Care of Dying Client

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This PPT discuss about Care of terminally ill client of Unit XV in Nursing foundation for B.Sc. Nursing i year as per INC Syllabus

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Mrs. P. Vadivukkarasi Ramanadin, Professor, Dept. Of OBG (N), Shri Vinoba Bhave College of Nursing, Shri Vinoba Bhave Civil Hospital, Silvassa, DNH. :

UNIT-XV: Care of Terminally ill patient SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA 1 Mrs. P. Vadivukkarasi Ramanadin , Professor, Dept. Of OBG (N), Shri Vinoba Bhave College of Nursing, Shri Vinoba Bhave Civil Hospital, Silvassa, DNH.

UNIT-XV: Care of Terminally ill patient:

UNIT-XV: Care of Terminally ill patient • Concepts of Loss, Grief, grieving process • Signs of clinical death • Care of dying patient; • special considerations • -Advance directives: • euthanasia will dying declaration , organ donation etc • Medico-legal issues • Care of dead body: • Equipment, procedure and care of unit • Autopsy o Embalming 2 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

LOSS:

LOSS Loss is an actual or potential situation in which something that is valued is changed or no longer available. People can experience the loss of body image, a significant other, a sense of well-being, a job, personal possessions, or beliefs. Illness and hospitalization often produce losses. Loss is an inevitable part of life 3 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

TYPES OF LOSS :

TYPES OF LOSS Necessary loss, which is a part of life. They learn to expect that most necessary losses are eventually replaced by something different or better. A maturational loss is a form of necessary loss and includes all normally expected life changes across the life span. A mother feels loss when her child leaves home for the first day of school. Unwanted, or unexpected loss . Some losses seem unnecessary and are not part of expected. Situational loss. For example, a person in an automobile accident sustains an injury with physical changes that make it impossible to return to work or school, leading to loss of function, income, life goals, and self-esteem. 4 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Cont . . . :

Cont . . . An actual loss occurs when a person can no longer feel, hear, see, or know a person or object. Examples include the loss of a body part, death of a family member, or loss of a job. Lost valued objects include those that wear out or are misplaced, stolen, or ruined by disaster. A child grieves the loss of a favorite toy washed away in a flood. A perceived loss is uniquely defined by the person experiencing the loss and is less obvious to other people. For example, some people perceive rejection by a friend to be a loss, which creates a loss of confidence or changes their status in a group. How an individual interprets the meaning of the perceived loss affects the intensity of the grief response. 5 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Sudden versus Predictable Loss Sudden or shocking losses due to events like crimes, accidents, or suicide can be traumatic. There is no way to prepare. They can challenge your sense of security and confidence in the predictability of life. You may experience symptoms such as sleep disturbance, nightmares, distressing thoughts, depressed mood, social isolation, or severe anxiety. Predictable losses, like those due to terminal illness, sometimes allow more time to prepare for the loss. However, they create two layers of grief: the grief related to the anticipation of the loss and the grief related to the loss itself 6 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Grief :

Grief Grief is a natural part of the healing process. Grief is a strong, sometimes overwhelming emotion for people. The reasons for grief are many, such as the loss of a loved one, the loss of health, or the letting go of a long-held dream. Dealing with a significant loss can be one of the most difficult times in a person's life. Individual experiences of grief vary and are influenced by the nature of the loss. Pattern of physical and emotional responses to bereavement may vary 7 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Grief:

Grief Grief is the emotional response to a loss, manifested in ways unique to an individual and based on personal experiences, cultural expectations, and spiritual beliefs (Walter and McCoyd , 2009) Mourning: Coping with grief involves a period of mourning, the outward, social expressions of grief and the behavior associated with loss. Most mourning rituals are culturally influenced, learned behaviors. A reaction activated by a person to assist in overcoming a great personal loss It is the behavioral process through which grief is eventually resolved or altered; it is often influenced by culture, spiritual beliefs, and Bereavement A common depressed reaction to the death of a loved one Encompasses both grief and mourning and includes the emotional responses and outward behaviors of a person experiencing loss (AACN, 2008). It is the subjective response experienced by the surviving loved ones. 8 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

TYPES:

