February 25, 2011

The Last Hours of Living: Practical Advice for Clinicians: When Death Occurs

MedscapeCME - Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Jamie H. von Roenn, MD

5. When Death Occurs

No matter how well families and professional caregivers are prepared, they may find the time of death to be challenging. Families, including children, and caregivers may have specific questions for health professionals.

Table 2. Signs That Death Has Occurred
The heart stops beating
Breathing stops
Pupils become fixed and dilated
Body color becomes pale and waxen as blood settles
Body temperature drops
Muscles and sphincters relax (muscles stiffen 4-6 hours after death as rigor mortis sets in)
Urine and stool may be released
Eyes may remain open
The jaw can fall open
Observers may hear the trickling of fluids internally, even after death

Basic information about death may be appropriate (eg, the heart stops beating; breathing stops; pupils become fixed; body color becomes pale and waxen as blood settles; body temperature drops; muscles and sphincters relax, and urine and stool may be released; eyes may remain open; the jaw can fall open; and observers may hear the trickling of fluids internally) (Table 2).[51,52]

There are no universally applicable rules that govern what happens when the patient dies (in any setting). If the patient dies an expected death at home, there is no need to call for emergency assistance. If a hospice program is involved, have the family call the hospice. If a hospice program is not involved, determine in advance who should be notified. Unless death is unexpected, or malice is suspected, involvement of the coroner's office is usually not required. State and local regulations vary. Healthcare professionals will need to familiarize themselves with the regulations in the areas in which they practice.

When an expected death occurs, the focus of care should shift from the patient to the family and those who provided care. Even though the loss has been anticipated for some time, no one will know what it feels like until it actually occurs, and indeed it may take hours to days to weeks or even months for each person to experience the full effect.

Many experts assert that the time spent with the body immediately after death will help people deal with acute grief.[53-55] Those present, including caregivers, may need the clinician's permission to spend the time to come to terms with the event and say their good-byes. There is no need to rush, even in the hospital or other care facility. Encourage those who need to touch, hold, and even kiss the person's body as they feel most comfortable (while maintaining universal body fluid precautions).

Because a visually peaceful and accessible environment may facilitate the acute grieving process, a health professional, usually the nurse, should spend a few moments alone in the room positioning the patient's body, disconnecting any lines and machinery, removing catheters, and cleaning up any mess, to allow the family closer access to the patient's body.[56,57]

REFERENCES
51. Aspen Reference Group. Palliative Care Patient and Family Counseling Manual. Gaithersburg, Md: Aspen Publishers Inc; 1996.
52. Martinez J, Wagner S. Hospice care. In: Groenwald SL, Frogge M, Goodman M, Yarbro M, Jones CH, eds. Cancer Nursing: Principles and Practices. 4th ed. Boston, Mass: Bartlett Publishers; 1997.
53. Sheldon F. Communication. In: Saunders C, Sykes N, eds. The Management of Terminal Malignant Disease. Boston, Mass: Edward Arnold: 1993:29-31.
54. The Hospice Institute of the Florida Suncoast, Hospice Training Program. Care at the Time of Death. Largo, Fl: The Hospice Institute of the Florida Suncoast; 1996.
55. Doyle D. Domiciliary palliative care. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 2nd ed. Oxford, England: Oxford University Press; 1998:957-973.
56. O'Gorman SM. Death and dying in contemporary society. J Adv Nurs. 1998;27:1127-1135. Abstract
57. Weber M, Ochsmann R, Huber C. Laying out and viewing the body at home -- a forgotten tradition? J Palliat Care. 1998;14:34-37.

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