Death. Everything a Registered Nurse should know.

Death and Dying – Nursing Issues.

Death is not easy subject to deal with. It difficult for the dying who is dying, and those around him/her. This article is written by a registered nurse with more than twenty years experience who has witnessed many deaths. There is no predicting when death will strike or whom it will strike next. Could be me, could be you. Just like taxes, it is real. Is has always happened, is happening and will continue to happen until at least the end of my life.

Picture A. Sudden Death in a young person is more traumatic than the death of an elderly person with chronic disease.

Issues discussed are death, fear of dying, insurance, next of kin, structured settlement, legal, death insurance, last rites, funeral insurance, funeral home

People who are dying have a life and are living it. As long as they are alive they have all the emotions, feelings and wishes that all of us have. This article is based on lengthy lonely talks sitting with dying patients on the night shift.

The night time is the most difficult time for the dying patient. The fear of death is real. Many Nurses will give the patient prescribed medications and say their “good night” and “will see you in the morning”. This is standard care, the medication is expected the patient to sleep. All family members are told to go home and get some sleep. The reality is very different. Patients cannot sleep, the fear of death is real. Switching off the lights, it’s like switching off life. In my experience, many patients have requested the light to be left on and I have not had any problem. Of course, I as a nurse, was subjected to the usual pressure from my bosses who would give me a lecture on how the quality of sleep is not so good when the lights are on. I have had many lengthy talks about “fear of dying” with many patients. As a Nurse, please respect the patient’s wishes, the fear is real and I will talk about it in the next paragraph.

Many patients fear of dying. The fear of dying is because many patients feel that death is preceded by pain. Death is not painful to many patients. The process of dying is usually the result of pathological disturbances which first alter blood chemistry which alter the level of consciousness of the patient. When the LOC (level of consciousness) is decreased the patient is not in pain and is not aware when the last breath will be. Pain can be controlled effectively by medications. Medications must be administered correctly. Please see: Administering Oral Medications (PO) Correctly

When a patient knows that he or she is going to die, he/she is usually “in crises”. He will seek company, be prepared to sit with the patient and make the patient comfortable. Patients who are dying are usually very nice and friendly and may seek your assistance because you are the person who is most readily available. Most patients want to leave on good terms with all around them. So try and anticipate what the patient needs and try to satisfy his/her needs. Being in crises also means that the person will be constantly negotiating with god and others around him/her. They are always hoping that god will grant them more time for more time here on earth.

Sometimes a patient will want to speak with close family members. If your patient is orientated, be kind, call the relatives. I know that it might breach the policies of some hospitals. You are an advocate for your patient; his/her rights come first. If your patient is confused, be prepared to sit and comfort him. Sometimes, family members would have left specific instructions for you to follow. Call them as per the agreement, the time on earth is not of any relevance to them.

Hospitals are difficult places for the relatives and friends of the patient. All communications must be done in accordance with the patient’s wishes, if these are known and if the patient is alert, conscious and orientated to person, place and time. If your patient is confused, all communications must be in accordance with the instructions of the next of kin. If there is a conflict in directions and your patient is orientated to time, person and place, the directions of the patient take priority and Should be respected.

Some Hospitals have contracts with specific funeral homes and the funeral home will have provided information about coffin and funeral arrangements. Even coffins can be quite expensive or may be part of a prepaid insurance policy. These may be some of the things a relative may ask you.

It is very distressing to see a patient with Cancer of the Bronchus or respiratory disease die. These patients are usually short of breath and it affects all around them. Positioning the patient and giving all the right medications will help. Interventions for patients with breathing difficulties are listed at: Respiratory Tract Infections Treatment & management

Picture B. A coffin could cost as much as $5,000. Funeral expenses are family responsibility. In some countries the department of social services pays for the burial of the poor.

Most of the time, the next of kin is helpful in making decisions about caring and treating the patient. However, this is not the rule of thumb. Sometimes, there are inheritance, family, and legal issues which are not resolved. If the patient is conscious he/she may want to sign documents. There is nothing wrong with signing documents in the hospital. However, it is important that the patient is not medicated at time of signing. You may be asked to be a witness to the signing of a document. There is nothing wrong with this as long as you know your patient. You are only witnessing the fact that the patient signed the document. You are not witnessing the contents and no witness ever witnesses the contents. Only the signatories are agreeing to it.

