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Imminent death texto web y (Power Point)
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crow Sin Conexión

Mensajes: 1,112
Registro en: Oct 2007
Mensaje: #1
Imminent death texto web y (Power Point)
Imminent death (Power Point)
(Este mensaje fue modificado por última vez en: 05-07-2008 04:12 AM por crow.)
02-02-2008 06:58 PM
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crow Sin Conexión

Mensajes: 1,112
Registro en: Oct 2007
Mensaje: #2
imminent death
Long Term Care
Intensive Train-The-Trainer Series

Imminent Death

Authors: Carol Barker, Ph.D., R.N., and Mary Foerg, CSW, ACSW ©
Hospice of Michigan

Jennifer Mendez, Ph.D.
Institute of Gerontology – Wayne State University

Presented by:
Institute of Gerontology Wayne State University

In partnership with:
Hospice of Michigan

The development of this training manual has been funded by a grant from the
Michigan Department of Community Health Long Term Care Initiatives
Imminent Death (Slide 1)
Module Overview:  (Slide 2)

This module provides an overview of care requirements at the time death including physical, psychological and spiritual care of the patient as well as support of family members.  Emphasis will also be placed on the death event, recognizing death, and after death care.

Definition of Terms: (Slide 3)

Catheterization: insertion of tube into patient’s bladder to facilitate removal of urine

Pulmonary edema: fluid accumulation in the tissues of the lungs

Terminal anguish: state prior to death where patient is unable to suppress or repress painful, unresolved psychological issues.

Terminal restlessness: Prior to entering semicomatose state patient becomes restless, confused and develops seizures.

Objectives: (Slide 4)

1. Describe the process of active dying and death.
2. Identify psychological and spiritual symptoms of active dying.
3. Describe physical signs of death.
4. Describe the signs and symptoms of imminent death.
5. Differentiate between “usual road” and “difficult road” to death.
6. Identify the signs of death.
7. Identify actions to take when death occurs.

Teaching Cues Content Resources
Describe the process of active dying and death. What’s death all about?
1.0 Everyone will die
1.1 Less then 10% will die suddenly
1.2 More than 90% of us will die due to a prolonged illness
1.3 There is no typical death.  Each person dies in their own way, own time, with their own culture, belief system, values, and unique relationships with others.
1.4 The time of death cannot be predicted
2.0 The final days and hours before a patient dies is the last opportunity for growth and development to occur in the patient/family unit.
2.1    The final hours allow for patient and family to say good-by and complete end-of-life closure
2.2    Emphasis should be placed on facilitating a comfortable death that honors patient/family choices.
            Slide 5

Explore with participants’ “feelings” regarding death experience. Discuss what it feels like to be with someone dying. Emphasize the importance of being present and “bearing witness.”
Dying is a physical, psychological, social, and spiritual event.
1.0 Patient/family must continue to be seen as the unit of care.
2.0 Emphasis must be place on optimizing patient comfort, dignity, choice, acceptance, final tasks, and life closure
3.0 All aspects of care need to intensify in order to minimize suffering.
4.0 The interdisciplinary team must remain focused in order to:
4.1 Help patient achieve dignified death
4.2 Identify emerging problems
4.3 Help family deal with immediate care needs up to and including the moment of death as well as after the death event.
4.4 Arrange for privacy and intimacy if possible Slide 6
Active Dying: Last Few weeks of Life
Continue the discussion of active dying. 5.0 Process of active dying
5.1 No one can predict exact time of death
5.2 Some patient instinctively know when death will occur
5.3 Signs and symptoms of the dying process only serve as a guideline. Not all patients experience all symptoms and the signs and symptoms do not necessarily occur in sequence.
5.4 The dying process is a natural slowing down of physical and mental processes.
5.5 Can occur days or weeks before death or may be present only hours/minutes prior to death Slide 7
Identify psychological and spiritual symptoms of active dying.

