. Abera S. keep social distance

91. What you can do : Offer, but do not force, fluids and medication. Sometimes, pain or other symptoms that have required medication in the past may no longer be present. For most patients, pain medications will still be needed, and can be provided by concentrated oral solutions placed under the tongue or by rectal suppository. Abera S. keep social distance

92. 2. Oligouria /Urinary output may decrease in amount and frequency. What you can do : No response is needed unless the patient expresses a desire to urinate and cannot. 3. F atigue/ As the body weakens, the patient will sleep more and begin to detach from the environment. He or she may refuse your attempts to provide comfort. Abera S. keep social distance

93. What you can do: Allow your loved one to sleep. You may wish to sit with him or her, play soft music, or hold hands. Your loved one’s withdrawal is normal and is not a rejection of your love. 4. Mental confusion may become apparent As less oxygen is available to supply the brain. The patient may report strange dreams or visions. What you can do : As he or she awakens from sleep, remind him or her of the day and time, where he or she is, and who is present. This is best done in a casual, conversational way. Abera S. keep social distance

94. 5. Vision and hearing may become somewhat impaired and speech may be difficult to understand. What you can do : Speak clearly but no more loudly than necessary. Keep the room as light as the patient wishes, even at night. Carry on all conversations as if they can be heard, since hearing may be the last of the senses to cease functioning. Abera S. keep social distance

95. Many patients are able to talk until minutes before death and are reassured by the exchange of a few words with a loved one. 6. Secretions may collect in the back of the throat and rattle or gurgle as the patient breathes though the mouth. He or she may try to cough, and his or her mouth may become dry and encrusted with secretions. Abera S. keep social distance

96. What you can do : if the patient is trying to cough up secretions and is experiencing choking or vomiting, call the hospice nurse for assistance. Secretions may drain from the mouth if you place the patient on his/her side and provide support with pillows. Cleansing the mouth with moistened mouth swabs will help to relieve the dryness that occurs with mouth breathing. Offer water in small amounts to keep the mouth moist. Abera S. keep social distance

97. 7. Apnea/ Breathing may become irregular with periods of no breathing The patient may be working very hard to breathe and may make a moaning sound with each breath. As the time of death nears, the breathing remains irregular and may become more shallow and mechanical. What you can do : Raising the head of the bed may help the patient to breathe more easily. The moaning sound does not mean that the patient is in pain or other distress; it is the sound of air passing over very relaxed vocal cords. Abera S. keep social distance

98. 8. As the oxygen supply to the brain decreases, the patient may become restless. It is not unusual to pull at the bed linens, to have visual hallucinations, or even to try to get out of bed at this point. What you can do : Reassure the patient in a calm voice that you are there. Prevent him/her from falling by trying to get out of bed. Soft music or a back rub may be soothing. Abera S. keep social distance

99. 9. The patient may feel hot one moment and cold the next as the body loses its ability to control the temperature. As circulation slows, the arms and legs may become cool and bluish. The underside of the body may darken. It may be difficult to feel a pulse at the wrist What you can do : Provide and remove blankets as needed. Abera S. keep social distance

100. Avoid using electric blankets, which may cause burns because the patient cannot tell you if he or she is too Sponge the patient’s head with a cool cloth if this provides comfort. 10. Urinary or fecal incontinence/ Loss of bladder and bowel control What you can do : Protect the mattress with waterproof padding and change the padding as needed to keep the patient comfortable. Abera S. keep social distance

101. 2.3 The death vigil Although every death is unique, it is often possible for the experienced clinician to assess that the patient is “actively” or imminently dying and to prepare the family in the final days or hours leading to death. As death nears, the patient may withdraw, sleep for longer intervals, or become somnolent. Abera S. keep social distance

102. The family should be encouraged to be with the patient, to speak and reassure him or her of their presence, to stroke or touch him or her, or to lie alongside him or her. In any setting, it is unrealistic for family members to be at the patient’s bedside 24 hours a day, and it is not unusual for patients to die when the family has stepped away from the bedside just briefly. Abera S. keep social distance

