SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary

Objective: Provides Care to Client when Death is Imminent Objective: 2.5.1 Discusses own feelings and attitude about death. Competency

NATCEP Time: Class: Lab: Clinical:

Course Content

Learning Activities

After the completion of the lecture/discussion, the student will: 1. List how the nurse aides own feelings about death can affect the care of a dying client

1. The health care provider must recognize and deal with her/his own feelings and attitudes towards death in order to provide essential support to dying clients. Many factors influence attitudes toward death. Examples include age, personal experiences, culture, and religion. First encounters with death and the dying process can be frightening. The nurse aide can utilize co-workers as support system for dealing with the experience.

Students write their own obituary prior to the lecture. They pick an age to live (not a date). Read and discuss their thoughts and feelings. This activity could expose fears in caring for the dying client and create empathy.

Self-Inventory Exercise: How Do I Feel?

2.5.1

USE A SELF-INVENTORY TO DETERMINE YOUR FEELINGS ABOUT CARING FOR DYING PATIENTS LEARNING ACTIVITY 3: How Do I Feel Purpose: In this activity, you will answer questions that will help you understand more about your feelings about caring for dying patients. The better you understand your own responses to death and loss, the better you will be able to deal with patients and families experiencing death and loss. Regardless of the type of nursing you plan to do, you will have patients who die. This activity will help prepare you to care for dying patients. Work individually on this activity Read the self-inventory and mark the number that most describes your feelings about the statement Total your score and compare it to the scoring scale Special tools/equipment: Application: None needed for this activity After scoring your self-inventory, write a paragraph about your strengths and weaknesses in caring for dying patients. - What experiences in your life have given you insight into loss? - What experiences have given you a desire to avoid being near others who are grieving? - How will you draw on and overcome these experiences to care for dying patients? Hand in your paragraph to your facilitator

Instructions:

(continued on next page)

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LEARNING ACTIVITY: How Do I Feel Self-Inventory of Attitudes Towards Caring for Dying Patients Place a checkmark in the space that corresponds to your feelings about each statement. Statement Strongly Agree Undecided Disagree Strongly Agree Disagree I am afraid to care for a dying patient. I am very uncomfortable around people who are sad or crying. I do not want to touch a dying patient. Dying patients should be left in peace, not given usual nursing care such as bathing and turning. Terminally ill patients should not be told that they are dying. If I cry around dying patients or their families, I am not being professional. I am afraid to go into the room after a patient has died. If one of my patients were to die unexpectedly, I would feel that I must have made an error in care. I dont want dying patients to talk to me about their feelings; it makes me feel frightened. I am afraid that I might have to care for dying children or young adults.

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LEARNING ACTIVITY How Do I Feel? Scoring the self-inventory: Give yourself 5 points for every answer marked Strongly Agree. Give yourself 4 points for every answer marked Agree. Give yourself 3 points for every answer marked Undecided Give yourself 2 points for every answer marked Disagree. Give yourself 1 point for every answer marked Strongly Disagree. Interpreting the score: Scores of 41-50 indicate that you have a great deal of anxiety about caring for dying patients. Scores of 31-40 indicate that you are unsure and slightly anxious about caring for dying patients. Scores of 21-30 indicate that you are fairly confident in your ability to care for dying patients. Scores of 10-20 indicate that you are quite confident in your ability to care for dying patients.

Student Workbook: Nursing Skill Information Sheet: Module 17. Skills for Care of a Dying Patient, pg. 10.

