Transcript THE DYING PATIENT AND LAST OFFICES

THE DYING PATIENT AND
LAST OFFICES
SHARON HARVEY
9/6/05
LEARNING OUTCOMES
the student will be able to:
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Reflect on experiences of breaking bad news to
patients and their relatives
Discuss factors that constitute a good death
Explore the signs of death in a patient
Discuss the nurses’ role with regard to
bereavement
Identify the measures required in caring for a
body after death
Discuss last rites and offices for patients of
different cultures and faiths
THE CHANGING CUSTOMS OF
DEATH
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One hundred years ago, childhood death was
common and the family units were larger which
meant that most young people had experienced
the death of someone close to them
Death was familiar and normal
Last century the pattern of dying changed.
Most deaths are of older people in the hospital
environment.
Many dying patients require some form of
palliative care.
PALLIATIVE CARE: WHAT IS IT?
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The World Health Organization (WHO)
defines palliative care as "the active total
care of patients whose disease is not
responsive to curative treatment."
Palliative care seeks to improve patients’
quality of life by relieving physical,
emotional, and spiritual pain for patients
and their caregivers.
HOW DO YOU KNOW IF A PATIENT
IS DYING?
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IT IS NOT NECESSARILY EASY TO DIAGNOSE DYING, BUT THERE
ARE COMMON SIGNS THAT INDICATE THE PATIENT IS
DETERIORATING
SYMPTOMS INCLUDE:
SEVERE WEAKNESS
DECREASED ORAL INTAKE
DIFFICULTY TAKING MEDICATION
DROWSINESS
SKIN MAY BE MOTTLED OR BLUE
PATIENT MAY HAVE A GAUNT APPEARANCE
HANDS AND FEET MAY BE COLD TO TOUCH
PATIENT MAY APPEAR DISORIENTATED AND MAY NOT BE ABLE TO
CONCENTRATE
FACTORS THAT MIGHT
CONSTITUTE A GOOD DEATH
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ACCEPTANCE OF IMPENDING DEATH
EMOTIONAL SUPPORT FOR THE DYING
PATIENT AND SIGNIFICANT OTHERS
MINIMISING SUFFERING BY MANAGING
SYMPTOMS
NOT LEAVING THE DYING PATIENT
ISOLATED, ENABLING COMPLETION OF
“UNFINISHED BUSINESS”
COMMUNICATING WITH DYING
PATIENTS AND THEIR FAMILY
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Traditionally telling the patient and their
family bad news has been the role of the
doctor, however nursing staff are now
more involved in this process.
Communication is more than just verbal
interaction but also involves non verbal
communication.
COMMUNICATING WITH DYING
PATIENTS AND THEIR FAMILY
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Some nurses apply “blocking” tactics when
a patient begins to discuss sensitive
topics.
Nurses worry about not knowing what to
say or saying the wrong thing.
All of which creates barriers to
communication.
WHAT QUALITIES DOES THE NURSE NEED
TO HAVE IN ORDER TO DEAL WITH
PATIENT’S AND THEIR FAMILY WHO HAVE
RECEIVED BAD NEWS.
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Sensitive
Understanding
Positive
Practical
Open
Respectful
Truthful
In a position to offer skilled approach to communication
Valuing
Empathetic
BREAKING BAD NEWS
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PREPARE YOURSELF
WHAT DOES THE PATIENT/FAMILY KNOW?
IS MORE INFORMATION WANTED?
GIVE WARNING SHOT, FOR EXAMPLE “I AM AFRAID ITS
RATHER SERIOUS” ALLOW A PAUSE FOR PATIENT
RESPONSE
ALLOW DENIAL
EXPLAIN – IF REQUESTED
LISTEN TO CONCERNS
ENCOURAGE EXPRESSION OF FEELINGS
SUMMARY AND PLAN
OFFER AVAILABILITY (YOURSELF, RELIGIOUS LEADERS,
BEREAVEMENT COUNSELLORS)
DIAGNOSIS OF DEATH
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ABSENCE OF THE MAJOR PULSES – CAROTID
AND FEMORAL
ABSENCE OF HEART AND LUNG SOUNDS AFTER
AUSCULATION CONTINUALLY FOR 1 MINUTE
AND INTERMITTENTLY FOR 5 MINUTES
ABSENCE OF RESPIRATORY EFFORT
FIXED AND DILATED PUPILS
ABSENCE OF CORNEAL REFLEX
SHOULD WE LET THE BEREAVED
RELATIVES SEE THEIR LOVED
ONE’S BODY?
