In a nursing home, nursing staff are always present. Unlike a hospital, a doctor is not in the facility all the time, but may be available by phone. Plans for end-of-life care can be arranged ahead of time, so when the time comes, care can be provided as needed without first consulting a doctor. If the person has lived in the nursing home for a while, the staff and family probably already have a relationship. This can make the care feel more personalized than in a hospital.
Additionally, if the person is enrolled in hospice , the hospice team will be available to assist nursing facility staff with end-of-life care. As in a hospital, privacy may be an issue in nursing homes.
You can ask if arrangements can be made to give your family more time alone when needed. Home is likely the most familiar setting for someone who needs end-of-life care. Family and friends can come and go freely. Care at home can be a big job for family and friends—physically, emotionally, and financially.
But, there are benefits too, and it is often a job caregivers are willing to take on. Hiring a home nurse is an option for people who need additional help and have the financial resources. Neither scenario is wrong, and the nurse caring for patients at the end of life needs to always remember that. There are often several nursing interventions and activities for the nurse to perform during the imminent phase. When the death is imminent, the family must be informed that death is near.
As mentioned before, sometimes this is shocking to the family, despite knowing that their loved one is dying. This has to be communicated to the family in a sensitive and calm manner. Each nurse will have their own way to exchange this information, but it is very important that the family be told that death can occur at any time so that they can prepare.
There may be family in the area or out of town that would like to come and see the patient and who is waiting until the patient gets closer to death. It is important to educate families during the dying process that the final phase may progress very quickly as a way to encourage loved ones to come sooner rather than later. The imminent phase is also the time when some families may want clergy or pastoral care present.
Depending on their religious affiliation, some patients and families may want sacraments or special blessings performed before death occurs. It is important to tell the family that the process leading to death has begun, and that if they would like clergy present they should begin that process now. The nurse can assist families with obtaining pastoral care if the family does not have their own. The coordination of spiritual support may be extremely important to the family at this time and the nurse should be sure to evaluate for this as part of their assessment.
There are two ways that death can be classified: clinical death and biological death. Circulation of the blood and respiration also stops once there is a cessation of heart beat. It is during this time that individuals can be revived by way of CPR. Oxygen can be given, the blood can be kept circulated and the heart beat could be potentially restored.
Most patients who are at the end of life opt for a do-not-resuscitate order, and therefore CPR is rarely given. There is a 4 to 6 minute window in which patients can be revived with CPR. Without CPR, in approximately minutes after clinical death the cessation of heart beat , brain cells will begin to die from lack of oxygen. This is called biological death and is called the point of no return, meaning that once the brain dies, CPR will not be able to bring that person back.
It is at this time that the cells in other organs, such as kidneys or eyes, will also begin to die. Several hours after biological death occurs, rigor mortis occurs. Rigor mortis is defined as the temporary rigidity of muscles occurring after death Merriam Webster, Rigor mortis will begin to set in several hours following death and be at its peak hours following death.
Rigor mortis will disappear 48 hours following death. As mentioned before, respirations can become quite erratic, very shallow with extended periods of apnea in between breaths. This time period can seem like an eternity for both the family and the nurse. Take extreme caution when determining whether or not the last breath has been taken. Extended periods of apnea close to death can last up to a minute or more.
Be certain that death has occurred before proceeding to assess for signs of life. The pulse in the carotid artery may still be palpable, although very faint and thready, until the heart catches up with the absent respirations.
This may take a minute or two. Be sure to listen for a heartbeat with a stethoscope for a full minute. In hospice this is performed for two reasons: to ensure that the patient has died, and also to provide the family with the extra peace of mind knowing that their loved one is really gone.
This function seeks to facilitate the decisions of relatives at a given moment. Death is also tied to the nurse as human being and means appropriating of the care and making the care something personal. The participating nurses mention how the appropriate of the care and on occasion of the person, given that they consider that patients are under their responsibility and their death behooves them; this is why they try not to cause harm or let no one else cause harm.
In the words of the participant: your patient dies Joel, 4 with emphasis on the voice field diary , showing that he perceives the patient as his property, which shows the other face and it is a way of not recognizing the patient in his or her condition of an autonomous being.
Three forms of appropriation emerged: making the care something personal for the patient, making the care something personal for the nurse, and committing to care. Nurses may also make decisions of care, stemming from their perspective and from what they would not want for themselves or for their families; thus, they make of care something personal for themselves, attributing the prerogative of making unilateral decisions: if you think, I'll care for you as I would want my mother to be cared for Scarlett, 3.
This form of appropriating of care may be taken by patients and their relatives as adequate and they are thankful because nurses place themselves in their position and are sensitive in light of their situation and pain. However, nurses do not always manage to fulfill the expectations and needs of patients and their relatives.
Appropriating of care also means making the commitment for the patient to have a humanized process of death. Thus, nurses may go beyond compliance of protocols and the function commissioned by the institution, and show that their motivation is not merely wage related: but it hurts me, that is why I get stressed; look at my cell phone and you will see my missed calls, I have left about 10 messages there Joel, 4.
Commitment may also lead to extending the schedules, as shown by the fragment: oh yes, I told him that even if I have to stay here during plate restriction [Scheduled restriction for vehicular circulation in the city, depending on the license plate number] and stay longer, I won't leave him Juliet, 7. Likewise, the deaths of patients touches nurses at the personal level in a way that can transcend the limits of their professional functions: that death also touches you, it is important to let death touch you as a person Celestine, Nurses can be affected by the patient's own death and because they are affected by the reality of a person who dies; a human being with a story, with a family and projects: well, because I am moved personally, I think nurses are touched greatly, all patients move us a lot Dulcinea, 4.