TYPES Normal Grief. Normal (uncomplicated) grief is a common, universal reaction characterized by complex emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death. Anticipatory Grief. A person experiences anticipatory grief, T he unconscious process of disengaging or “letting go” before the actual loss or death occurs, especially in situations of prolonged or predicted loss (Simon, 2008). When grief extends over a long period of time, people absorb loss gradually and begin to prepare for its inevitability. They experience intense responses to grief (e.g., shock, denial, and tearfulness) before the actual death occurs and often feel relief when it finally happens. 9 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Disenfranchised Grief. People experience disenfranchised grief, also Known as marginal or unsupported grief, when their relationship to the deceased person is not socially sanctioned, cannot be openly shared, or seems of lesser significance. The person’s loss and grief do not meet the norms of grief acknowledged by his or her culture. Ambiguous Loss . Sometimes people experience losses that are marked by uncertainty. Ambiguous loss, a type of disenfranchised grief, occurs when the lost person is physically present but not psychologically available, as in cases of severe dementia or severe brain injury. complicated grief a person has a prolonged or significantly difficult time moving forward after a loss. He or she experiences a chronic and disruptive yearning for the deceased; has trouble accepting the death and trusting others; and/or feels excessively bitter, emotionally numb, or anxious about the future. 10 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Exaggerated Grief: A person with an exaggerated grief response often exhibits self-destructive or maladaptive behavior, obsessions, or psychiatric disorders. Suicide is a risk for these people. Delayed Grief: A person’s grief response is unusually delayed or postponed, often because the loss is so overwhelming that the person must avoid the full realization of the loss. A delayed grief response is frequently triggered by a second loss, sometimes seemingly not as significant as the first loss. Masked Grief: Sometimes a grieving person behaves in ways that interfere with normal functioning but is unaware that he is in grief 11 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Factors affecting death and grief :

Factors affecting death and grief Whether the death is expected or unexpected. The personality of the bereaved. The religious beliefs  The age of the bereaved. 12 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Stages of grief reaction:

Stages of grief reaction According to Kübler-Ross’s there are five stages of normal grief that were first proposed by Elisabeth Kübler-Ross Denial Anger Bargaining Depression Acceptance Denial : It is a normal reaction to rationalize overwhelming emotions. It is a defense mechanism that buffers the immediate shock. It is a conscious or unconscious refusal to accept facts, information, reality, etc. 13 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Anger: Anger can manifest in different ways. People dealing with emotional upset can be angry with themselves, and/or with others, especially those close to them. Bargaining: The third stage involves the hope that the individual can somehow undo or avoid a cause of grief.  The normal reaction to feelings of helplessness and vulnerability is often a need to regain control. This is a weaker line of defense to protect us from the painful reality. 14 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Depression: During the fourth stage, the grieving person begins to understand the certainty of death. It's natural to feel sadness and regret, fear, uncertainty, etc. It shows that the person has at least begun to accept the reality. Acceptance: In this last stage, individuals begin to come to terms with their mortality or inevitable future, or that of a loved one, or other tragic event. This stage varies according to the person's situation. This phase is marked by withdrawal and calm. This is not a period of happiness and must be distinguished from depression. 15 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

SYMPTOMS OF NORMAL GRIEF :

SYMPTOMS OF NORMAL GRIEF Feelings • Sorrow • Fear • Anger • Guilt or self-reproach • Anxiety • Loneliness • Fatigue • Helplessness/hopelessness • Yearning Cognitions (Thought Patterns) • Disbelief • Confusion or memory problems • Problems with decision making • Inability to concentrate • Feeling the presence of the deceased 16 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Physical Sensations • Headaches • Nausea and appetite disturbances • Tightness in the chest and throat • Insomnia • Oversensitivity to noise • Sense of depersonalization (“Nothing seems real”) • Feeling short of breath, choking sensation • Muscle weakness • Lack of energy • Dry mouth Behaviors • Crying and frequent sighing • Distancing from people • Absentmindedness • Dreams of the deceased • Keeping the deceased’s room intact • Loss of interest in regular life events • Wearing objects that belonged to the deceased 17 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Frequent, intense, or prolonged exposure to grief and loss places nurses at risk for developing compassion fatigue. Compassion fatigue, described as physical, emotional, and spiritual exhaustion resulting from seeing patients suffer, leads to a decreased capacity to show compassion or empathize with suffering people 18 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Type of care for terminally ill client :