103. Experienced hospice clinicians have observed and reported that some patients appear to “wait” until family members are away from the bedside to die, perhaps to spare their loved ones the pain of being present at the time of death. The nurse can reassure family members throughout the death vigil by being present intermittently or continuously, modeling behaviors (such as touching and speaking to the patient), providing encouragement in relation to family caregiving , providing reassurance about normal physiologic changes, and encouraging family rest breaks. Abera S. keep social distance

104. When the patient dies while the family is away from the bedside, the family may express feelings of guilt and profound grief and will need emotional support. Abera S. keep social distance

105. 2.4 Care of the terminally ill patient Objectives: At the end of this lesson, you will be able to: Define terminally ill care List purposes of assisting the dying client Assemble the necessary equipment for care of dying patient Practice the care of terminally ill patients Abera S. keep social distance

106. Terminally ill patient Definition: A patient needs intensive physical and emotional support as S/he approaches death. Purpose To provide personal hygiene To provide spiritual support To support the family

107. Equipment 1. Clean bed linens, clean gowns, gloves 2. Water-filled basin 3. Soap and wash cloth 4. Towels , lotion, linen - saver pads 5. Lemon-glycerin swabs 6. Petroleum jelly 7. Suction and resuscitation equipment, as necessary 8. Optional: indwelling urinary catheter.

108. Procedures 1. Introduce self and verify client’s identity. 2. Explain the procedure to the client 3. Gather appropriate equipment. Meeting physical needs 4.Take vital signs often, and observe for pallor, diaphoresis, and decreased LOC 5. Reposition the patient in bed at least every 2 hours because sensation, reflexes, and mobility diminish first in the legs and gradually in the arms. Make sure the bed sheets cover him loosely to reduce discomfort caused by pressure on arms and legs.

109. 6 . When the patient's vision and hearing start to fail, turn his head toward the light and speak to him from near the head of the bed. Because hearing may be active despite loss of consciousness, avoid whispering or speaking inappropriately about the patient in his presence .

110. Cont’d… 7. Change the bed linens and the patient's gown as needed. Provide skin care during gown changes, and adjust the room temperature for patient comfort if necessary. 8. Observe for incontinence or anuria , the result of diminished neuromuscular control or decreased renal function. If necessary, obtain an order to catheterize the patient, or place linen saver pads beneath the patient's buttocks. Put on gloves and provide perineal care with soap, a washcloth, and towels to prevent irritation.

111. Cont’d… 9. With suction equipment, suction the patient's mouth and upper airway to remove secretions. Elevate the head of the bed to decrease respiratory resistance. As the patient's condition deteriorates, s/he may breathe mostly through his/her mouth. 10. Offer fluids frequently, and lubricate the patient's lips and mouth with petroleum jelly or lemon-glycerin swabs to counteract dryness.

112. Cont’d…terminally ill pt 11. If the comatose patient's eyes are open, provide eye care to prevent corneal ulceration. Such ulceration can cause blindness and prevent the use of these tissues for transplantation 12. Provide ordered pain medication as needed. Keep in mind that, as circulation diminishes, medications given I.M. will be poorly absorbed. Medications should be given I.V., if possible, for optimum results. Some medications can be given sublingually or rectally if the patient can't swallow or has no I.V. access.

113. Meeting emotional needs 13. Fully explain all care and treatments to the patient even if he's unconscious because he may still be able to hear. Answer any questions as candidly as possible without sounding callous/unfeeling/. 14. Allow the patient to express his feelings, which may range from anger to loneliness. Take time to talk with the patient. Sit near the head of the bed, and avoid looking rushed or unconcerned. 15. Notify family members, if they're absent, when the patient wishes to see them. Let the patient and his families discuss death at their own pace.

114. …procedure 16. Offer to contact a member of the clergy/religious person/ or social services department, if appropriate. 17 . Record changes in the patient's vital signs, intake and output, and LOC. Note the times of cardiac arrest and the end of respiration, and notify the physician when these occur.

115. Special considerations If the patient has not signed a living will, the physician will write a Do-not-resuscitate (DNR) order on his progress notes and order sheets. Know your state's policy regarding the living will. If it's legal, transfer the DNR order to the patient's chart or Kardex and, at the end of your shift, inform the incoming staff of this order. If family members remain with the patient, show them the location of bathrooms, lounges, and cafeterias.