Ira Byock, M.D. has published extensively on this subject – use as a reference r or additional materials 6.0 Some or all of these may be present
6.1 Fear of dying
6.2 Fear of abandonment
6.3 Fear of the unknown
6.4 Dreams and visions with powerful themes and symbols (bridge or river to cross, etc.)
6.5 Withdrawal from family/friends: patient may speak very little to family
6.6 Increased focus on spiritual issues
6.7 Terminal anguish: As death approaches, some patients are unable to repress painful, unresolved psychological events. Become restless, moan or exhibit similar behaviors. Slide 8

Usually participants have witnessed these findings in their own life experiences. Ask them to discuss. Have them identify which symptoms they found most prevalent.
Describe physical signs of death 7.0 Managing physical signs requires an interdisciplinary approach
7.1 Medications and other forms of therapies may be required. Slide 9

Review each of the following physical signs with participants. Encourage discussion based on participants’ level of experience. 8.0 Increased weakness and fatigue
8.1 Weakness and fatigue generally progress to point patient is unable to move muscles and joints independently.
8.2  Turning may be painful. Head may need to be supported and/or positioned for patient.  All activities of daily living must be completed for patient. Slide 10

Use for caregiver information
9.0 Loss of appetite, physical wasting
9.1 May begin earlier in dying process. Tends to intensify during active phase of dying.
9.2  Loss of appetite may be protective mechanism of body. Results in chemical imbalance which, in turn, creates a greater sense of well-being in the patients as well as a                  diminished perception of pain. Slide 11
10.0 Nausea and vomiting
10.1 Along with loss of appetite may come nausea -vomiting
10.2 Needs to be managed aggressively in order to promote and maintain patient comfort. Slide 12
11.0 Dehydration/decreased fluid intake
11.1 Like food, patients usually stop drinking fluids before the phase of active dying
11.2 Giving fluids can prevent kidney failure with subsequent electrolyte imbalance and some elements of confusion and restlessness.
11.3 HOWEVER, as death approaches, aggressive hydration therapy can actually hasten death due to pulmonary edema, worsened breathlessnes, and increased oral/bronchial secretions.
11.4Oral care is essential during this time to minimize sense of  thirst, avoid bad odors in mouth, prevent painful cracking of lips. Slide 13
12.0 Changes in kidney and bladder functions
12.1 Urine output usually diminishes gradually in response to decreased fluid intake.
12.2 Incontinence and/or retention may occur.  Retention may require catheterization to promote comfort. Slide 14

13.0 Changes in bowel functions
13.1 Constipation may continue as a problem sue to decreased food intake, decreased activity of gut due to continued pain medication routines.
13.2 Impaction may need to be addressed if contributing to marked patient discomfort. Slide 15
14.0 Pain
14.1 Like other symptoms, pain must continue to be managed with the same vigor as at any point in the illness
14.2 Although pain intensity may decrease and/or may not be self reported due to altered states of consciousness, pain therapy  may need to be adjusted to accommodate for changes in level of consciousness or respiratory rate. Slide 16
Last Hours of Life
Describe the signs and symptoms of imminent death. Discuss the fact primary, irreversible organ failure is occurring. As death approaches the heart, lungs, and nervous system begin to fail. The patient becomes semicomatose and the following signs and symptoms will be evident. Slide 17

15.0 Semicomatose State
15.1 Eyes become sunken and glazed; often are half open
15.2 Sense are generally dulled except for hearing may not be lost; sensitivity to light remains
15.3 Ability to move decreases, beginning in legs and progressing to the arms
15.4 Body becomes stiff and joints painful when moved
Slide 18
16.0 Impaired heart and renal functioning
16.1 Cardiac output decreases with a corresponding decrease in peripheral and renal perfusion
16.2 Pulse rate increases initially and then weakens and becomes irregular. Radial pulse may be so faint as nonpalpable.
16.3 Blood pressure decreases
16.4 There is peripheral pooling, bluish coloring and mottling of skin
16.5 Patient may perspire. Peripheral  swelling may occur.
16.6 Body temperature may increase due to the result of infection and/or increased tumor activity. Slide 19
17.0 Respiratory dysfunction
17.1 Breathing may become shallow or labored
17.2 Respirations may increase in rate and then decrease, increase in rate again and then slow.
17.3 Secretions may increase. Patient may have difficulty coughing, clearing secretions and swallowing effectively.
17.4 Feelings of “lack of air” and breathlessness may increase as death approaches.
17.5 “Death rattle”: Terminal congestion occurs due to changes in respiratory rate and inability of patient to clear secretions. Very distressing to family but often less troublesome to patient. Slide 20
18.0 Neurologic dysfunction
18.1 Result of multiple factors: metabolic imbalances, kidney failure, infection, reduced blood flow to brain
18.2Leads to “2” road to death: “The Usual Road” or “The Difficult Road” Slide 21
Differentiate between “usual road” and “difficult road” to death. 19.0 The “Usual Road”
19.1 The majority of patients “travel this road”. They experience increasing drowsiness and eventually become unarousable.
19.2 Eventually become comatose and die. Slide 22
20.0 The “Difficult Road”; Terminal restlessness
20.1 The nervous system is highly agitated prior to entering the semicomatose state. The following occurs: confused and starts to tremor.
21.2Experiences hallucinations and mumbling delirium. May progress to muscle jerking and seizures before progressing                      to coma and death. Slide 23
Encourage discussion of feelings among participants. Ask them to describe the challenges they have faced caring for a patient experiencing terminal restlessness.
Signs that death has occurred
Identify the signs of death. 21 With death the following will be noted:
21.1 Absence of heart beat/respirations
21.2 Pupils fixed
21.3 Release of stool and urine
21.4 No response to stimulation
21.5 Body color waxen and pale as blood settles
21.6 Body temperature drops
21.7 Eyes remain open
21.8 Jaw may fall open Slide 24
What to do when death occurs
Identify actions to take when death occurs. 22 Care shifts from patient to family/ caregiver. Some points to consider include:
22.1 Know who to call. Goal in hospice is not to call 911.
22.2 Follow traditions, rites, rituals; prepare body accordingly
22.3 Know whether patient has requested organ donation – how to proceed.
22.4 Follow procedures as outlined per agency
            22.5Initiate bereavement support. Slide 25
Last Thoughts!
23 Dying is a unique experience. Consider these thoughts drawn from working with dying patients:
23.1 Stay with me.
23.2 Walk with me.
23.3 Help me to “fear no evil”.
23.4 Comfort me.
23.5 Facilitate my closure
23.6 Help me leave my legacy in peace. Slide 26