Type of care for terminally ill client Palliative Care: in Acute and Restorative Settings. Interventions for people who face chronic life-threatening illnesses or who are at the end of life need palliative care. Palliative care focuses on the prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness, including care of the dying and bereavement follow-up for the family. The primary goal of palliative care is to help patients and families achieve the best possible quality of life. Although it is especially important in advanced or chronic illness, it is appropriate for patients of any age, with any diagnosis, at any time, or in any setting. Hospice Care. Hospice care is a philosophy and a model for the care of terminally ill patients and their families. Hospice is not a place but rather a patient- and family-centered approach to care. It gives priority to managing a patient’s pain and other symptoms; comfort; quality of life; and attention to physical, psychological, social, and spiritual needs and resources. Patients accepted into a hospice program usually have less than 6 to 12 months to live. Hospice services are available in home, hospital, extended care, or nursing home settings. 19 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Sign of clinical death :

Sign of clinical death Clinical death  is the medical term for cessation of blood circulation and breathing, the two necessary criteria to sustain life. [1]  It occurs when the  heart stops beating in a regular rhythm, a condition called cardiac arrest . At the onset of clinical death, consciousness is lost within several seconds. Measurable brain activity stops within 20 to 40 seconds.  Absence of pulse, heart beat and respirations Pupil becoming fixed and not reacting to light Absence of all refluxes. Rigor mortis: Stiffing of the body after death. The arms & legs cannot be bent or straightened while rigor mortis is present unless the tendons are torn 20 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Sign of approaching death Respiration becomes irregular, rapid and shallow breath or very slow  Circulatory changes cause alterations in the temperature, pulse and respirations. Radial pulse gradually fails Usually the pulsations are seen even after the patient has stopped breathing Hiccoughs, Nausea, Vomiting, abdominal distensions are seen. the patient feels the inability to swallow. “DEATH RATTLE”-A rattling sound heard in throat caused by secretions that the patient cannot cough longer.  21 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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The skin may become pale, cool and sweats lot (cold sweats).Ears and nose are cold to touch. -Reflexes and pain are gradually lost. Patient may be restless due to lack of oxygen CHANGES IN SIGHT, SPEECH, AND HEARING.- Sight gradually fail. The pupil’s fails to react to light. Eyes are sunken and half closed. 22 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Meeting the need of dying patient :

Meeting the need of dying patient Psychological support: The psychological need : Relief from loneliness, fear and depression. Maintenance of security, self confidence and dignity. Maintenance of hope.  Meeting the spiritual needs according to his religious customs . SYMPTOMATIC MANAGEMENT  Problem associated with breathing: The dying person who is restless, apprehensive and short of breath may be given- Oxygen inhalation to remove his discomfort.  Elevation of the patient’s head and shoulders may make breathing easier. Keep the room well ventilated and keep crowed away. Periodic suctioning is necessary. 23 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Problem associated with eating and drinking : Anorexia, nausea, and vomiting are commonly seen in dying patient person The patient is unable to swallow even the sips of water poured in the mouth. Most of them may require I.V fluids. If they can tolerate the oral fluids, sips of water is given with teaspoon. That will help the patient to keep the mouth moist.  Give frequent oral hygiene. Apply emollients to the dry lips. The denture are removed and kept safely. 24 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Problem associated with elimination : Constipation, retention of urine and incontinence of urine and stool are some of problem faced by the patient.  Catheterization has to be done Through skin and Perineal care is to be given, to keep the patient clean and to prevent skin breakdown.  Problem associated with immobility : Frequent skin care should be given with particular attention to the pressure point. Patient should be comfortably placed and their position frequently changed in the bed. 25 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Problem associated with sense organ :  Since the patient loses sight, before given any care to the patient, the nurse should touch the patient and say what she is going to do. Since the hearing is retained longer, speak only what is appropriate. Avoid whispering any think in patient room. Speak distinctly so that patient may understand what is done for him. Since the eyes are opened, protect the eyes from corneal ulceration with protective ointment. 26 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Problem associated with rest and sleep :  Patient may distressing symptoms in these patients. Patient should not be disturbed while sleeping.  The visitors should be instructed not to disturbed the patient during his resting.  Maintain calm and quit environment.  Problem associated with cleanliness and grooming: Cleanliness and appearance are important until the end. Cleanliness of the skin, hair, mouth, and cloth has to be maintained. 27 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Management of dying patient :