Nurses are the patient’s advocates. Nurses and physicians have the most amount of obligation to the patient. Your commitment is less to your employer, the board and the Hospital. If you suspect that a next of kin is behaving is a suspicious manner then you have an obligation to notify the nursing administration and/or police. In my life time there have been times when the next of kin was not acting in the patient’s best interests. These situations arise when there is family conflict and legal settlements and legal issues are pending.

Physicians in palliative care facilities are very good at prescribing appropriate pain medications. Other medications which may be used include antidepressants, steroids (particularly prednisolone) and all treatments. In other facilities you will need to be an advocate for the patient. Ask your patient if he wants any pain medication. Request the physician to prescribe it. Remember, pain is what the patient says it is.

Discharge home is one of the best choices, if the patient can be cared for at home. This is because it allows the patient more control over his situation. However, not all patients can be discharged home.

Do not accept any gifts from the ill patient. You have a lot of “power” over the patient. He must not be given any perception that the care he receives depends upon the rewards he gives you.

The patient’s next of kin is an important person, he is under a lot of stress too. Offer the next of kin a cup of tea and something to bite. This creates a more comfortable environment for the patient and visitors who may be seeing their relative for the last time. The next of kin will remember this cup of tea for a long time, positively.

Some hospitals are stocked with limited amount of seating and have a “two visitors” only rule. You must be the patient’s advocate, break the rules as long as you follow the infection control and other regulations. You will have the patient’s blessings and your moral courage will pay dividends when you have to handle another similar issue.

Visiting Hours: Some hospitals enforce the visiting hours vigorously, you need to have the moral courage to brave this issue too. A dying patient’s wishes are more important than man’s control issues.

If you are not a nurse of a doctor and wish to know more about how the patient is likely to fare just from seeing his/her breathing you may wish to read the section on breathing types: Types of breathing for Nurses

Comfort measures include personal hygiene, care, medication administration, and comfort issues. Please position a dying patient in a manner which is most comfortable for him/her. Review article: Patient Positions for Nurses

Religious wishes. These must be respected for all communities. These are very important for orthodox groups. The need for a religious representative should be clarified as soon as possible. Last rites should be given in accordance with the patients (or next of kin) wishes.

Once the patient has died, he/she needs to be certified to be dead. In some counties a Registered Nurse can certify death. In others, a physician must do this. In some countries no certification in needed.

The cause of death must be recorded accurately because it will affect insurance payout to the next of kin. If there are pending legal issues – structured settlements etc may be in the works. Charges for murder may be laid if an assaulted patient dies, even if he dies as a result of withdrawal of treatment.

The last rites – labelling, washing, packing, disposing and releasing the body to the family for cremation/burial must be done strictly according to protocol. Document the time of death and notify patient information services / switchboard about the patient’s death so that inquiry calls are informed of the death.

After the patient has passed away, it is usual for the next of kin to see the patient’s body. Some families hold a prayer at the bedside. Permit this in accordance with hospital policies. Generally, allow the patient’s relatives to see the body for up to two hours. After that the body may begin to deteriorate and will need to be moved to the mortuary for storage.

The nurse on duty is also responsible for insuring that the property of the deceased patient is documented properly and sent to security of given to the next of kin. Always request the person taking the property to sign for it.

Last but not least, look after yourself. Have your own time outs. Speak with colleagues. Ask your employer to provide you a debriefing session. The situation is more difficult, for the Nurse if the patient has been a victim of trauma or violence.

I still get night mares about two patients: I was working as a Nurse on a surgical ward. I admitted a patient from the operating theatre. A leg had to be amputated. He had lost a lot of blood and was unconscious all the time. He did not know about the loss of his leg and the instructions to me were not to tell him that. The Surgeon was going to do that in the morning.

The other situation which I still dream about was a holiday maker who was the victim of a bomb blast in Bali. I looked after him when he arrived from the injury. He did not die, but the trauma left him blind from both eyes and had multiple injuries. My employing Hospital said, on TV that counselling services were provided to staff. Now you know the other side of the story.