DEATH AND DYING

Definition of Terms
Bereavement period during which mourning for a loss takes place
Brain death irreversible loss of all brain functions, including those of the brainstem
Cheyne-Stokes respiration pattern of breathing characterized by alternating
periods of apnea and deep, rapid breathing
Death cessation of heart function, lung function or of whole brain function or of
higher brain function
Death rattle noisy, wet-sounding respirations which are caused by mouth breathing
and accumulation of mucus in the airways
Grief personal feeling that accompany an anticipated or actual loss
Mourning individual, family, group, and cultural expression of grief and associated
behaviors
Spirituality personal belief systems that focus on a search for meaning and purpose
in life, intangible elements that impart meaning and vitality to life, and a
connectedness to a higher or transcendent dimension
PHYSICAL MANIFESTATIONS AT END OF LIFE
SYSTEM
MANIFESTATIONS
Sensory system
Hearing
Usually the last sense to disappear
Touch
Decreased sensation
Decreased perception of pain and touch
Decreased with disease progression
Taste
Blurring of vision
Sinking and glazing of eyes
Blink reflex absent
Eyelids remain half-open
Cardiovascular system
Increased heart rate; later slowing and
weakening of pulse
Irregular rhythm
Decreased blood pressure
Delayed absorption of drugs administered
intramuscularly or subcutaneously
Respiratory system
Increased respiratory rate
Cheyne-Stokes respiration (pattern of
respiration characterized by alternating
periods of apnea and deep, rapid
breathing)
Inability to cough or clear secretions
resulting in grunting, gurgling, or noisy

Urinary system

Gastrointestinal system

Musculoskeletal system

Integumentary system

congested breathing (death rattle)

Irregular breathing, gradually slowing
down to terminal gasps (may be described
as guppy breathing)
Gradual decrease in urine output
Incontinence of urine
Inability to urinate
Slowing or cessation of GI function (may
be enhanced by pain-relieving drugs)
Accumulation of gas
Distention and nausea
Loss of sphincter control, producing
incontinence
Bowel movement before imminent death
or at time of death
Gradual loss of ability to move
Sagging of jaw resulting from loss of
facial muscle tone
Difficulty speaking
Swallowing becoming more difficult
Difficulty maintaining body posture and
alignment
Loss of gag reflex
Jerking seen in patients on large amounts
of opioids
Mottling on hands, feet, arms, and legs
Cold, clammy skin
Cyanosis of nose, nail beds, knees
Waxlike skin when very near death

Changes in body after death:

1. Rigor Mortis: body becomes stiff within 4 hours after death as a result of decreased ATP
production. ATP keeps muscles soft and supple.
2. Algor Mortis: Temperature decreases by a few degrees each hour. The skin loses its
elasticity and will tear easily.
3. Livor Mortis: Dependant parts of body become discolored. The patient will likely be
lying on their back, their backside being the 'dependant' body part. The discoloration is a
result of blood pooling, as the hemoglobin breaks down.

PSYCHOSOCIAL MANIFESTATIONS AT END OF LIFE

Altered decision making
Anxiety about unfinished business
Decreased socialization
Fear of loneliness
Fear of meaninglessness of ones life
Fear of pain
Helplessness
Life review
Peacefulness
Restlessness
Saying goodbyes
Unusual communication
Vision-like experiences
Withdrawal
KUBLER-ROSS MODEL OF GRIEF
STAGE
CHARACTERISTICS
Denial
Denies the loss has taken
place and may withdraw. This
response may last minutes to
months.

Anger

Bargaining

Depression

Acceptance

May be angry at the person

who inflicted the hurt (even
after death) or at the world for
letting it happen. May be
angry with self for letting an
event take place, even if
nothing could have stopped it.
May make bargains with God,
asking
If I do this, will you take
away the loss?
Feels numb, although anger
and sadness may remain
underneath.
Anger, sadness, and mourning

NURSING IMPLICATION
Provide a buffer after bad
news. Assess the patients and
familys coping style,
information needs, and
understanding of the illness
and treatment to establish a
bases for empathetic
listening.
Allow the patient and the
family to express anger,
treating them with
understanding, respect, and
knowledge that the root of the
anger is grief over impending
loss.
Nurses should be patient,
allow expression of feelings,
and support realistic and
positive hope.
Nurses should encourage the
patient and the family to fully
express their sadness.
Family may be rejected by

have tapered off. Accepts the

reality of the loss.

the patient so the nurses need

to support the familys
expression of emotions and
encourage them to continue
to be present for the patient.

Sources:
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner &
Suddarth's Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott Williams &
Wilkins.
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2011). Medical-Surgical Nursing: Assessment and
Management of Clinical Problems. Canada.
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