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SUPPLEMENTAL MATERIALS: HANDOUTS

SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary Objective: Provides Care to Client when Death is Imminent

NATCEP Time: Class: Lab: Clinical:

Objective: 2.5.2 Explains how culture and religion influence a persons attitude toward death. Competencies Course Content

Learning Activities

After the completion of the lecture/discussion, the student will: 1. List how cultural and religious influences can affect how a dying client vies death 2. List 3, probing questions that can help the team indemnify specific cultural needs 3. List 4 examples of cultural variations/beliefs regarding death

1. Culture and religion provide a framework within which personal experiences with death take on meaning. Personal experiences, culture, religion, and age influence a persons individual set of beliefs in ways that may differ from your personal beliefs about death. The nurse aide must NOT impose his/her beliefs upon the dying client, the family, or those people close to the dying client. The nurse aide must show respect for the clients beliefs and the clients need for spiritual support. It is very important to identify the clients particular beliefs or practices before death occurs. Locate your facilitys policy regarding religious observances and requirements to be followed when death occurs. 2. It is important for the team to discover specific, cultural issues in order to provide respectful care to the dying client. Probing questions are: Who is allowed to provide personal care? (In some cultures, a member of the opposite sex cannot provide care.) Does the client or family have any special customs? Are there customs unique to their culture? What is the clients/caregivers understanding about medications? Are there specific post-mortem customs that the staff should know? 3. Samples of cultural variations regarding death and dying: Chinese culture Traditional healing practices include using herbal preparations that are given only once. Autopsy and disposal of the body are not permitted by religion; therefore, organ donation is encouraged.

Invite a hospice nurse (resource instructor) to share experiences of working with clients from different cultures.

Handout: Specific Religious Practices Handout Case Study: A well-liked client expires unexpectedly

SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary Objective: Provides Care to Client when Death is Imminent

NATCEP Time: Class: Lab: Clinical:

Objective: 2.5.2 Explains how culture and religion influence a persons attitude toward death. Competencies Course Content

Learning Activities

Japanese culture The number 4 means death, so getting medication four times a day (Q.I.D.) could be problematic. Some cultures view talking about funeral arrangements as problematic. Some cultures believe dying at home is preferable while others fear death at home. Vietnamese culture they believe in reincarnation, so quality of life is more important than the length of life. Hindu culture Persons are often accepting of Gods will. The clients desire to be clear headed at the time of death is critical. Prayer helps deal with anxiety and conflict. Blood transfusions, organ transplants, and autopsies are allowed. Cremation is preferred. Reincarnation is a Hindu belief.

2.5.2 SPECIFIC RELIGIOUS PRACTICES Judaism (Orthodox) Visits to dying person is a religious duty Witness must be present when death occurs Conversation kept to minimum Someone stays with body until burial (within 24 hours) Do not touch or wash body

Buddhism Buddhist priest is present at death Last rites chanted at bedside

Hinduism Priest ties thread around neck or wrist of deceased and pours water in mouth

Islam (Muslim) Before death reads Koran and prays Client confesses sins and asks forgiveness of family Only family touches and washes body After death body is turned toward Mecca

Baptist Clergy ministers through counseling and prayers

Roman Catholic Sacrament of sick administered to ill clients, to clients displaying signs of approaching death, or shortly after death.

Lutheran & Episcopalian Last rites optional

Eastern Orthodox Christian Last rites are mandatory and handled by an ordained priest.
SUPPLEMENTAL MATERIALS: HANDOUTS

2.5.2

CASE STUDY: Mrs. Jones is a 90 year old client who has resided in a long term care facility for 15 years. Over the years she has developed close bonds with the staff and her roommate, Mrs. Smith. One night Mrs. Jones passed away in her sleep unexpectedly. Mrs. Smith was in the room at the time Mrs. Jones expires.

Mrs. Jones is Jewish and her religion requires that she be buried prior to sunset the next day. Her family is located out of state and wishes to see her prior to burial.

QUESTION: 1. Identify you own feelings about death and how you would feel if you were in the same room when your room mate expired. How could the staff effectively express feelings of grief? How could you balance Mrs. Jones religious doctrines with the wishes of the family? How would you address needs of the roommate in terms of her loss?

2. 3. 4.

