Grief and and Comfort Care
provide an informative response to 3 of my classmates with 250 words or more, the response needs to add on to their discussion
the topic of discussion is on The Dying Person’s Bill of Rights
Clinical Manifestations – End of Life
Cultural Considerations – End of Life and Death
The Dying Person’s Bill of Rights
The right to expect continued medical and nursing attention even though “cure” goals have been changed to “comfort” goals.
I chose this specific “right” as often see the reaction or stigma to “comfort care” or “hospice”. This decision is not releasing an individual of all medical care and assistance. I have witnessed
the idea that “comfort” care is less care and hands on medical staff. Historically, this must have been the case if there is a Bill of Rights to ensure it does not happen to a person during their
end of life stage. It can be fearful thinking that a person might be cared for less, given less thought, provided different medical attention, etc. if they did not choose aggressive measures. I
love that this Bill of Rights is an advocate for those individuals who want to choose a different path for their diagnosis that has more quality of life than quantity. I know from a personal
perspective that Hospice services are rendered to ensure the exact opposite of this fear and provide additional hours of service despite patient’s terminal illness and choice to manage symptoms
rather than fight disease.
Clinical Manifestations – End of Life
*Body Temperature may change as perfusion decreases and body compensation naturally attempts to perfuse major organs. A nurse may see coolness to toes, feet, fingers, hands, legs, and arms.
*Mental Status changes may occur due to a multitude of reasons; some being electrolyte imbalances, decreased organ perfusion, decreased PO intake, dehydration
*Sleep Pattern changes may occur and usually increase during end of life. A person may become very different than their normal, everyday personality. Examples include difficulty arousing them,
decreased communication, and decreased responsiveness.
*Incontinence will occur as body functions that were once voluntary become involuntary.
*Terminal restlessness can be seen in patients when oxygen levels are low. Agitation may cause them to be unable to lay still, pull at clothes/linens/tubing, kicking feet
*Increased secretions and moisture to airways. It may be related to decreased swallow function and increased function of secretory cells.
*Decreased urine output from decreased fluid intake, potential organ failure
*Respiratory Changes may vary from patient to patient, but many common known end of life patterns are known as Cheyne-Stokes.
*Vital sign changes – blood pressure, pulse, temperature, oxygen, and respirations all may decrease
*Mottling of skin may occur when blood is settling in body, giving extremities purple, blue, gray color.
*Hallucinations may occur
Cultural Considerations – End of Life and Death
Native Americans are a special population with rich cultural background of spirit and harmony in the earth. Understanding a few concepts that a Native American might believe can be helpful as a
*Afterlife – may be largely ruled by the spirit. Many believe that the spirit never dies and is always on a journey from one life to the next. It is sometimes believed that a spirit journeys on the
earth for approximately 4 days or longer. If this earthly journey is poor, the spirit may not continue onto another life and will return to a ghost to haunt the living. However, ghosts are not
*Funerals – Community meals a few days prior to the actual funeral allows for an extended period of grieving time and gives time to the spirit to have its earthly journey. Children are not excluded
as teaching them about death and the reality of it are important to the Native American culture. An interesting fact may include that a deceased person or spirit cannot be left alone until after
the funeral has been completed.
*Burial Rituals – this can range from geographical location and tribal customs.
*Nursing Interventions:Tentatively expect passing patient to have conversations and/or see deceased relatives. Foods to be offered that are of tradition to family and favorite to patient, food may
used in place of bouquets to honor the dead. Autopsy, embalming is questioned by family and sometimes looked down upon. Nursing staff to not move deceased body until family gives permission
Death is defined as the cessation of all vital functions of the body including the heartbeat, brain activity and breathing. Grief is a deep sorrow that is caused by someone’s death. The fact
remains that everyone who is born will die whether expected or unexpected. The dying process is as variable as the birthing process. Following are the signs of physical and emotional changes as a
person approaches death:
1. Loss of appetite- As the individual approaches death, the metabolism slows down and they no longer have the same taste in food.
2. Excessive Fatigue and Sleep – Periods of wakefulness becomes shorter. A person becomes more and more difficult to arouse.
3. Increased Physical Weakness – Overall energy declines to the point of being unable to lift one’s head and being able to swallow.
4. Mental Confusion/Disorientation – Organs begins to fail along with the brain. A person may respond less often, may not be aware of who they are or who else is in the room. The dying person may
talk to someone as if that person or being is in the room when they are not.
5. Labored Breathing – Breathing becomes irregular and labored. Cheyne Stokes breathing which is a loud, deep respiration followed by a pause to approximately 5 seconds up to a full minute.
Excessive secretions create loud gurgling with inhalation and exhalations that people call, “death rattle”.
6. Social Withdrawal – As the body slows down a person may not respond or turn their head away from loved ones or staff. A burst of alertness or attention can occur a few days before a person’s
death. This process can last from an hour up to a day.
