A patient needs intensive physical and emotional support as he approaches death. Signs and symptoms of impending death include reduced respiratory rate and depth, decreased or absent blood pressure, weak or erratic pulse rate, lowered skin temperature, decreased level of consciousness (LOC), diminished sensorium and neuromuscular control, diaphoresis, pallor, cyanosis, and mottling.
Emotional support for the dying patient and his family usually means reassurance and the nurse's physical presence to help ease fear and loneliness. More intense emotional support is important at much earlier stages, especially for patients with long-term progressive illnesses, who can work through the stages of dying. (See Five stages of dying, page 112.)
Respect the patient's wishes about extraordinary means of supporting life. The patient may have signed a living will. This document, legally binding in most states, declares the patient's desire for a death unimpeded by the artificial support of defibrillators, respirators, life-sustaining drugs, auxiliary hearts, and other artificial means. If the patient has signed such a document, the nurse must respect his wishes and communicate the physician's “no code” order to all staff members.
Equipment
Clean bed linens • clean gowns • gloves • water-filled basin • soap • washcloth • towels • lotion • linen-saver pads • lemon-glycerin swabs • petroleum jelly • suction and resuscitation equipment, as necessary • optional: indwelling urinary catheter.
Implementation
  • Assemble equipment at the patient's bedside as needed.
Meeting physical needs
  • Take vital signs often, and observe for pallor, diaphoresis, and decreased LOC.
  • Reposition the patient in bed at least every 2 hours because sensation, reflexes, and mobility diminish first in the legs and gradually in the arms. Make sure the bed sheets cover him loosely to reduce discomfort caused by pressure on arms and legs.
  • When the patient's vision and hearing start to fail, turn his head toward the light and speak to him from near the head of the bed. Because hearing may be acute despite loss of consciousness, avoid whispering or speaking inappropriately about the patient in his presence.
  • Change the bed linens and the patient's gown as needed. Provide skin care during gown changes, and adjust the room temperature for patient comfort if necessary.
  • Observe for incontinence or anuria, the result of diminished neuromuscular control or decreased renal function. If necessary, obtain an order to catheterize the patient, or place linen-saver pads beneath the patient's buttocks. Put on gloves and provide perineal care with soap, a washcloth, and towels to prevent irritation.
  • With suction equipment, suction the patient's mouth and upper airway to remove secretions. Elevate the head of the bed to decrease respiratory resistance. As the patient's condition deteriorates, he may breathe mostly through his mouth.
  • Offer fluids frequently, and lubricate the patient's lips and mouth with petroleum jelly or lemon-glycerin swabs to counteract dryness.
  • If the comatose patient's eyes are open, provide eye care to prevent corneal ulceration. Such ulceration can cause blindness and prevent the use of these tissues for transplantation should the patient die.
  • Provide ordered pain medication as needed. Keep in mind that, as circulation diminishes, medications given I.M. will be poorly absorbed. Medications should be given I.V., if possible, for optimum results. Some medications can be given
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    sublingually or rectally if the patient can't swallow or has no I.V. access.

Meeting emotional needs
    • Fully explain all care and treatments to the patient even if he's unconscious because he may still be able to hear. Answer any questions as candidly as possible without sounding callous.
    • Allow the patient to express his feelings, which may range from anger to loneliness. Take time to talk with the patient. Sit near the head of the bed, and avoid looking rushed or unconcerned.
    • Notify family members, if they're absent, when the patient wishes to see them. Let the patient and his family discuss death at their own pace.
    • Offer to contact a member of the clergy or social services department, if appropriate.
    Special considerations
    • If the patient has signed a living will, the physician will write a “do-not-resuscitate (DNR)” order on his progress notes and order sheets. Know your state's policy regarding the living will. If it's legal, transfer the DNR order to the patient's chart or Kardex and, at the end of your shift, inform the incoming staff of this order.
    • If family members remain with the patient, show them the location of bathrooms, lounges, and cafeterias. Explain the patient's needs, treatments, and care plan to them. If appropriate, offer to teach them specific skills so they can take part in nursing care. Emphasize that their efforts are important and effective. As the patient's death approaches, give them emotional support.
    • At an appropriate time, ask the family whether they have considered organ and tissue donation. Check the patient's records to determine whether he completed an organ donor card. (See Understanding organ and tissue donation.)
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    Documentation
    Record changes in the patient's vital signs, intake and output, and LOC. Note the times of cardiac arrest and the end of respiration, and notify the physician when these occur.