Source Unknown: Submitted by a PA Nurse Aide Training Program, 2011

SUPPLEMENTAL MATERIALS: HANDOUTS

SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary Objective: Provides Care to Client when Death is Imminent Objective: 2.5.3 Discusses the stages of dying. Competency

NATCEP Time: Class: Lab: Clinical:

Course Content

Learning Activities

After the completion of the lecture/discussion, the student will: 1. List the 5 stages of death and dying that a client may go through

Dr. Elizabeth Kubler-Ross distinguished five stages that dying people may experience. These stages are emotional experiences that are common to terminally ill patients. The experience is not the same for every person. Family and friends of the client may also go through the stages of loss and grief. The stages are not experienced in the exact order at all times and may fluctuate between any stage, in any order. The client may not show the same stage to all personnel at the same time. 1. The stages of death and dying are: Denial No, not me. a. The client and/or family refuse to believe the client is dying. They may feel a mistake has been made. They are not able to talk about death during this phase. Anger Why me? a. As the client faces death, they may be angry. Anger may be expressed at anyone or anything. It is important that the nurse aide not take the anger personally. Bargaining Yes, but if I could live to dance at my daughters wedding. a. Client may start a bargaining process with God in hopes of recovery or extended life. Depression Sadness a. As the dying client becomes weaker or symptoms become more obvious, they may become deeply sad or depressed. b. It is important to listen if the client wishes to talk.

Handout: Death and Dying Game.

Suggestion: A TV show called Three Rivers portrays various patients, families, and healthcare workers. It creates an understanding of the 5 stages of death and dying and how a person can go in and out of the stages and in more than one stage at a time.

SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary Objective: Provides Care to Client when Death is Imminent Objective: 2.5.3 Discusses the stages of dying. Competency

NATCEP Time: Class: Lab: Clinical:

Course Content

Learning Activities

Acceptance Peace a. Some clients eventually are able to accept death and prepare for it. b. They may ask to see an attorney, accountant, clergy, and family members.

2.5.3 DEATH AND DYING: A SIMULATION GAME CAUTION: Make sure this activity is appropriate for your students (e.g. anyone suffered a recent loss?) Purpose: To help individuals reach a conscious awareness of their thoughts, feelings, attitudes, and values associated with loss through dying and death. Objectives: At the completions of the simulation, each participant will be able to: Personalize issues of loss through dying and death Identify own thoughts, feelings, and attitudes about loss through dying and death Clarify own values about loss through dying or death Enable further private self-encounters about loss through dying and death Type: Group experience Equipment: One packet of twelve slips of paper for each individual in the group One pencil for each individual in the group Overhead transparency of questions for discussion (optional) Procedure and Instructions: Distribute the packets of paper and give the following instructions: On each of the small slips of paper, write one from each of the following twelve items: Three people who are very dear to you Three things you own that you regard as very special Three activities in which you enjoy participating, and Three personal attributes of which you are very proud Arrange the twelve slips of paper in front of you so that you can see all of them. Now get into a comfortable position and take a deep, relaxing breath. Listen without comment and follow the instructions I give you while I describe some happenings, some situations, and some people.

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SUPPLEMENTAL MATERIALS: HANDOUTS

2.5.3 Scenarios: (Scenarios should be developed carefully, with effort to awaken all the senses) 1. You are at your doctors officeyou hear the diagnosis. You have thirty seconds to select and tear up three of your slips of paper. You are back at homewho is there? Who do you want to be there? What do you say? What do you want to hear? Tear up another three slips of paper. Two months lateryou are aware your symptoms are worsening and you are feeling weaker. Where are you? What is your lifestyle? What do you continue to do? What can you do? Tear up another two slips of paper. Four months lateryou are undeniably ill. The pain has increased considerably. Where are you? Who stays with you? Who visits you? Who are the people you want around you? Tear up another two slips of paper.

2.

3.

4.

5.

Six months have passed, and you find that even the smallest activity of daily living takes most of your energy. How do you feel about yourself? Where are you? Who is with you? Turn over the last two slips of paper on the desk in front of you. I will take one from you at random. (Go to each participant and take one slip if paper.) Say only: Tear up your last slip of paper. You are dead.

6.