116. LO 3. DEATH Death is the permanent cessation of all biological functions that sustain a particular living organism Associated terms; - When a person has died, it is also said they have passed away , passed on , or expired . The dead person is then a corpse , cadaver , a body , a set of remains , and finally a skeleton . Abera S. keep social distance

117. Legal Aspect of Death 1.Certification of death: - A death certificate must be made out when a person dies. 2.Labeling of the deceased: - you have to handle the deceased with dignity and label the corpse appropriately. Mishandling can cause emotional distress to the survivor. 3.Autopsy: - Post mortem examination is an examination of the body after death. To know the exact cause of death. Abera S. keep social distance

118. 4.Organ donation: - It is process of make a gift of all or any part of the body for the following purposes. For medical or dental science, therapy or transplantation. The donation can be made by a provision will or by signing a card like form in the presence of two witnesses. 5. Inquest: - is a legal inquiry into the cause or manner of a death. 6. Euthanasia: - is the act of painlessly putting to death persons suffering from incurable or distressing disease. It is commonly referred to as “Mercy killing Abera S. keep social distance

119. Signs of death Signs of death or strong indications that an animal is no longer alive are: Cessation of breathing Cardiac arrest (no pulse ) Pallor , paleness which happens in the 15–20 minutes after death Algor morti s , the reduction in body temperature following death. Rigor mortis , the limbs of the corpse become stiff (Latin rigor ) and difficult to move or manipulate. Abera S. keep social distance

120. 3 .1. Stages of death and dying The Kübler -Ross model , commonly referred to as the " five stages of grief ", is a hypothesis introduced by Elisabeth Kübler -Ross and says that when a person is faced with the reality of impending death or other extreme he or she will experience a series of emotional stages: denial , anger , bargaining , depression , and acceptance . Abera S. keep social distance

121. Stages The stages, popularly known by the acronym DABDA , include: Denial : - "I feel fine."; "This can't be happening, not to me." Denial is usually only a temporary defense for the individual. Denial can be conscious or unconscious refusal to accept facts, information, or the reality of the situation. Denial is a defense mechanism and some people can become locked in this stage. Abera S. keep social distance

122. Anger :- "Why me? It's not fair!"; "How can this happen to me?"; '"Who is to blame?" the individual recognizes that denial cannot continue. Because of anger, the person is very difficult to care for due to misplaced feelings of rage and envy. Anger can manifest itself in different ways. People can be angry with themselves, or with others, and especially those who are close to them. It is important to remain detached and non-judgmental when dealing with a person experiencing anger from grief. Abera S. keep social distance

123. Bargaining -"I'll do anything for a few more years."; "I will give my life savings if...“ The third stage involves the hope that the individual can some how postpone or delay death. Usually, the negotiation for an extended life is made with a higher power in exchange for a reformed lifestyle. Psychologically, the individual is saying, "I understand I will die, but if I could just do something to buy more time..." Abera S. keep social distance

124. Depression — "I'm so sad, why bother with anything?"; "I'm going to die soon so what's the point?"; "I miss my loved one, why go on?“ During the fourth stage, the dying person begins to understand the certainty of death. Because of this, the individual may become silent, refuse visitors and spend much of the time crying and grieving. This process allows the dying person to disconnect from things of love and affection. Abera S. keep social distance

125. Depression could be referred to as the dress rehearsal for the 'aftermath'. It is a kind of acceptance with emotional attachment. ]It's natural to feel sadness, regret, fear, and uncertainty when going through this stage. Abera S. keep social distance

126. Acceptance — "It's going to be okay."; "I can't fight it, I may as well prepare for it.“ In this last stage, individuals begin to come to terms with their mortality, or that of a loved one, or other tragic event. This stage varies according to the person's situation. People dying can enter this stage a long time before the people they leave behind, who must pass through their own individual stages of dealing with the grief. Abera S. keep social distance

