Mrs . Neriza G.

Mamasabulod, RN, MAN

Needs of the Dying Patient

To be able to help the grieving and the dying one

needs to know the changes that are going on. A dying person goes through physical, psychological changes and experiences spiritual awakening. These changes require support and immediate attention.

A. Physical Needs
The dying patients undergo many physiologic changes,

slowing of body processes and homeostatic imbalance. These changes cause pain and discomfort at the end of life. Besides, that there are alterations in patient energy levels, in respiratory capabilities, in bladder and bladder control, sensory perceptions.

The nurses responsibility include interventions in:

Personal hygiene measures Pain control Relief of respiratory difficulties Assistance and movement Nutrition Hydration

Elimination
Measures related to sensory changes

1. Personal Hygiene Measures

Because energy level wanes, patients are less capable

to maintain cleanliness of the skin, hair and mouth. Dying patients experience excessive diaphoresis. This may necessitate frequent baths and linen changes. Secretions may gather in the eyes and require cleaning of the eyelids with absorbent cotton and saline. Due to elevated temperature, the patients mouth may become dry, requiring mouth care.

2. Pain Control
Pain is unpleasant sensory and emotional experience.

There are three major techniques of managing pain:

Pharmacologic: Use of narcotic or non-narcotic analgesics administered orally, parenterally or rectally. b. Non-invasive: applications of heat or cold, massage, topical anesthetics, hypnosis, relaxation or distraction. c. Neurologic: acupuncture or nerve block.
a.

Assessment for Pain Management

Physical signs

findings
Changes in vital signs Diaphoresis

Agitation Change in facial expression

(e.g., frown) Apathy or withdrawal Crying Whimpering Moaning Screaming Clenching of fist or jaw

Nausea & vomiting

Muscle tension Weakness Spasms Changes in skin color Restlessness

 Psychological concerns/Development factors

Attitude of family towards illness
Past experience w/ pain & coping efforts used Fear Perceptions regarding pain & pain relief Emotional reactions (1.e., anxiety, depression,

withdrawal, anger or apathy, helplessness, hopelessness)

3. Relief of respiratory difficulty

a. For conscious patients, fowlers position & throat

suctioning are indicated. b. For unconscious patients, a semiprone position facilitates drainage of mucus from mouth & throat. c. Oxygen therapy by cannula or mask may be necessary for both conscious & unconscious patients in some instances.

4. Movement
Assisting patients in & out of the bed & changing

positions is important. Bedridden patients require regular changes of position to prevent decubitus ulcers w/ progressive loss of muscle tone. The patient needs increasing support in maintaining a comfortable position. Patients should preferably be placed in lateral position so that saliva w/c cannot be swallowed will drain from the mouth. When patients are seated, it is important to elevate the lower extremities to prevent pooling of blood brought about by poor circulation.

5. Nutrition & hydration

The digestive system of dying patients slows down.:

peristalsis is reduced, there is accumulation of flatus. This condition makes patients anorexic & nauseated. Antiemetics are prescribed to control nausea. High caloric, high vitamin diets are indicated. At this stage, patients would have difficulty in swallowing due to loss of muscle tone. The nurse must assess patients gag reflex. This is to ensure effective swallowing.

6. Elimination
Patients may develop constipation, incontinence

(fecal & urinary), or urinary retention brought a bout by loss of muscle tone. Skin irritation may apply soothing ointment around the anus & perineum. A bedpan, urinal or commode should be available for incontinent patients. The nurse should assist or position the patient on the bedpan or urinal at scheduled intervals. For urinary retention catheterization may be necessary. In some cases an indwelling catheter may be placed. The nurses role to ensure that proper asepsis is maintained.

7. Measures related to sensory changes

As death nears, the patients vision becomes blurred.

Many patients prefer a lighted room. Although the sense of touch will be diminished, the patient will sense pressure. A dying patient may hear what people are saying after he or she can no longer respond. When talking to a dying patient, nurses & visitors need to take care to speak clearly & avoid whispering since patients tend to become disturbed when unable to hear.

B. Emotional Needs
Grieving is the normal response to loss, i.e., loss of

loved one, loss of something external to us, loss of some part of us. A dying person responds to his eventual death by grieving. Kubler Ross, a psychiatrist has done studies on feelings & experiences of terminal patients. Out of her studies she identified psychological stages of grieving that are usually experienced when an individual is facing death.