Management of dying patient Cassen (1991) suggests seven essential features in the management of the dying patient: Concern: Empathy, compassion, and involvement are essential. Competence: Skill and knowledge can be as reassuring as warmth and concern. Communication: Allow patients to speak their minds and get to know them. Children : If children want to visit the dying, it is generally advisable; they bring consolation to dying patients. Cohesion: Family cohesion reassures both the patient and family. Cheerfulness: A gentle, appropriate sense of humor can be palliative; a somber or anxious demeanor should be avoided. Consistency: Continuing, persistent attention is highly valued by patients who often fear that they are a burden and will be abandoned; consistent physician involvement mitigates these fears. 28 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Nursing care of a dying individual :

Nursing care of a dying individual The person who deals with the dying patient must commit (Schwartz and Karasu , 1997) to: Deal with mental anguish and fear of death, Try to respond appropriately to patient’s needs by listening carefully to the complaints and Be fully prepared to accept their own counter transferences, as doubts, guilt and damage to their narcissism are encountered. Management of the dying patient often elicits anxiety in nursing staff.  Education and role playing can improve perspective taking and empathetic skills, respect each other’s point of view as well as appreciate the situation of patient and their families. Developing a sense of control and efficacy. Encouraging peer groups for families coping with bereavement. Developing increased resourcefulness in dealing with death related situations. Recognizing that a moderate level of death anxiety is acceptable. Improving our understanding of pain and suffering will also improve communication and effective interactions. 29 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

CARING FOR THE BODY AFTER DEATH :

CARING FOR THE BODY AFTER DEATH  After the physician has pronounced death legally documented the death in the medical record, care of the body is usually performed by the nurse.  An autopsy consent may be requested & obtained if required.  If the patient is to be an organ donor arrangements will be made immediately.  The family often wishes to view the body before final preparations are made, they may be allowed.  If the patient had any valuables, they are handed over to the relatives 30 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

PURPOSES :

PURPOSES   Make body look as natural & beautiful as possible. Perform his last duty tenderly. Protect other patients from unpleasant sights and sounds which could frighten them   ARTICLES REQUIRED  Articles for bath Extra bandages and cotton swabs Perineal pads Sheets Restraints for jaw, hands and legs. Pair of gloves Thumb forceps Patients own set of clothes. 31 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

POSTMORTEM CARE:

POSTMORTEM CARE Rigor mortis is the stiffening of the body that occurs about 2 to 4 hours after death. Rigor mortis starts in the involuntary muscles (heart, bladder, and so on), then progresses to the head, neck, and trunk, and finally reaches the extremities. Algor mortis is the gradual decrease of the body’s temperature after death. When blood circulation terminates and the hypothalamus ceases to function, body temperature falls about 1°C (1.8°F) per hour until it reaches room temperature. Simultaneously, the skin loses its elasticity and can easily be broken when removing dressings and adhesive tape. After blood circulation has ceased, the red blood cells break down, releasing hemoglobin, which discolors the surrounding tissues. This discoloration, referred to as livor mortis, appears in the lowermost or dependent areas of the body. Tissues after death become soft and eventually liquefied by bacterial fermentation. The hotter the temperature, the more rapid the change. Therefore, bodies are often stored in cool places to delay this process. 32 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Changes in body after death: :

Changes in body after death: Rigor Mortis:  body becomes stiff within 4 hours after death as a result of decreased ATP production. ATP keeps muscles soft and supple. Algor Mortis:  Temperature decreases by a few degrees each hour. The skin loses its elasticity and will tear easily. Livor Mortis:  Dependant parts of body become discolored. The patient will likely be lying on their back, their backside being the 'dependant' body part. The discoloration is a result of blood pooling, as the hemoglobin breaks down. 33 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