127. 3 .2. After-death care The terminology “care after death” has been introduced to reflect the range of nursing responsibilities involved. These include the following: Supporting any family and carers present who want to take part in the caring process; Honoring the religious or cultural wishes/requirements of the deceased and their family while ensuring legal obligations are met; Preparing the deceased for transfer to the mortuary or the funeral director’s premises; Abera S. keep social distance

128. Ensuring the deceased’s privacy and dignity is maintained; Ensuring the health and safety of everyone who comes into contact with the deceased is protected; Returning the deceased’s personal possessions to the next of kin. Abera S. keep social distance

129. 3 .2.1. care of the body No matter your role in death pronouncement, a final nursing assessment should be performed and documented.  Documentation regarding the death of the patient may include: The patient’s name, time of physician contact, and death pronunciation Abera S. keep social distance

130. The time of the assessment ( General appearance) Lack of reflex or response to stimulus including pupils that are fixed and dilated The absence of breathing and lung sounds The absence of both apical and carotid pulse Any other pertinent details from the physical examination Time the physician assessed the patient or was notified Identification of all parties notified of the death Abera S. keep social distance

131. Special plans for disposition organ donation, autopsy, or cultural/religious needs After death, the body should be prepared in order to give a clean, peaceful impression for those family members who desire an opportunity to say good-bye before funeral home removal.  Kindly caring for the body shows the family empathy and concern, the continued value of the deceased, as well as modeling grief facilitating behaviors for others present.  Religious or cultural practices the family may find comforting should be encouraged.  Abera S. keep social distance

132. It is also appropriate to invite them to participate in the preparation of the body. After the patient is pronounced, you'll prepare the body for viewing by the family and transport to the morgue or funeral home. Keep in mind that once the heart stops, the body generally loses heat ( algor mortis) at a rate of about 1.5 F (0.84 C) per hour until it reaches room temperature. While the patient feels cool to the touch, he's still warm enough for bacteria to begin breaking down body tissues. Abera S. keep social distance

133. Refrigeration is necessary to slow decomposition, so try not to keep the body on your unit for more than an hour. (Some hospital polices permit a maximum of two hours.) You'll have to juggle the timing of care to accommodate the family. Abera S. keep social distance

134. 3 .2.2. Positioning of a cadaver (dead body) (post mortem care) Procedures for death pronouncement vary from state to state and sometimes within the individual state as well.   Abera S. keep social distance

135. Place patient in supine position. Once the patient's death has been confirmed, place the patient in an upright position, straightening his/her limbs by his/her sides and lowering the eyelids. If his/her eyelids will not remain closed on their own initially, you can place wet gauze pads over the closed eyes until they remain closed on their own. This is part of preparing the body for the family to view it before it is taken to the morgue and both procedures make the patient seem at peace. Abera S. keep social distance

136. Bathe the dead body. It is normal for any excess secretions in the body, such as those in the bowel and bladder, to exit the body once death has occurred. Out of respect for the patient and his family, the deceased should be bathed completely with just as much care as you'd give if he were still alive. Once the bath is complete, dress the patient in a fresh gown, comb his hair and cover him with fresh linen up to his chin, leaving his arms exposed at his sides. Abera S. keep social distance

137. Raise the head of the bed. A condition called liver mortis will begin to set in approximately 20 minutes after the patient has passed. Once the circulation in the body has stopped, gravity takes over, pulling the blood downward. If the head is not elevated, the blood will begin to pool around the sides of the face, the earlobes and the neck, leaving a deep, reddish-purple discoloration in these areas. To prevent this, raise the head of the bed to a 30-degree angle and place one or two pillows under the patient's head. Abera S. keep social distance

138. Place a washcloth under the patient's chin. Rigor mortis, a stiffening of the muscles, can begin as soon as ten minutes after death and can take up to six hours to occur. Placing a rolled up washcloth under the deceased's chin will help the jaw stay closed until rigor mortis takes place. Abera S. keep social distance

139. Place deceased in the shroud bag. Once the family has had time to spend with the patient, it is time to place his/her into the shroud bag. Before doing so, fill out the tags that come in the shroud kit so that the patient can be properly identified. One tag will be attached to a big toe. The other tag will be placed on the outer zipper of the bag, once the deceased has been placed inside Abera S. keep social distance