Stages of Grieving
1st Stage: Denial (Hindi kaya nagkamali ang doktor sa kanyang diagnosis/) Patient uses denial to protect himself against the anguish & despair of his situation. Denial is an adoptive coping mechanism to delay the pain & shock until the patient is better able to deal with the reality.

nd 2

Stage: Anger & Rage

(Bakit ako? Sa milyong milyong mga tao ako pa ang

natamaan ng cancer) Anger & rage are felt regarding the unfairness of the diagnosis. These feelings are projected on to family & caregivers who are able to continue w/ life & activities.

rd 3

Stage: Bargaining

(Hinihingi ko sa Diyosna mabigyan siya ng anim na

taon pa. Sana maka-graduate man lang siya ng high school... [Sigh] ) Bargaining is an attempt to postpone dying until certain tasks are completed. These requests are usually made to God & provide a way for the patient to deal w/ the situation in small increment.

th 4

Stage: Depression

(Wala akong gana sa lahat ng gawain. Para saan pa

ang mga pag-aayos ng sarili eh tutal...) Depression occurs when the patient realizes that he is about to lose many things. E.g., family, job, control, his life itself. This realization produces profound sadness & depression.

th 5

Stage: Acceptance

(Mrs. Jacinto told the doctors, Malapit na akong mamatay,

Please dont give oxygen, dont put me on respirator. I am 70 years old. My time has come to be w/ my Creator. I am ready to go dont delay me.) Acceptance comes when a patient acknowledges & recognizes that death is inevitable. The patient accepts it after having gone through all the other stages. She/he may become increasingly detached & show readiness to go. Some patients never reach stage & die in denial w/ anger & sorrow. The emotional needs are different at each stage. The nurse is significant. Presence & intervention are needed.

The following guide on meeting emotional needs of the dying patients:

Stage Denial Dos Support patients denial Rationale: It serves a protective function; patients needs time before facing death. Be alert to cues that the phase is ending. Donts Allow patient to experience denial as needed without reinforcing denial; Do not force acceptance of truths patient is not yet ready to deal with. In discussing the reality of the situation do not strip patient of all hope.

Anger

Help patient understand that anger is normal response to feelings of loss & powerlessness created by the impending death.

Do not withdraw or retaliate w/ anger. These isolate the patient & family further & increase guilt & anxiety.

Rationale: Anger is often directed at a trusted person w/ whom patient feels safe & who will accept the anger & not cease to care. Deal w/ some of the needs underlying anger.
Provide structure & continuity in patients care this increases patients feelings of security. Allowing patient as much control as possible over his or her life helps to decrease feeling of powerlessness.

Should not take anger personally or label patient or support persons as ungrateful or uncooperative.

Bargaining

When cues are present, nurse needs to listen attentively, encourage patient to talk. For some patients bargaining is based on guilt or fear of retribution for past sins, real or fake. Talking can relieve guilt & irrational fears. In some situations it may be advisable to refer the patient to a member of the clergy.

Depression

Rationale: Patient has reason to be sad & must be allowed to express sadness. Some patients review past losses:, e.g., of money or a job at this time & need a listening ear & support from the nurse.

Dont avoid the patient. Dont try to cheer the patient up.

Most helpful nursing intervention: is to communicate nonverbally, e.g., by sitting quietly & not expecting conversation or conveying caring touch.
Being with the patient in silence is very important.

Acceptance

Direct patient activities toward maintaining tyhe patients self-worth & ensuring that patient is not alone. Encourage the patient to participate as much as possible in his or her treatment program. Spend time w/ patient & convey caring can relieve patients feelings of loneliness or fear.

C. Spiritual Needs
Terminally ill persons have develop deep spiritual needs. Illness is the time when people are confronted w/ the issue of mortality. This is the time when patients question the meaning of suffering & the meaning of life. Patients become keenly aware of their failure to live up to the expectations of God, expectation of others & their own expectations. This sense of failure results in guilt. The issue of guilt can only be resolved through repentance & receiving forgiveness.

Dying is a journey taken solely by the patient. For many, making the journey alone can be fearsome. The fear of the unknown can be assuaged through connecting w/ a supreme being. By being personally related to God, his need for love & belonging is, thus adequately satisfied. In summary, a dying person experiences spiritual crises if his spiritual needs are not met satisfactorily. The spiritual needs are (1) need for meaning & purpose (2) the need for forgiveness & (3) the need for love & belonging.

The Nurses Role

The last days of the patient are crucial times. His last leg of earthly journey should be characterized by peace w/ God, peace w/ other people, & peace w/ himself. The nurse plays an important role in helping the patient meet his spiritual needs. Meeting spiritual needs is a top priority in this period.

This demands that the nurse cultivate sharp clinical eye for spiritual needs. Clinical sharpness is assessing unmet spiritual needs & skills in meeting these needs can be developed gradually. An efficient way of providing spiritual care is through the nursing process. Nursing process is central to nursing actions. It assists the nurse to organize those process includes assessment, needs, planning, implementation & evaluation.