Death and Dying

Definitions and Signs of Death

• Heart-lung death –traditional clinical signs of death
which includes cessation of the apical pulse, respirations,
and blood pressure
• Guidelines for physicians as indications of death adopted by
the World Medical Assembly:
Total lack of response to external stimuli
No muscular movement especially breathing
No reflexes
Flat encephalogram (brain waves)
• Cerebral/higher brain death –occurs when the higher
brain center, the cerebral cortex, is irreversibly destroyed
Responses to Dying and Death
• Grieving –include denial, guilt, anger, despair, feelings
of worthlessness, crying, and inability to concentrate
• Fear –the feeling of disruption that is related to an
identifiable source (in this case someone’s death)
• Hopelessness –occurs when the person perceives no
solutions to a problem
• Powerlessness –a person who does perceive a solution
to the problem but does not believe that it is possible
to implement the solution
 In cases of terminal illness, the state of awareness shared by the dying person
and the family affects the nurse’s ability to communicate freely with clients and
other health care team members to assist in the grieving process.

Three Types of Awareness:

• Closed Awareness –the client is not made aware of impending
death
• Mutual Awareness –the client, family, and health personnel
know that the prognosis is terminal but do not talk about it and
make an effort not to raise the subject.
• Open Awareness –the client and the others know about the
impending death and feel comfortable discussing it, even
though it is difficult
Kubler-Ross Stages of Dying or Grief
Precipitating Factors of Grief
• Death in family

• Separation

• Divorce

• Physical Illness

• Work failure disappointments

Kubler-Ross Stages of Dying or Grief
1. Denial
Initial response to protect the self from anxiety.
“No not me”, “Its not true”, “Its not impossible”
May continue to make impractical/unrealistic plans
May comment that a mistake has been made about the diagnosis
of terminal illness
May appear normal and can continued ADL as if nothing is
wrong
May not conform with the advised treatment regimen
Adaptive response – crying, verbal denial
Maladptive response – absence or reaction such as crying.
Kubler-Ross Stages of Dying or Grief
2. Anger
Individual feel that they are victims of incompetence or a vengeful
God (they did something wrong so they are being punished), fate
(karma), circumstances (wrong place and wrong time).
“Why me”, “What did I do to deserve this?”
They seek for reasons, answers and explanations
May express anger overtly – being irritable, impatient, critical
verbally abusive.
May express anger covertly by neglecting self, not eating, nor
going to check ups, committing suicide, drinking alcohol.
Adaptive response – verbal expression
Maladaptive – persistent guilt or low self esteem, aggression, self
destructive ideation or behavior.
Kubler-Ross Stages of Dying or Grief
3. Bargaining
The person try to inhibit good behavior, make up for perceived
wrong doings or other engage in behaviors that would please GOD
so he will be given more time- an extension of life or granted
recovery.
“Yes, me but”
“If I live until Christmas or until my child’s graduation ( So many
if’s), I will do this…”
Adaptive response – bargains for treatment control, express wish
to be alive for specific events in the near future.
Maladaptive response – bargains for unrealistic activities or events
in the distant future.
Kubler-Ross Stages of Dying or Grief
4. Depression
Occurs when the reality of loss or impending loss cannot be
ignored anymore and the person grieves for himself and those he
will leave behind, for the things that he can no longer accomplish or
experience.
“Yes, I’m dying”
Withdrawn, has no energy and interest to interact.
Cries
Makes few demands
Adaptive response – crying, withdrawing from interaction
Maladaptive response – self destructive actions, despair.
Kubler-Ross Stages of Dying or Grief
5. Acceptance
Occurs when the person has come to peace with himself and
others
“Yes, I am ready”
Stage of affective void – not happy nor sad
Only persons who are highly significant to him stimulates a
reaction. Others are merely tolerated.
Makes realistic preparation
Adaptive response – may wish to be alone, limit conversation,
complete personal and family business.
Kubler-Ross Stages of Dying or Grief
Nursing Interventions:
Assess; specific loss, meaning of loss, coping skills, support
persons.
Accept the client; do not respond personally to the client.
Support adaptive responses; allow to express feelings
Support defense mechanism – reassure client that denial and
wanting to be alone is normal.
Help find constructive outlets of anger. Do not take clients
hostility personally. Do no retaliate.
Monitor for self destructive behaviors
Help express feelings: Ask how they feel
Meet needs
Allow as much decision making as possible to maintain dignity
by giving choices and alternatives.
Clinical Manifestations of Impending
Clinical Death

Loss of Muscle Tone

Slowing of the Circulation

Changes in the Respirations

Sensory Impairment