Discussion of Experience 1. Give participants 15-20 seconds to react and follow the last instruction. Say something reassuring, such as "Thanks for your involvement; Everyones reaction to this simulation is different; This can be painful for you, depending upon your experience with death and dying; I appreciate the thoughtfulness and effort you have put into this experience; You have done well, and now are ready for the next part." In small groups of three to four people, with one person acting as recorder, initiate discussion of some or all of the following questions: What issues came up for you with each scenario? Fears? Concerns? What were the easiest items to give up? The most difficult? When did this experience stop being just a game?

2.

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2.5.3

What emotional reactions did you have with each scenario? (Watch for denial, anger, bargaining, depression, acceptance, avoidance, relief, comfort) What did you think, feel, and/or experience when I took a slip of paper from you at random? Did I take the right one? Did you anticipate or expect the content of the last scenario? What were your thoughts, feelings and /or reactions to the tearing up of the last slip of paper?

*Note: The original Death and Dying Simulation Game was provided by Reverend Dick Lentz at St. Vincents Hospice in Indianapolis, IN. It was first introduced to a group of students on the Bloomington campus in April, 1986 by Carol Ebeling, executive director, Hospice of Bloomington.

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SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary Objective: Provides Care to Client when Death is Imminent Objective: 2.5.4 Identifies goals of hospice care. Competencies

NATCEP Time: Class: Lab: Clinical:

Course Content

Learning Activities

After the completion of the lecture/discussion, the student will: 1. Define hospice services 2. List 7 goals of hospice

1. Hospice care, also known as end-of-life care, focuses on the Handout: emotional, social, physical, and spiritual needs of dying The Dying Persons Bill of Rights persons and their families. Emphasis is placed on palliative care such as pain relief and comfort measures and not life-saving measures. Most people opt to have hospice service in their home. Generally, hospice is extended to individuals who have a life expectancy of 6 months or less. The goal is to improve the dying persons quality of life. Hospice also offers support groups for familys survivors or health team members. 2. The goals of hospice are: Offer compassionate care for a person with a terminal illness Focus on the client and family as a unit Include entire health care team in a medically managed plan of care Emphasize pain and symptom control Provide an alternative to traditional hospital care

2.5.4

The Dying Persons Bill of Rights

I have the right to: be treated as a living human being until I die maintain a sense of hopefulness, however changing its focus may be be cared for by those who can maintain a sense of hopefulness, however changing this might be express my feelings and emotions about my approaching death my own way participate in decisions concerning my care expect continuing medical and nursing attentions even though cure goals must be changed to comfort goals not die alone be free from pain have my questions answered honestly not be deceived have help from and for my family in accepting my death die in peace and dignity retain my individuality and not be judged for my decisions which may be contrary to beliefs of others discuss and enlarge my religious and/or spiritual experiences, whatever these may mean to others expect that the sanctity of the human body will be respected after death be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death

(This was created at a workshop on The Terminally Ill Patient and the Helping Person, sponsored by Southwestern Michigan In-service Education Council, and appeared in the American Journal of Nursing, Vol. 75, January, 1975, p.99.)

SUPPLEMENTAL MATERIALS: HANDOUTS

SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary Objective: Provides Care to Client when Death is Imminent

NATCEP Time: Class: Lab: Clinical:

Objective: 2.5.5 Identifies complementary therapies utilized during the stages of dying. Competency Course Content

Learning Activities

After the completion of the lecture/discussion, the student will: 1. List the members of the team and what they provide during the stages of dying

Care of a client during the stages of dying is supported by a holistic continuum of professionals and volunteers. 1. The team directs care to satisfy the client and family needs in the following way: Attending Physician: a. Present throughout the stages b. Certifies the terminal diagnosis c. Assesses the clients needs and prescribes treatment d. Directs and approves the clients care plan e. Coordinates therapies Social Worker: a. Assesses the clients and familys emotional needs through all stages b. Provides support during depression c. Refers to community agency as needed during acceptance (e.g., funeral arrangements and attorney for will) d. At the final stage, provides bereavement support. Chaplain: a. Provides support throughout b. Instrumental in assisting the client and family at the bargaining stage c. At the final stage, assists with memorial service and bereavement Volunteers: a. Provide companionship through, especially during depression b. Services during acceptance stage (e.g., letter writing, errands, respite time for family) c. Support during bereavement d. Contemporary therapy. E.g. Raki, massage, music, aroma

SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary Objective: Provides Care to Client when Death is Imminent

NATCEP Time: Class: Lab: Clinical:

Objective: 2.5.5 Identifies complementary therapies utilized during the stages of dying. Competency Course Content

Learning Activities

Home Health Aide/Nurse Aide: a. Provides direct personal care throughout all stages b. Provides comfort measures throughout c. Provides emotional support at time of death and bereavement RN: a. Assesses needs through all stages b. Develops plan of care throughout all stages and coordinates the team c. Ensures symptom control and pain management d. Provides client and family teaching as needed Physical Therapy as needed by physician to help maintain joint range and help with pain control (e.g., hydrotherapy and TENS) Occupational Therapy assists with ADLs, especially with adaptive devices

SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary Objective: Provides Care to Client when Death is Imminent

NATCEP Time: Class: Lab: Clinical:

Objective: 2.5.6 Explains and reports the common signs of approaching death. Competencies Course Content

Learning Activities

After the completion of the lecture/discussion, the student will: 1. List the signs of approaching death for 7, different body systems 2. List how the nurse aide can meet the needs of the dying client and family 3. Define what happens with the sense of hearing as a client is dying 4. List 4 signs of death

1. Physiological changes occur, either suddenly or gradually, that indicate approaching death. Physiological changes associated with approaching death include: a. Changes in vital signs i. Lower blood pressure ii. Temperature may be below normal or elevated iii. Pulse is weak, irregular, rapid iv. Respirations may be - Shallow, rapid - Slower, labored - Cheyne-Stokes slow and irregular breathing. - Death Rattle mucous collects in throat and bronchial tubes b. Changes in circulation i. Blood flow slows down ii. Skin cool, perhaps clammy iii. Mottling c. Changes in muscle tone i. Bowel or bladder incontinence ii. Flatus iii. Body limp iv. Jaw may hang open v. Eyes fail to close client appears to be staring d. Changes in vision i. Increased secretions ii. Blurred iii. Pupils non-reactive to light iv. No eye movement e. Changes in mental state i. May be lucid, confused or alert ii. Loss of consciousness f. Changes in speech i. Difficulty speaking, understanding

SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary Objective: Provides Care to Client when Death is Imminent

NATCEP Time: Class: Lab: Clinical:

Objective: 2.5.6 Explains and reports the common signs of approaching death. Competencies Course Content

Learning Activities

g. Changes in touch i. Decreased sense of touch ii. Loss of feeling beginning in the legs and feet 2. The nurse aide has a responsibility to meet the needs of the client approaching death as well as his/her significant others Interact with family/significant others in a professional positive manner Permit family members (if they desire) to assist in simple care-giving activities If client is unconscious, continue to speak in normal tone of voice and treat the client as if he/she can hear Provide routine ADLs Report any changes in the clients condition to licensed nurse immediately Be aware of current Advanced Directives of DNR [Do Not Resuscitate status], as the status of directives can change 3. Hearing is thought to be the last sense to leave the body. Do not speak unprofessionally in any manner around a client who is dying or has just died. 4. Signs of death include: No pulse No respiration No blood pressure Eyes fixed and dilated When death occurs, the physician or head nurse (depending on facility policy) are responsible for: a. Certifying death b. Notifying the family (The nurse aide NEVER informs the family that death has occurred) c. The supervisor will direct the nurse aide as to when to provide postmortem care

SECTION 2: BASIC NURSING AND PERSONAL CARE SKILLS Unit 5: Caring for Client when Death is Imminent Primary Objective: Provides Care to Client when Death is Imminent

NATCEP Time: Class: Lab: Clinical:

Objective: 2.5.7 Provides post-mortem care while maintaining the clients right to dignity and respect. Competencies Course Content