7. Changes in urination – This occurs from kidney organ shutting down and little or no output. Urine may become tea colored. Loss of control of bladder and bowels occurs.
8. Swelling in feet and ankles – Due to kidneys shutting down, it is not able to process body fluids and accumulation occurs away from the heart to the extremities.
9. Coolness in tips of fingers and toes – At the last stage of dying process, blood circulation draws from the peripheral areas to the vital organs.
10. MottleVeins – Skin that is pale or ashen becomes purple/reddish/bluish in color that is called “mottling”. (Crossroads Hospice)
Everyone has different ways of expressing grief and loss following the death of a loved one. Cultures play an important role in this matter. With the Filipino culture, the spouse is the only
one that can dress the dead. The body is delivered in their home and placed in a casket. The wake is held in the home with an open casket for family and friends to pay their respects. I believe
that carrying out these practices offers a sense of security and stability for the loved ones left behind.
Lastly, the goal of end-of-life for all humans is to die in a compassionate manner. In the United States, there is a Bills of Rights for dying. These rights include respecting your advance
directives, and living will and access to hospice and palliative care. Unfortunately, most of the End-of-Life-Rights are not protected in the U.S. and are highly varied by state laws. There are
13 Bill of Rights of the Dying. I chose, the part of the Bill of Rights in Dying,” I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my
needs and will be able to gain some satisfaction in helping me face my death”. This is very important to me as I believe this is very important for nurses to render when caring for the dying.
Terminally ill patients are still human and have rights that protect them. As nurses we are taught to help “nurse” them back to health, therefore we might not be as comfortable and not be trained
to care for the dying. As nurses we need to shift from saving lives to preparing for death.
When caring for the patient it is important to do what is more appropriate for the patient. The standard old way of turning the patient every one to two hours, giving a complete bed bath,
forcing fluids or trying to get them to eat may not be appropriate for the dying patient or their families. A nurse needs to know that death is very individualistic and what is helpful for one may
not be helpful for another. The nurse must understand the patient’s disease, learn about their coping abilities and communicate effectively regarding the patient’s wishes. In doing this we are
respecting the dying patient’s Bill of Rights ,the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some
satisfaction in helping me face my death”.
When providing palliative care for a patient who is in the process of dying it is important that we provide a caring and comfortable environment for not only the patient but the family as well.
While it’s hard to pick one right from the Dying Person’s Bill of Rights because they are all important, the one that stands out to me the most is the “I have the right to be cared for by caring,
sensitive, knowledgeable people who attempt to understand my needs and will be able to gain some satisfaction in helping me face my death.” (Alexander, 2015.) As nurses we need to be knowledgeable
in the signs of deaths and cultural considerations to be able to provide a safe, caring and comfortable environment.
There are several clinical manifestations in a patient who is dying. General changes include profound weakness and fatigue, decreased level of consciousness, they may be disorientated to person,
place and time, and the patient may have hallucinations of speaking with persons who have already died. The dying patient may have a decreased interest in food and fluids and could have difficulty
swallowing. The urinary functioning may change with either decreased urinary output and/or urinary incontinence. Respiratory changes can include dyspnea, Cheyne-Stokes respirations, also referred
to as the death rattle, which is periodic breathing with alternate periods of apnea and hyperventilation and they may experience retention of secretions in the upper respiratory tract causing a
gurgling sound. Due to decreased blood perfusion the skin of a dying patient may become mottled, which is patches of purplish colored spots that are usually noticeable on the back, arms and legs.
They may develop decubitus ulcers, or Kennedy ulcers from being bedbound and having a decreased nutritional status. To prevent ulcers from developing we need to keep the patient repositioned at
least every two hours or provide specialty mattresses made to relieve pressure from bony prominences. The dying patient may also experience tachycardia and hypotension due to a decrease in cardiac
output. (Alexander, 2015.)
Some interesting religious cultural considerations I found include for Buddhists once the death has been confirmed the body should be covered with a cotton sheet and not disturbed. They leave the
body just as it is for up to eight hours to allow for the spirit to pass into the next world. When a Hindu passes away you would not remove any rings, threads, necklaces or medals they may be
wearing. You’d close the eyes and straighten the arms and legs. The family washes the body and then the body is wrapped in plastic and prepared for cremation within 24 hours. When some one of
Islamic faith passes away they prefer the body to be handled by a person of the same gender and the body is placed on one side or on their back facing Mecca and you must provide the family time to
read the Qu’ran over the body. After death has been confirmed with some one who practices Judaism it is the children or friends of the patient that close the eyes and mouth. Dentures are left in
place and you do not wash the body or wrap it in plastic. The body is laid flat with arms down to the sides and feet face the doorway. It is important that we as nurses take the time to research
and be informed of different religious cultural preferences when caring for a patient. (Dimopoulos, 2013.)