PROCEDURE :

PROCEDURE  Nursing action Rationale Scientific principles Nursing principles Wash hands and put on gloves  Helps prevent cross infection Prevents direct contact with infection Safety Soon the death is pronounced, remove the backrest, extra pillows and gently put the patient in a supine position with the head elevated on the pillow.  Keeping the patient in a supine position prevents post mortem hypostasis of blood. The body after death should look as normal as possible Comfort Positioning is important after death, because of rigor mortis. close the patients eyes and mouth. Rigor mortis sets in shortly after death.to give a normal appearance ot the body eyes to be closed and jaw supported Body should be kept in position before rigor mortis occurs workmanship 34 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Remove all tubes and other devices from the patients body. The patient looks more peaceful Reduce the anxiety of the relatives Comfort consult close relatives before preparing the body for removal from the ward to the mortuary where the relatives will receive the body To meet customs and wish of the relatives in caring for the body Reduce the tension of relatives If the relatives require, the nurse should help them to sponge the patient as necessary. brush and comb hair.  To reduce odor and for aesthetic sense for normal appearance Appearance of the body after death should be presentable Replace soiled dressing with cleaned ones To avoid odor For better appearance comfort 35 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Apply perineal pads and plug the rectum & vagina (in females) with cotton balls.). To prevent soiling of bed and the patient cloth After death there may be leaking of secretions form orifices Safety Provide clean cloths(own For better appearance Take care of valuables and personal belongings by handing over to members of family. For legal considerations Allow members of family to see the patient & remain in the room & remember that the body is still dear to someone. Provide emotional support and helps grieving process by helping family to accept death It allows them to ventilate their grief and feelings 36 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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Close the body from side to side and head to foot with the sheet. Hospital policy is for relatives to claim the body from the mortuary Legal aspects of nursing Prepare the identification slip and attach it to the patients pack sheet. . Helps to identify the patient It is for legal purpose Attach a special label if the patient had a contagious disease. Protect those who handle the body Infection may spread if proper precautions are not taken Transfer the body to the mortuary They will get another certificate according to hospital policy Remove contaminated articles from room. Prevent contamination of others from body fluids Prevent spread of infection 37 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Advance Directives:

Advance Directives Advance Directive is a Scottish term, but in other parts of the UK these documents are also called Advance Decisions. An advance directive tells the health care team what kind of care the patient would like to have if he is unable to make medical decisions (e.g., if in coma) A good advance directive describes the kind of treatment the patient would want depending on the sickness An Advance Directive allows you to make a refusal of treatment in advance of a time when you can’t communicate your wishes, or don’t have the capacity to make a decision. It only comes into effect if either of these situations occur. You can use an Advance Directive to refuse any treatment, including life-sustaining treatment such as resuscitation, artificial nutrition and hydration, or breathing machines.  An Advance Directive enables healthcare professionals to know what your wishes are even if you cannot tell them yourself, e.g. if you had severe dementia or were in a coma. If you change your mind you can change your Advance Directive to reflect this. If you have mental capacity and can communicate your wishes then your Advance Directive will not apply. 38 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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An Advance Health Care Directive (AHCD) is a generic term for a document that instructs others about your medical care should you be unable to make decisions on your own. It only becomes effective under the circumstances delineated in the document, and allows you to do either or both of the following: Appoint a health care agent.  The AHCD allows you to appoint a health care agent (also known as “Durable Power of Attorney for Health Care,” “Health Care Proxy,” or “attorney-in-fact”), who will have the legal authority to make health care decisions for you if you are no longer able to speak for yourself. This is typically a spouse, but can be another family member, close friend, or anyone else you feel will see that your wishes and expectations are met. The individual named will have authority to make decisions regarding artificial nutrition and hydration and any other measures that prolong life—or not. Prepare instructions for health care.  The AHCD allows you to make specific written instructions for your future health care in the event of any situation in which you can no longer speak for yourself. Otherwise known as a “Living Will,” it outlines your wishes about life-sustaining medical treatment if you are terminally ill or permanently unconscious, for example. The Advance Health Care Directive provides a clear statement of wishes about your choice to prolong your life or to withhold or withdraw treatment. You can also choose to request relief from pain even if doing so hastens death. A standard advance directive form provides room to state additional wishes and directions and allows you to leave instructions about organ donations. 39 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Importance of an Advance Health Care Directive :