Discuss case study.

Case Study
Imminent Death

Mrs. Hauf was a 93 year old woman with dementia and decreased renal function. She has been a resident of the nursing facility for 12 months. When she was admitted, she was able to feed herself and dress herself with assistance. She frequently attended activities in a wheelchair. She ate approximately 80% of her meals on the days when her favorite foods were served. Mrs. Hauf was pleasant but had difficulty remembering recent events.  After residing in the facility for three months, she began to recognize nursing assistants who frequently care for her.

About three months ago, her appetite started to diminish. She would eat approximately 30% of her meals and often declined her favorite foods. She frequently fell asleep during activities and requested to be put to bed. She began sleeping approximately 16 hours a day. She complained of pain in her lower legs which were slightly swollen. She was no longer able to do any of her care. She continued to smile and chat with staff who cared for her.

About 2 months ago, Mrs. Hauf became too weak to get out of bed. When placed in a wheelchair, she would slump over and sleep. She began sleeping 18 hours a day. She ate approximately 10% of her meals. She developed a decubitus ulcer on her right heel.
She became more confused and disoriented but remained pleasant when awake. She was incontinent day and night. She seemed calm when her minister visited and prayed with her.

Three days ago, Mrs. Hauf seemed to withdraw from those providing her with care. She refused food and accepted only teaspoons of ice chips. She was running a low grade fever. She repeatedly stated that she wanted to go home with her mother. Her respirations were noisy and congested. Her feet were cold and blue.

On day ago, Mrs. Hauf became comatose. She has no swallow reflex. Her respirations are shallow with 5 second periods of no breathing. Her neck is rigid and slightly extended backward. Her B/P is 60/40.

Discussion Questions:

1. When do you think the active process of dying began? Describe the signs and symptoms that were present.

2. What evidence indicates Mrs. Hauf is facing imminent death?

3. What do you think should have been included in this resident’s plan of care when she began to actively die?

4. What concerns you the most regarding this resident’s quality of life prior to death?


Berry, P., Griffie, J. (2001). Planning for the actual Death. In B. R. Ferrell, & N. Coyle, N. (Eds.) Textbook of Palliative Nursing. New York, NY:  Oxford University Press.

Doyle, D., G.W.C. Hanks, MacDonald (Eds.). Oxford Textbook of Palliative Medicine.  2nd ed. New York, NY: Oxford University Press.

Emanuel, L. L., Von Gunten, C. F., Ferris, F. D. (1999). The Education for Physician on End-of-Life Education. 222.Epec.net: The EPEC Project.

Lipson, J., Dibble, S., Minarik, P. Culture and Nursing Care: A Pocket Guide. San Francisco, CA: UCSF Nursing Press.

Lindley-Davis, B. (1991). Process of dying. Cancer Nursing, 6 (4), 328-333.
(Este mensaje fue modificado por última vez en: 05-07-2008 04:11 AM por crow.)
02-02-2008 06:59 PM
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