Learning Activities

After the completion of the lecture/discussion, the student will: 1. Define post-mortem care 2. List the goals of postmortem care 3. List 3, general guidelines to follow in providing postmortem care

1. The care of the body after death is call post-mortem care. The nurse aide is usually responsible for performing post-mortem care. 2. In providing post-mortem care, the goals are to: Appropriately identify the body Sustain the bodys appearance Prevent discoloration and skin damage Position in normal alignment before rigor mortis develops Allow family viewing before body is taken to morgue Provide respect and gentle care Maintain privacy 3. General guidelines include: Following the facility policy/procedure when providing post-mortem care Not beginning until directed by nurse to do so Reporting to the nurse: a. The time the body was taken (to morgue or by mortician) b. What was done with jewelry and personal items, including dentures

Handout: Guidelines for Post-Mortem Care. Procedure Evaluation Checklist: Provides Post-Mortem Care.

2.5.7

GUIDELINES FOR POSTMORTEM CARE Assemble equipment: 1. 2. 3. 4. Gloves Basin with warm water, washcloth, towels Pads as needed Postmortem kit (facility oriented: shroud/body bag/sheet, tags)

Maintain attitude of respect; work quietly and efficiently: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Put on gloves Remove tubing, appliances and used articles only if instructed to do so Bed flat, body in supine position (flat on back) -elevate head and shoulders on pillow Close the eyes by grasping the eyelashes and gently pulling the eyelids down Insert dentures if included in facility policy. If they are not to be inserted in the mouth, place the dentures in a labeled denture container If used, replace artificial eye according to facility policy Straighten arms and legs and place arms by sides Remove jewelry Bathe the body as needed Place disposable pads under buttocks Comb hair Put clean gown on client Replace top bed linen Collect the clients belongings-package appropriately and label

If family is to view the body: 1. 2. 3. 4. 5. Make sure room is neat Provide privacy Give clients belongings to the family or follow facility policy Complete the information on the identification tags, or obtain the tags from the nurse Apply ID tags as required by facility policy (Example, one on right great toe, one on top of shroud) 6. After the family has left the room, apply the shroud, body bag or sheet 7. Bring the top down over the head, bring the bottom up over the feet, fold one side over the body and fold the remaining side over the body-tape closed or secure with safety pins (Attach the second ID tag to the shroud)

Final steps: 1. 2. 3. 4. Leave the body on the bed for the mortician or Transport to the in-facility morgue via cart Strip the unit after the body has been removed Wash hands

SUPPLEMENTAL MATERIAL: HANDOUTS

2.5.7

PROCEDURE EVALUATION CHECKLIST NATCEP

U=Unsatisfactory S U Comments

Procedure Guidelines 1. Assemble equipment: a. Gloves b. Basin with warm water, washcloth, towels c. Pads as needed d. Postmortem kit 2. Maintain attitude of respect, work quietly and efficiently 3. Put on gloves 4. Remove tubing, appliances and used articles and jewelry if instructed to do so 5. Place body in supine position; straighten arms and legs; place arms by sides 6. Close the eyes by grasping the eyelashes and gently pulling the eyelids down 7. Insert dentures if included in facility policy. If they are not to be inserted in the mouth, place the dentures in a labeled denture container 8. Bathe the body as needed, combing hair and dressing in a clean gown 9. Apply completed ID tags as required by facility policy 10. Apply shroud, body bag or sheet: a. Bring the top down over the head b. Bring the bottom up over the feet c. Fold one side over the body and fold the remaining side over the body d. Tape closed or secure with safety pins e. Attach the second ID tag to the shroud

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PROCEDURE EVALUATION CHECKLIST: PROVIDES POSTMORTEM CARE

2.5.7

11. Leave the body on the bed for the mortician (as per facility policy) Close curtains and dispose of supplies 12. Wash hands

_________________________________________________
(Signature of Instructor(s)

___________
(Date)

_________________________________________________
(Signature of Student)

___________
(Date)

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PROCEDURE EVALUATION CHECKLIST: PROVIDES POSTMORTEM CARE