Importance of an Advance Health Care Directive While most people would prefer to die in their own homes, the norm is still for terminally-ill patients to die in the hospital, often receiving ineffective treatments that they may not really want. Their friends and family members can become embroiled in bitter arguments about the best way to care for the patient and consequently miss sharing the final stage of life with their loved one. Also, the opinions and wishes of the dying person are often lost in all the chaos. It’s almost impossible to know what a dying person’s wishes truly are unless the issues have been discussed ahead of time. Planning ahead with an Advance Health Care Directive can give your principal caregiver, family members, and other loved ones peace of mind when it comes to making decisions about your future health care. It lets everyone know what is important to you, and what is not. Talking about death with those close to us is not about being ghoulish or giving up on life, but a way to ensure greater quality of life, even when faced with a life-limiting illness or tragic accident. When your loved ones are clear about your preferences for treatment, they’re free to devote their energy to care and compassion 40 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Euthanasia:

Euthanasia Euthanasia literally means “good death”. It is basically to bring about the death of a terminally ill patient or a disabled. Generally, the word euthanasia is defined as the act or practice of painlessly putting to death or withdrawing treatment from a person suffering an incurable disease. [ 3 ] From the definition, one can say that euthanasia is an unethical act as much as it is a great sin for those who strongly believe in God. Euthanasia is intentionally killing another person to relieve his or her suffering. [ 4 ] It is not the withdrawal or withholding of treatment that results in death, or necessary pain and symptom-relief treatment that might shorten life, if that is the only effective treatment. It is the intentional killing by act or omission of a dependent human being for his or her alleged benefits. 41 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Types of euthanasia :

Types of euthanasia Euthanasia can be classified in different ways, including: Active euthanasia  (action)– where a person deliberately intervenes to end someone’s life – for example, by injecting them with a large dose of sedatives   Passive euthanasia ( ommission )  – where a person causes death by withholding or withdrawing treatment that is necessary to maintain life, such as withholding  antibiotics  from someone with pneumonia    Voluntary euthanasia  – where a person makes a conscious decision to die and asks for help to do this Non-voluntary euthanasia  – where a person is unable to give their  consent  (for example, because they are in a  coma  or are severely brain damaged) and another person takes the decision on their behalf, often because the ill person previously expressed a wish for their life to be ended in such circumstances Involuntary euthanasia  – where a person is killed against their expressed wishes 42 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

WILL/ Dying Declaration :

WILL/ Dying Declaration A will is a document by which a person regulates the rights of others over his property or family after death. A statement by a person who is conscious and knows that death is imminent concerning what he  or she believes to be the cause or circumstances of death that can be introduced into evidence  during a trial in certain cases  A person who makes a dying declaration must, however, be competent at the time he or she makes a statement, otherwise, it is inadmissible. 43 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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ORGAN DONATION A person 18 years or older and of sound mind can donate all or any part of their own body for the following purposes: For medical or dental education Research Advancement of medical or dental science Therapy Transplantation The request for organ donation should be done   by patent in the presence of a physician or a nurse Organs removed from the body following the death cannot be sold. All organ donation are voluntary and there should not be any compulsion for the patient / family members Organs usually donated :- kidney, heart, lungs, liver, bone, cornea  Organ donation should take place with in 2-6hrs after the death. 44 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Counselling for Organ Donation :

Counselling for Organ Donation Organ transplantation is truly one of the miracles of modern medicine, saving the lives of many patients and improving the quality of life for many more. Given the ever-increasing gap between the number of organs needed and the supply, nurses have an ethical obligation to help ensure that the desires of people who want to donate organs are respected. Nurses have to ensure that the consent process is informed and voluntary. Information to the patient should consist of a balanced discussion of the available options and counseling to help patients or their families reach the choice that is best for them, including the provision of information about the urgent need for organs and the consolation that many families derive from knowing that their loved one was able to help others. 45 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

MEDICO LEGAL ISSUES :