140. If she had dentures, they need to be placed in a cup with his/her name clearly labeled on the lid and tucked inside the bag with her. Lift the patient, taking special cares for his/her head and limbs and transfers her onto the cart from the morgue. The head of the cart should be elevated in a continuing effort to prevent liver mortis. Abera S. keep social distance

141. Tips & Warnings Before the family members leave the facility, they should be given a bag with the patient's clothing and any valuable items he may have had. Abera S. keep social distance

142. Postmortem care/Care after Death Postmortem care involves the physical caring for the body after death, respecting as much as possible the wishes of the deceased and family. Abera S. keep social distance

143. Purpose To show respect for the dead To prepare the body for morgue To prevent spread of infection To show kindness to the family To preserve the natural appearance of the body for the family and relatives Abera S. keep social distance

144. Body Changes 1. Rigor mortis: - Is the stiffening of the body that occurs about 2 to 4 hours after death. It results from a lack of ATP which is not synthesized because of a lack of glycogen in the body. ATP is necessary for muscle fiber relaxation. Rigor mortis starts in the involuntary muscles (hearts, bladder and soon) then progresses to the head, neck and trunk and finally reach to the extremities. Place dentures in the mouth and close eye and mouth before rigor mortis set in. Abera S. keep social distance

145. 2. Algor mortis: - is gradual decrease of body temperature after death. When blood circulation terminates and hypothalamuses cease to function body temperature falls about 1.5co per hour. 3. Livor mortis : - After blood circulation has ceased the skin become discolored. The red blood cells break down releasing hemoglobin which discolors the surrounding tissue. This discoloration referred to as Livor mortis. The hotter the temperature the more rapid the change. Therefore bodies are often stored in cool places to delay this process Abera S. keep social distance

146. Equipment Gauze or soft string ties, gloves Chin straps, cotton balls, plastic shroud or body wrap Three identification tags Adhesive bandages to cover wounds or punctures Plastic bag for patient's belongings Water-filled basin, soap, towels, washcloths, stretcher Abera S. keep social distance

147. Procedure 1.Note the exact time of death and chart it 2.If the doctor is present call him to pronounce death 3. Document any auxiliary equipment, such as a mechanical ventilator, still present. Put on gloves. 4. Place the body in the supine position, arms at sides and head on a pillow. Then elevate the head of the bed 30 degrees to prevent discoloration from blood settling in the face. Abera S. keep social distance

148. Procedure …. 5. If the patient wore dentures and your facility's policy permits, gently insert them; then close the mouth. Close the eyes by gently pressing on the lids with your fingertips. If they don't stay closed, place moist cotton balls on the eyelids for a few minutes, and then try again to close them. Place a folded towel under the chin to keep the jaw closed. Abera S. keep social distance

149. 6. Remove all indwelling urinary catheters, tubes, and tape, and apply adhesive bandages to puncture sites. Replace soiled dressings. 7. Collect all the patient's valuables to prevent loss. If you're unable to remove a ring, cover it with gauze, tape it in place, and tie the gauze to the wrist to prevent slippage and subsequent loss. 8. Clean the body thoroughly, using soap, a basin, and washcloths. Place one or more ABD pads between the buttocks to absorb rectal discharge or drainage. Abera S. keep social distance

150. 9. Cover the body up to the chin with a clean sheet. 10. Offer comfort and emotional support to the family and intimate friends. Ask if they wish to see the patient. If they do, allow them to do so in privacy. Ask if they would prefer to leave the patient's jewelry on the body. 11. After the family leaves, remove the towel from under the chin of the deceased patient. Pad the chin, and wrap chin straps under the chin and tie them loosely on top of the head. Then pad the wrists and ankles to prevent bruises, and tie them together with gauze or soft string ties. Abera S. keep social distance

151. 12. Fill out the three identification tags. Each tag should include the deceased patient's name, room and bed numbers, date and time of death, and physician's name. Tie one tag to the deceased patient's hand or foot, but don't remove his identification bracelet to ensure correct identification. Abera S. keep social distance