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ALL EVIDENCE SUGGESTS THAT SEEING THE
BODY OF A DEAD PERSON IS AN IMPORTANT
PART OF THE ADJUSTMENT PROCESS.
IT PROVIDES AN OPPORTUNITY TO SEE AND
BECOME FAMILIAR WITH THE REALITIES OF
DEATH.
IT IS AN OPPORTUNITY TO SEE AND TOUCH,
FOR THE LAST TENDERNESS, FOR THE LAST
GOODBYE; PERHAPS HOLD THE DEARLY LOVED
ONE FOR THE LAST TIME….
(RAPHAEL, 1984)
PHASES OF BEREAVEMENT
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ACCEPTANCE THAT THE PERSON IS
GOING TO DIE
EXPERIENCING GRIEF
ADAPTING TO LIFE WITHOUT A LOVED
ONE
RELOCATING THE DECEASED
INTERNALLY
SCENARIO WORK
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WORK IN GROUPS OF 4 OR 5
GUIDELINES FOLLOWING A DEATH
IN HOSPITAL
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INFORM DOCTOR WHO SHOULD EXAMINE
PATIENT AND CERTIFY DEATH
INFORM RELATIVES (IF THEY HAVE NOT
ALREADY BEEN INFORMED)
PERFORM LAST OFFICES FOR PATIENT
RELATIVES CAN SEE THEIR LOVED ONE AT
THIS POINT
PATIENT PROPERTY TO BE ACCOUNTED FOR
AND GIVEN TO RELATIVES IF POSSIBLE
GUIDELINES (CONTINUED)
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THE PATIENT’S BODY NEEDS TO BE TAGGED
THEY SHOULD BE DRESSED IN A SHROUD
WHICH SHOULD BE TAGGED
THE PATIENT SHOULD THEN BE WRAPPED IN A
SHEET
THE PATIENT SHOULD THEN BE PLACED IN A
BODY BAG WHICH AGAIN SHOULD BE TAGGED
THE PORTERS SHOULD BE ASKED TO REMOVE
THE BODY TO THE MORTUARY
GUIDELINES (CONTINUED)
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THE DOCTOR WILL CONTACT THE CORONER
TO DECIDE WHETHER A POST MORTEM IS
REQUIRED
IF A POST MORTEM IS NOT REQUIRED THEN A
MEDICAL CERTIFICATE OF CAUSE OF DEATH
WILL BE ISSUED (IF THE PATIENT IS TO BE
CREMATED AN ADDITIONAL FORM WILL NEED
TO BE FILLED IN BY THE DOCTOR)
THE FAMILY SHOULD BE INFORMED THAT
REGISTRATION OF THE DEATH SHOULD BE
MADE WITHIN 5 DAYS OF DEATH AND IN THE
LOCAL REGISTRAR’S OFFICE (NOT THE
NEAREST ONE TO THEIR HOME)
GUIDELINES (CONTINUED)
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IF A POST MORTEM IS REQUIRED THE
DOCTOR WILL NOT BE ABLE TO ISSUE A
MEDICAL CERTIFICATE OF CAUSE OF
DEATH AND IT IS IN THE HANDS OF THE
CORONER
REASONS WHY A DEATH IS
REPORTED TO THE CORONER
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IF THE CAUSE OF DEATH IS UNCERTAIN
IF THE DEATH WAS SUDDEN, VIOLENT OR CAUSED BY
AN ACCIDENT
IF A DEATH WAS CAUSE BY AN INDUSTRIAL DISEASE
IF DEATH HAPPENED DURING AN OPERATION OR
UNDER ANAESTHETIC
WHERE THE PATIENT HAS NOT BEEN SEEN BY A
DOCTOR FOR 14 DAYS BEFORE DEATH
IF DEATH OCCURS WITHIN 24 HOURS OF ADMISSION
TO HOSPITAL
WHAT IS LAST OFFICES?
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LAST OFFICES IS THE FINAL SERVICE
OFFERED AS A MARK OF RESPECT TO
THE DEAD PERSON BEFORE BURIAL OR
CREMATION.