MEDICO LEGAL ISSUES ·          Abuse of children, elderly, and spouse ·          Drug-related injury ·          Unknown cause of death ·          Suicide ·          Violent death ·          Poisoning ·          Accidents ·          Suspicion of criminal action o   Obtain death reports o   Do investigation -the natural death and infant/child death o   Conduct post mortem , sexual assault/child abuse examinations o   Collaborate with organ/tissue procurement agencies o   Provide link between pathologists and lay investigative staff o   Normally, only uniformed officers attend the natural death scene o   Understand subtle signs of abuse and neglect o   Collaborate with pathologist to determine the appropriate medical records o   Review medical records once received o   Obtain follow-up information 46 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Care of unit after death :

Care of unit after death Inform the nurse in charge and inform the medical staff of the patient’s death In the case of an expected adult death, a registered nurse deemed competent by the Trust may confirm death Confirmation of death must be recorded in the patient’s healthcare record An unexpected death must be confirmed by the attending medical officer and if confirmed the service manager should be contacted or duty manager out of hours. Incident form to be completed 47 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide48:

Inform the patient’s relatives/next of kin of the patient’s death. Ensure that this is handled in a sensitive and appropriate manner with as much privacy as possible. Ask if the relatives wish to see the chaplain or an appropriate religious leader or other appropriate person to the person’s faith or ethnic origins that need to be attended to immediately 48 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide49:

If relatives are in the hospital ask if they wish to assist with the last offices and/or if they have any particular wishes regarding the procedure If the relatives are not in the hospital ask if they wish to view the body on the ward or at a later date Assemble required equipment Wash hands and put on disposable gloves and apron 49 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide50:

Any injuries sustained whilst carrying out the procedures on the deceased must be reported through the Trust risk system and follow the Trust Sharps and Inoculation Management Procedure Lay the patient on their back with one pillow in place (adhere to the Moving and Handling Policy) Straighten the patient’s limbs (if possible) and place their arms by their sides Gently close the patient’s eyes if open by applying light pressure for 30 seconds. If corneal or eye donation to take place, close the eye with gauze moistened with normal saline 50 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide51:

Do not apply tape If syringe driver in situ, disconnect and remove battery In cases where there is no referral to the coroner required infusions can be discontinued and infusion lines, cannulae, drainage and other tubes can be removed If referred to the coroner endo-tracheal tubes, catheters and infusion lines should remain in situ. (see section 3) Discard all sharps into a sharps bin as per Trust Sharps and Inoculation Management Procedure 51 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide52:

Place a receiver between the patient’s legs and drain the bladder by pressing on the lower abdomen. Pads and pants can be used to absorb any leakage Exuding wounds should be covered with absorbent gauze and secured with an occlusive dressing Wash the patient if necessary, unless requested not to do so for religious/cultural reasons or patient has died in suspicious circumstances 52 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide53:

It may be important to the family and carers to assist with washing, thereby continuing the care given to the patient in the period before death Clean the patient’s teeth and gums using a moistened, soft small headed nylon toothbrush and or suction to remove any debris and secretions Clean any dentures and replace them in the mouth – a small pillow or rolled up towel placed under the patient’s chin may help to keep the jaw closed and teeth in situ 53 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide54:

Tidy the hair as soon as possible after death and arrange into the preferred style (if known) Patients should not be shaved; usually a funeral director will do this. Some faiths prohibit shaving Remove all jewellery , in the presence of another nurse, unless requested by the family to do otherwise. Any jewellery removed must be documented on a property form and placed in the hospital safe until collected by the family. Wedding rings may be left in situ and taped in place. Any jewellery remaining on the body should be documented on the identification card accompanying the patient to the mortuary or undertakers 54 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide55:

Record all property in the patient property book and pack in a labelled property bag, keeping secure until collected by the family. Pack personal property showing consideration for the feelings of those receiving it. Discuss the issues of soiled clothes sensitively with the family and ask whether they wish them to be disposed of or returned Unless a specific request has been made by the family for alternative clothes the patient should be dressed in a hospital gown If relatives are present at the time of death, or attend the hospital shortly after, staff should ensure that they are given the Trust Bereavement information copies of which are available on the ward. Relatives should be told to contact the relevant Trust officer who supports bereavement or the patient’s GP to collect the death certificate 55 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide56:

