ch 36 (aging)

denial

On becoming aware of their impending death, most individuals initially react by denying the reality of the situation. "It isn't true" and "There must be some mistake" are among the comments reflective of this Perhaps the most important nursing action during this stage is to accept the dying individual's reactions and to provide an open door for honest dialogue.

direct involvement with dying individuals

With fewer people dying at earlier ages than in the past and most deaths occurring in hospitals or nursing homes, most people have minimal

Kubler-Ross stages of dying

denial, anger, bargaining, depression, acceptance

DNR (do not resuscitate)

medical order advising providers not to initiate cardiopulmonary resuscitation in the event of cardiac or respiratory arrest

anger

"why me?" often extremely difficult for individuals surrounding the dying person because they are frequently the victims of displaced anger. In this stage, the dying person expresses the feeling that nothing is right. For example, nurses do not answer the call light soon enough, the food tastes awful, the doctors do not know what they are doing, and visitors either stay too long or not long enough the nurse should be accepting, implying to the dying person that it is fine to vent these feelings. Anticipating needs, remembering favorite things, and maintaining a pleasant attitude can counterbalance the anticipated losses that are becoming more apparent to the dying individual

prevent pain

For the dying patient, the goal of pain management is to rather than treat it once it occurs. not only helps patients avoid discomfort but also ultimately reduces the amount of analgesics they use

decreases in the mortality rate over the years

In today's Western culture, many people have very limited experiences with death or the dying process, but this was not always the case. This change is due in part to

determination of death

Much current thought and investigation are focused on the need for a single criterion in the The controversy lies in deciding at which level of death a person is considered dead. In some situations, an individual with a flat EEG still has cardiac and respiratory functions; could this individual be considered dead?

holistic manner

Nursing now offers a more humanistic approach to end-of-life care. Emphasis on meeting the total needs of the patient in a

death, age, health status, philosophy of life, and religious, spiritual, and cultural beliefs.

Patients' reactions to dying are influenced by previous experiences with

depression

When a patient is hospitalized with increasing frequency and experiences declining functional capacity and more symptoms, the reality of the dying process is emphasized. The older patient may already have had many losses and experienced depression. The depression of the dying person is usually a silent one. It is important for the nurse to understand that cheerful words may be far less meaningful to dying individuals than holding their hand or silently sitting with them (Fig. 36-2). Being with the dying person who openly or silently contemplates the future is a significant nursing action during this stage

Depression, anxiety, fear, and isolation

are all characteristics of an aging client with altered thought processes. Deficient knowledge is not typically associated with altered thought processes or fear.

Meperidine and pentazocine

are contraindicated for pain control in older adults because of their high incidence of adverse effects, particularly psychosis, at relatively low dosages. Nurses

nuclear families

are mobile and frequently composed of young members; older parents and grandparents live in different households, often in different parts of the country. Furthermore, more deaths occur in an institutional or hospital setting. Rarely do family and friends remain with the individual or witness the dying process.

Understanding one's own mortality

can be therapeutic to the nurse personally, as well as helpful in the care of dying patients.

palliative care

care that relieves suffering and provides comfort when cure is not possible Nurses must regularly assess pain because it can increase or decrease over time.

hope

commonly permeates all stages of the dying process. Hope can be used as a temporary but necessary form of denial, as a rationalization for enduring unpleasant therapies, and as a source of motivation. It may provide a sense of having a special mission to comfort an individual through the last days. A realistic confrontation of impending death does not negate the presence of hope.

rational suicide

decision by competent terminally ill person to end his or her life suicide plans should not be accepted without some exploration of the factors that led to this decision.

signs of imminent death

decline in blood pressure rapid, weak pulse dyspnea and periods of apnea slower or no pupil response to light profuse perspiration cold extremities bladder and bowel incontinence pallor and mottling of skin loss of hearing and vision *it is important patient is not alone

Bargaining

dying persons may attempt to negotiate a postponement of the inevitable. They may agree to be a better Christian if God lets them live through one more Christmas is important that these often covert feelings be explored with the dying person.

ginger herb

has been effective in controlling nausea for some individuals without the side effects of antiemetic drugs.

respiratory distress

interventions such as elevating the head of the bed, pacing activities, teaching the patient relaxation exercises, and administering oxygen can prove beneficial. Atropine or furosemide may be administered to reduce bronchial secretions; narcotics may be used for their ability to control respiratory symptoms by blunting the medullary response.

constipation

nursing staff should take measures to promote regular bowel elimination in terminally ill patients. Increasing activity and the intake of fluids and fibers are beneficial. Laxatives usually are administered on a regular schedule, and bowel elimination patterns should be recorded and assessed. It must be remembered that what may appear to be diarrhea may actually be seepage of liquid wastes around a fecal impaction

more than 80%

of deaths occur in old age

end of life

period when recovery from illness is not expected, death is anticipated, and focus is on comfort

hospice care

program that delivers palliative care to dying individual and support to dying person and that person's family and caregivers professionalism does not preclude human emotions in the nurse-patient relationship. These factors have contributed to increased nursing involvement with the dying individual. pain relief symptom control home care and institutional care coordinated among an interdisciplinary team social work and counseling services medical equipment and supplies volunteer assistance and support bereavement follow-up and counseling

advnance directive

protects the patient's right to make decisions about terminal care and eases some of the burden of family members during this difficult time.

religious affiliation

religion and spirituality are not synonymous (see Chapter 15). Religion is but one aspect of spirituality; patients can be highly spiritual without

nursing staff

should be encouraged to express their own feelings about patients' deaths. may feel powerless as they realize that their best efforts can do little to overcome the reality of impending death. It is not unusual for a nursing caregiver who is involved with a dying patient to also experience the stages of the dying process

assisted suicide

suicide committed with the help of another individual

pain

the absence of such expressions of pain does not mean it does not exist. Some patients may not overtly express their pain; in these individuals, signs such as sleep disturbances, reduced activity, diaphoresis, pallor, poor appetite, grimacing, and withdrawal may provide clues to the presence of pain. In some circumstances, confusion can be associated with pain. patients with cancer more likely to experience severe pain

acceptance

the struggling ends and relief ensues. It is as though a final rest is being taken to gain the strength for a long journey. This acceptance should not be mistaken for a happy state; it implies that the individual has come to terms with death and has found a sense of peace. It is important that their silence and withdrawal not result in isolation from human contact. Touching, comforting, and being near the person are valuable nursing actions.

Patient Self-Determination Act

which gives individuals the right to express their choice regarding medical and surgical care and to have those preferences honored at a later time if they are unable to communicate it. Nurses