DEATH AND DYING

1. DEATH AND DYING Emotional and Physiologic Elements of Death and Dying

2. EMOTIONAL TRANSITIONS AT LIFE’S END There are many theories about the emotional transitions encountered by dying people, the best known is. . . . .

3. ELISABETH KUBLER-ROSS • Landmark work entitled On Death and Dying • IDed 5 emotional stages experienced by dying individuals.

4. FIVE EMOTIONAL STAGES • Denial - or “no, not me” • Anger - or “why me?” • Bargaining - or “Yes, but. . .” • Depression - or “It’s me!” • Acceptance - or “It’s part of life. I have to get my life in order.”

5. FIVE EMOTIONAL STAGES • There is not a linear progression. • People go back and forth between stages. • May stay in 1 stage. • Fear may be an element.

6. Death Can Involve Fears That Are Physical, Social, And Emotional • PHYSICAL: • Helplessness, • Dependence on others, • Loss of physical faculties, • Mutilation, • Uncontrolled pain.

7. Death Can Involve Fears That Are Physical, Social, And Emotional • SOCIAL: • Separation from family & home, • Leaving behind unfinished business: • Responsibilities • Jobs.

8. Death Can Involve Fears That Are Physical, Social, And Emotional • EMOTIONAL/SPIRITUAL: • Being unprepared for death and what happens after death.

9. INTERVENTIONS FOR FEARS • Talk as needed. • Avoid superficial answers, i.e. “It’s God’s will.” • Provide religious support as appropriate. • Stay with the patient as needed. • Work with families to strengthen and support them and their responses to the dying person.

10. PHYSIOLOGY OF DYING • Somatic death aka death of the body. • Series of irreversible events leading to cell death.

11. PHYSIOLOGY OF DYING • Cause of death varies. • There are basic body changes leading to all deaths. • Result in the death of all vital body systems.

12. These Changes Result In The Death Of All Vital Body Systems • PULMONARY: • Unable to oxygenate the body. • Respirations become stridorous or noisy, leading to “death rattle”.

13. These Changes Result In The Death Of All Vital Body Systems • PULMONARY: • Cheyne-Stokes respiration: • Sign of pulmonary system failure. • Consists of alternate hyperpneic and apneic phases. • These phases reduce the concentration of carbon dioxide in the body.

14. These Changes Result In The Death Of All Vital Body Systems • PULMONARY: • Sensors within body prevent the body from breathing, • in order to increase the level of carbon dioxide. • Never able to reach an adequate balance, • Ultimately respirations cease.

15. These Changes Result In The Death Of All Vital Body Systems • Assessment for poor oxygenation. • Skin pale, • Cyanotic, • Mottled, • Cool. • In dark skinned people: • Assess mucous membranes, palms of hands, soles of feet.

16. CARDIOVASCULAR • Heart unable to pump strongly enough to keep blood moving. • Blood backs up first throughout the heart. • Ultimately blood backs up into the lungs and the liver, causing congestion

17. CARDIOVASCULAR • Lung failure causes a large load on the heart. • The heart cannot get needed oxygen. • Pumping heart not strong enough to circulate blood. • Blood backs up causing failure. • Leads to pulmonary and liver congestion.

18. BLOOD CIRCULATION • Skin becomes cool and pale to the touch. • Person appears cyanotic, possibly mottled. • In dark-skinned people, perfusion and oxygenation of the body is determined by mucous membranes and palms of hands and feet. • Failure of peripheral circulation frequently results in a drenching sweat cooling the body surface.

19. BLOOD CIRCULATION • Decreased, as heart less able to pump. • May have a “drenching sweat” as death approaches. • Pulse becomes weak and irregular. • If pulse is relatively strong, death is hours away. • If pulse is weak and irregular, death is imminent. • An apical pulse might be required.

20. Combination Of These Events Leads To Cell Death And Death Of Organism Pulmonary & cardiovascular systems fail, other body systems begin to fail. Metabolism rates decrease as the cardiovascular system fails.

21. FAILING METABOLISM • Metabolic rate decreases, almost stopping • Feces might be retained or incontinence might be present

22. FAILING URINARY SYSTEM • Urinary output decreases. • Blood pressure too low for kidney filtration. • Further load on cardiovascular system due to increase circulating volume.

23. FAILING NERVOUS SYSTEM • Decreased oxygen to brain, • Decreasing brain function. • Sensation and power lost • Legs first, • Then arms. • May be • Conscious, • Semi-conscious, • Comatose.

24. Specific Sensory Decline • Dying person turns toward light, • sees only what is near. • Can only hear what is distinctly spoken. • Touch is diminished, • response to pressure last to leave.

25. Specific Sensory Decline • Dying person might turn toward or speak to someone not visible to anyone else. • Eyes may remain open even if unconscious. • Person might rally in clarity and consciousness just before dying.

26. Further Neurological Decline At Death • Pupils might react sluggishly or not at all to light. • Pain might be significant. • Signs of pain if person unable to talk: • Restlessness, • Tight muscles, • Facial expressions, • Frowns. • Provide pain medication PRN.

27. NEVER LOSE SIGHT. . . • Death is the end, as we know it, for that person. • We can support and listen therapeutically. • Make the person as physically comfortable as possible. • We can also use our knowledge and expertise to strengthen, support, and prepare the family.

28. Physiological Aspects Of Death • Criteria for death • Often determined by a hospital’s policy. • One may be pronounced dead in one hospital and alive in another, • Depends on the criteria used for determining death. • Most widely accepted criteria for death is a flat electroencephalogram, • Meaning that brain death has occurred.

29. Physiological Aspects Of Death • Heart, lungs, and brain form the trinity on which standards for irreversible death are established. • absence of respiration • absence of heart beat • flat electroencephalogram • When the above signs are present along with absence of pupillary reflexes, clouding of the cornea, and absence of movement, death has certainly occurred.

30. Physiological Aspects Of Death • Study of death known as thanatology. • Studies show that clinical death (described above) is not the same as biological death. • For example after clinical death, the hair continues to grow for several hours, liver converts glycogen to glucose, and muscles contract(referred to as rigor mortis).

31. Physiological Aspects Of Death • Rigor mortis generally begins about 2 hours after death; • Muscles remain contracted for about 30 hours.

32. Physiological Aspects Of Death • Healthy muscle contraction works like this: • nervous system tells a muscle to contract, • calcium channels are open in the muscle and calcium ions move into the muscle fibers causing it to contract. • In order to relax again, the muscle must get rid of the calcium; • this happens in one of two ways, • 1. The calcium is stored in the sarcoplasmic reticulum, • 2. The calcium is pumped back through the channels.

33. Physiological Aspects Of Death • In death, the calcium can’t be pumped back, and remains in the muscle. • This causes the muscles to contract and stiffen. • The entire body stiffens and is called rigor mortis.