Label one wrist and one ankle with an identification band containing the following information:  Full name  NHS Number  Date of Birth Complete patient identification cards and notification of death book clearly in capitals If the patient has an implant device such as a pacemaker or an infectious disease is known or suspected – record this fact on both patient identification cards 56 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide57:

Tape one identification card to clothing or hospital gown Wrap the body in a sheet, ensuring that face to feet are covered and that all limbs are held securely in position If the body may be infectious or there is a risk of leakage of body fluids place the body in a body bag and put the second identification card into the pocket of the body bag If the deceased person has a known infectious disease Category 3 & 4 they must be placed in a heavy duty body bag and you must inform anyone else who comes in contact with this patient e.g. funeral directors, porters. 57 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide58:

Remove gloves and aprons. Dispose of equipment according to local policy and wash hands If mortuary on site request porters to remove body from the ward to the mortuary If no on site mortuary, contact local funeral directors or the funeral directors according to the relatives wishes Screen off the area where removal of the body will occur Screen off the area where removal of the body will occur Record all the details and actions in the nursing records Any property retained on the ward out of hours must be stored in a secure area and any valuables stored in the ward or hospital safe 58 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

An autopsy:

 —it is also known as a  post-mortem examination ,  It is a highly specialized surgical procedure that consists of a thorough examination  of a  corpse  to determine the cause and manner of  death  and to evaluate any  disease  or  injury  that may be present. It is usually performed by a specialized medical doctor called a  pathologist . Autopsies are performed for either legal or medical purposes. An autopsy 59 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

types:

types Autopsies are divided into 2 categories: Medical, authorized by the decedent, decedent's family or healthcare surrogate forensic, authorized by statute. 60 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide61:

AUTOPSY An autopsy or postmortem examination is an examination of the  body after death. It is performed in certain cases such as: o   Committed suicide o   Unknown cause of death o   Unknown dead bodies o   Homicide (The killing of one human being by another ) ·         The organs and tissues of the body are examined to establish the exact cause of death , to learn more about a disease ·         A consent should be obtain from the immediate relative :surviving spouse, adult children, parents, siblings. ·         After an autopsy , hospitals cannot retain any tissues/ organs without the permission of the person who signed the consent form 61 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Embalming :

It is the art and science of preserving human remains by treating them (in its modern form with chemicals) to forestall  decomposition . The intention is to keep them suitable for public display at a funeral, for religious reasons, or for medical and scientific purposes such as their use as anatomical specimens. [1]   The three goals of embalming are  sanitization ,  presentation  and preservation (or restoration). Embalming has a very long and  cross cultural  history, with many cultures giving the embalming processes a greater religious meaning. Embalming prevents the process through injection of chemicals into the body to destroy the bacteria It is the process of preserving dead body from decay Injection of chemicals into the body to destroy the bacteria ; thereby prevents rapid decomposition of tissues. Embalming fluid contains a mixture of formaldehyde, methanol, ethanol and other solvents Embalming  62 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide63:

Make sure the body is face up Remove any clothing that the person is wearing.   Disinfect the mouth, eyes, nose, and other orifices Shave the body.   Break the rigor mortis by massaging the body. Setting the Features Close the eyes. Close the mouth and set it naturally Moisturize the features.  A small amount of creme should be used on the eyelids and lips Casketing the Body 63 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

Slide64:

Process of Embalming Embalming fluid is injected into the arteries of the deceased during embalming. Many other body fluids may be drained or aspirated and replaced with the fluid as well. The process of embalming is designed to slow decomposition of the body. The actual embalming process usually involves 4 parts: Arterial embalming : which involves the injection of embalming chemicals into the blood vessels, usually via the right common carotid artery. Blood is drained from the right jugular vein. Cavity embalming : The suction of the internal fluids of the corpse and the injection of embalming chemicals into the body cavities, using an aspirator and trocar . Hypodermic embalming : The injection of embalming chemicals under the skin as needed. Surface embalming : Which supplements the other methods especially for visible, injured body parts. 64 SHRI VINOBA BHAVE COLLEGE OF NURSINGH, SILVASSA

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