OTHERWISE KNOWN AS LAYING OUT
THERE MUST BE SENSITIVITY TO THE
BELIEFS OF THE FAMILY AS TO HOW LAS
OFFICES ARE CARRIED OUT.
LAST OFFICES INVOLVES:
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WASHING THE BODY
CLOSING THE EYELIDS
ENSURING THE JAW REMAINS CLOSED
WASHING HAIR(IF NECESSARY)
STRAIGHTENING OF ARMS AND LEGS
PACKING OF BODY ORRIFICES (NOT ALWAYS
NECESSARY)
SHAVING MEN
RIGOR MORTIS
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IS A STIFFENING OF THE MUSCLES, WHICH USUALLY
BEGINS WITHIN ABOUT 2 TO 4HOURS AFTER DEATH
AND GRADUALLY EXTENDS OVER THE WHOLE BODY IN
ABOUT 48 HOURS AFTER THIS IT USUALLY BEGINS TO
WEAR OFF.
RIGOR MORTIS CAN BE LESS PRONOUNCED IN THE
BODY OF AN ELDERLY PATIENT
WHEN SOMEONE HAS BEEN DEAD FOR HALF AND
HOUR OR MORE, PARTS OF THE SKIN DISCOLOUR
WITH PURPLE/BLACK PATCHES. THIS IS CALLED
HYPOSTASIS AND IS DUE TO BLOOD SETTLING IN THE
BODY DUE TO GRAVITY
POST MORTEM
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THERE ARE TWO TYPES:
POST MORTEM WHICH THE DOCTOR
REQUESTS (HOSPITAL POST MORTEM) MUST
HAVE THE CONSENT OF THE NEXT OF KIN
POST MORTEM WHICH THE CORONER
REQUIRES (NO CONSENT REQUIRED)
RELATIVES WILL NOT AUTOMATICALLY BE
TOLD THE RESULTS OF A POST MORTEM
AFTER REGISTRATION
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A DEATH CERTIFICATE WILL BE ISSUED
USUALLY MORE THAN ONE CERTIFICATE
IS REQUIRED
THE REGISTRAR WILL ISSUE A GREEN
CERTIFICATE TO SAY THAT THE DEATH
HAS BEEN REGISTERED AND THAT A
FUNERAL MAY TAKE PLACE
FUNERAL ARRANGEMENTS
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THE RESPONSIBILITY OF FAMILY OR
FRIENDS
OR THE HEALTH AUTHORITY WHERE
THERE ARE NO FAMILY OR FRIENDS
LAST OFFICES FOR DIFFERENT
RELIGIONS AND CULTURES
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United Kingdom is a multicultural, multiracial
and multireligious society.
All wards, units, hospices, etc. should have some
form of reference material with regard to
managing patients of different religions and
cultures.
The Royal Marsden “Manual of Clinical Nursing
Procedures” looks at the last offices of patients
from different religions and cultures.
CHRISTIANITY
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Customary last offices are acceptable
Family may ask for hospital chaplain,
minister or priest to perform last
rites.
Some Roman Catholic families may
wish to place a rosary in the
deceased hands or a crucifix at the
patient’s head.
Some orthodox families may wish to
place an icon (holy picture) at either
side of the patient’s head.
HINDUISM
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If available relatives may wish to read
from the Bhagavad Gita or make a
request that staff read extracts during the
last offices
Relatives of the same sex as the patient
may wish to wash his or her body
preferably in water mixed with water from
the river Ganges
The patient’s family may request that the
patient be placed on the floor and they
may wish to burn incense
Post mortems are viewed as disrespectful
to the deceased person, so are only
carried out when strictly necessary
MUSLIM
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The family will want to stay with the dying patient and perform last
rites.
The patient’s head should point towards Mecca, which in the U.K. is
south east or alternatively turn the patient on their right side so that
the deceased face is facing towards Mecca
The body should be untouched by non-muslims but if they are to be
touched gloves should be worn
The patients eyes should be closed and the body straightened. The
head should be turned to the right shoulder and the body covered
with a plain white sheet. The body and hair should not be washed
nor the nails cut.
The patients body is normally taken home or to a mosque as soon
as possible to be washed by another muslim of the same sex. A
wife may wash her husband but the reverse is not permitted
Burial never cremation is preferred within 24 hours of death