Three variations are contemplated: consider the patient as a similar, adopt the patient affectively, or be moved. Nurses believe that to care for patients it is necessary to consider them as similar, with whom they share - among other things - the condition of mortality, nursing care depends a lot on you being a person, on accompanying them, on showing that we are not made of stone; rather, that we are human like them Sherezade, Thus, nurses do not establish distance among them, the patients, and their relatives in the care relationship; they become accessible, sensitive, with a capacity to understand the situation of another, without the cultural idea that they must hide their feelings because they are professionals.
The following fragment highlights the importance of converting care into a person-to-person encounter without establishing a professional distance: I think that is what a nurse should do, remove that veil of degrees and things and just be a person who accompanies; cut distances, it is no longer nurse, patient, family, now we are people Mafalda, 3.
Sometimes, nurses relate with patients in ways that they end up establishing affective ties with them, carrying out a process of affective adoption: because she was almost adopted by us; that is, she was a baby that became part of the healthcare staff Celestine, 6. This phenomenon occurs with patients of all ages. It was also found that the nurses in the study consider it important to be moved by the suffering of patients and their relatives, given that they consider that, thus, the care can be better: I have a personal motto that the day I stop feeling pain for the people and not offer that companionship, I stop being a nurse, that will be my last day Ana Karenina, 8.
Nurses feel vulnerable because they are in frequent contact with death and must support the pain of others: enduring pain, we must support because we live amid much pain and suffering Celestine, 17 , a situation that, according to the participants, has not been recognized or intervened: but nobody intervenes in us Celestine, In turn, lack of recognition may keep them from communicating it.
Furthermore, nurses sense a lack of legal protection to back their decisions at a given moment: from the legal standpoint, we are not covered because they only talk about the medical part, so we are being exposed Faust, 2.
This study among nurses found that for them caring for a person during the death process - in great measure - is a nursing responsibility, thus, caring for the moribund affects their professional lives, but they also indicated feeling affected in their personal lives, an aspect that coincides with findings by Castanedo et al.
It was found that the participating nurses consider they have the duty of caring for patients and their relatives, within care that does not end, for the purpose of patient receiving comfort, company, and relief of annoying symptoms; likewise, Hodo and Buller 13 think that nursing care is crucial in creating a peaceful experience at the end of life. In this sense, they have a role and functions to comply in patient care.
In this regard, Codorniu et al. One of these care functions at the end of life is service , which coincides with Paredes, who also mentions it as an important part of the professional identity. The fifth function of nursing is support to patients and relatives, which coincides with the findings among nurses by Bello et al. Additionally, this study found that nurses must "bear up", which according to the same author is a way of suffering to do what must be done.
The function of advocacy comes about because nurses feel they are there to protect patients; likewise, Hodo and Buller found that the advocacy of nurses contributes to better communication among the healthcare staff, the terminal patient, and the relatives. The second category of death has to do with nurses because they feel affectation in their personal lives. In this respect, Watson 22 holds that "care transcends the level of the nurse's professional control"; this is contrary to the view of a culture of objective professionals who should not get involved at the personal level.
This study found that nurses take the death of the person as something personal and, to this measure, they appropriate of the care, thus, showing empathy toward patients and their relatives and make care decisions by placing themselves in their shoes, which could have good results or, on the contrary, homogenize those who die, given that they do not listen or understand their necessities and preferences.
Bello et al. In this regard, Skilbeck and Payne 23 describe that the ideal is a position that gets to know the patients and meets their preferences and necessities. Nurses appropriate of care by showing commitment, the same way King and Thomas found that nurses in their study see themselves as strongly committed to patients having an end as comfortable, peaceful, and dignified as possible.
But taking patient care as something personal may make nurses more vulnerable due to the possible implications on mental health, leading to "stress due to compassion". However, it would be interesting to explore if the sense of vulnerability increases in the mental health of nurses by the fact that they withhold showing their feelings, by being in this cultural amalgam of the duty and the need to withstand and be a support.
To diminish this vulnerability, psychological support is important. In conclusion, death transcends the limits of professional functions to become a human obligation. In this sense, caring for a patient in the process of dying and for their relatives means a professional and human obligation. Additionally, nursing as a discipline cares during the whole vital cycle, until the end of life and even after, with specific functions that seek to improve the patient's quality of life and to help their relatives; but balance is also needed with care taken as a personal issue where involvement goes beyond the professional, a situation that is not always evidenced by the scientific culture where they are immersed, where they understand that as professionals they should not get too involved as people.
Further research is recommended in this respect to strengthen the concept of nursing that shows commitment and compassion without suffering or wavering. It must be kept in mind that nurses can have personal implications with the death of their patients, even if they do not express it, for the purpose of facilitating support and educational groups where they can manifest their emotions and strengthen coping mechanisms that help them to find a balance between their personal and professional perspectives.
Henderson V. Aguinaga O. Meleis A. Transitions theory: Middle-Range and situation-Specific theories in nursing research and practice. New York: Springer; Toward a conceptual evaluation of transience in relation to palliative care.
In: Meleis A.
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