152. 13. Place the shroud or body wrap on the morgue stretcher and, after obtaining assistance, transfer the body to the stretcher. Wrap the body, and tie the shroud or wrap with the string provided. Then attach another identification tag to the front of the shroud or wrap, and cover the shroud or wrap with a clean sheet. If a shroud or wrap isn't available, dress the deceased patient in a clean gown and cover the body with a sheet. Abera S. keep social distance

153. 14. Place the deceased patient's personal belongings, including valuables, in a bag and attach the third identification tag to it. 15. If the patient died of an infectious disease, label the body according to your facility's policy. 16. Close the doors of adjoining rooms if possible. Then take the body to the morgue. Use corridors that aren't crowded and, if possible, use a service elevator. Abera S. keep social distance

154. 3 .2.3Grief, Mourning, and Bereavement A wide range of feelings and behaviors are normal, adaptive, and healthy reactions to the loss of a loved one. Grief is defined as the primarily emotional/affective process of reacting to the loss of a loved one through death. The focus is on the internal, intra-psychic process of the individual. Normal or common grief reactions may include components such as the following: Abera S. keep social distance

155. Numbness and disbelief. Anxiety from the distress of separation. A process of mourning often accompanied by symptoms of depression . Eventual recovery. Grief reactions can also be viewed as abnormal, traumatic, pathologic, or complicated. Although no consensus has been reached, diagnostic criteria for complicated grief have been proposed. Abera S. keep social distance

156. Bereavement :- is defined as the objective situation one faces after having lost an important person via death. Bereavement refers to the period of time during which mourning takes place. Abera S. keep social distance

157. Mourning is defined as the public display of grief. While grief focuses more on the internal or intra-psychic experience of loss, mourning emphasizes the external or public expressions of grief. Consequently, mourning is influenced by one's beliefs, religious practices, and cultural context. Abera S. keep social distance

158. 3 .3 Coping with Death and Dying All fear death and they all believe that they will live forever. But death will enter our lives. Why the Fear of Death? There are several reasons why we afraid of dying: The premature interruption of life activities. Effects of death upon family members, classmates and friends. The fear of death without dignity, for example, being kept alive by machine. The fear of nothingness after death. Abera S. keep social distance

159. Impact of Loss: The Grieving Process The grieving process usually consists of the following stages. Note that not everyone goes through all these stages. Denial and Shock At first, it may be difficult for you to accept your own dying or the death of a loved one. As a result you will deny the reality of death. Abera S. keep social distance

160. Anger During this stage the most common question asked is "why me?". You are angry at what you perceive to be the unfairness of death and you may project and displace your anger unto others. When given some social support and respect, you will eventually become less angry and able to move into the next stage of grieving. Abera S. keep social distance

161. Bargaining Many peoples try to bargain with some sort of diety . They probably try to bargain and offer to give up an enjoyable part of their lives in exchange for the return of health or the lost person. Guilt You may find yourself feeling guilty for things you did or didn't do prior to the loss.Forgive yourself. Accept your humanness Abera S. keep social distance

162. Depression You may at first experience a sense of great loss. Mood fluctuations and feelings of isolation and withdrawal may follow. It takes time for you, the grieving person, to gradually return to your old self and become socially involved in what's going on around you. Abera S. keep social distance

163. Loneliness As you go through changes in your social life because of the loss, you may feel lonely and afraid. The more you are able to reach out to others and make new friends, the more this feeling lessens. Abera S. keep social distance

164. Acceptance Acceptance does not mean happiness. Instead you accept and deal with the reality of the situation. Hope Eventually you will reach a point where remembering will be less painful and you can begin to look ahead to the future and more good times. Abera S. keep social distance

165. Ways to Cope with Death and Dying Discuss feelings such as loneliness, anger, and sadness openly and honestly with others and family members. Maintain hope. Join a support group. Take good care of yourself. Eat well-balanced meals. Get plenty of rest. Be patient with yourself. It takes time to heal. Some days will be better than others. Abera S. keep social distance

166. Z End ! THANK YOU! Abera S. keep social distance