Long term care staff become very experienced with death and dying – we grieve too. PSW’s and nurses become very attached to their charges and we grieve too when they pass. It is the desire of the staff in the nursing home to give the resident the highest quality of care through their time with them to their final hours.
Final Placement
It has been said that once someone moves into a nursing home they are there until they die. This is usually true for the frail elderly who move into the home, especially if it is a final placement. The resident becomes accustomed to their surroundings and end up dying in their room. Even if there is a hospice facility nearby, the nursing home resident will not go there.
Palliative Orders
So most, if not all, nursing homes become the place where death and dying is a normal and final part of their stay.
If staff know that death is near, the nursing staff will call the physician for palliative orders. This will include the comfort kit of medication. Usually there will be a cancellation of oral meds; and food and water will only be given if the resident is able to consume it or wants it. Family will be called if they are not already involved. It is usually the policy with a palliative resident that family can visit at any time, 24/7; and as many who care to come, can come. It is not uncommon to have someone in the home with their dying family member for several days.
Pain and Comfort Management
At this time, the focus of the staff will change from ensuring the resident is fed and clothed, to ensuring the resident is simply comfortable. Tub baths are changed to bed baths. The resident is monitored for pain and agitation. The best time to notice this is when care is being rendered. Turning and positioning every two hours alerts staff to residents being agitated or in pain. Pain and comfort management is paramount. The nurse will administer medication to ensure the dying person is comfortable.
The so-called comfort kit is a group of medications that ensure exactly that – comfort. Zofran and Haldol are used for nausea and agitation. Midazolam is used for sedation and agitation. Scopolamine is for excess secretions. Tylenol suppositories are used for pain. And Morphine helps relax the diaphragm and makes breathing easier.
Waiting for someone to come
Each person’s journey through death and dying is different. We will all die, but we will all do it differently. Much is dependent on our physical condition, illness and belief system. Generally, we don’t want to die but acceptance of death makes a huge difference. What works for one person and their family may not work for another.
Having family around may be a comfort to the dying person or it may not. The dying person may be waiting for that one family member to arrive before they can go. Or, at least, that’s how it seems sometimes. Often, Long Term Care staff see someone actively dying for what seems like a very long time. Then, when that certain person comes and sits down, it seems that they sigh and pass away immediately.
Restlessness and agitation are common but are easily managed with medication. Also, just having people around can ease that agitation. If you find the thing that works keep doing it. Anything that upsets the dying person – that should be stopped. Just telling your loved one that you are there and will keep them safe goes a long way.
It’s about them
One of the things staff observe when family members visit their dying loved one is that they sit – uncomfortably waiting. It is not inappropriate to have a plan, if you can call it that, when visiting someone who is dying. Of course, you might not feel you have time but, believe me, you do. You feel it’s heartless to talk about “what do I do in my life? It’s about them.” It is and it isn’t. By a plan I mean that you can bring a book or magazine and read to the dying person. Go in twos or as a small group and converse about mundane things like your plans for the week. Include your loved one. Can the dying person hear you? Maybe. Does it matter? No.
In the last hours before death, people may become active, alert. They may talk about seeing loved ones who have passed before. My mother had a long conversation with Pierre Elliott Trudeau. I hate to think what happened to him after she died. You may see blotchiness, called mottling. Hands and feet will cool down. The dying persons eyes will often be open and not blinking. Conversely, he or she may seem to be sleeping, in a coma or just ignoring you. Their skin may not change in colour or texture.
Family Support
Do you need to be with the dying person when they pass? No. Long Term Care staff really understand how hard it is to be with someone who is dying. There is no judgement. If no family is there when the resident passes away, believe me, there will be a staff member with the dying person. It is rare that someone at the home will miss holding someone’s hand to say goodbye. It is our honour to be there, no matter what else is happening in the home.
There is no time limit on saying goodbye to your loved one. Staff will support family for as long as it takes. With the nursing home it is surprising how little the family has to do. The nursing staff calls the funeral home or cremation service. We assist with transferring the body. We call the doctor for the death certificate. All the forms necessary are done by the nursing staff. Drugs are discontinued. Referrals, if any, are cancelled. Then the funeral home takes over. It may seem like a daunting, complicated time for families but the system is set up to allow the family to grieve. Aside from choosing the final resting place and the manner of internment, the family should only have to support each other.
Conclusion
Long Term Care staff work with people who are dying all the time. We know that death and dying are a natural, foreseeable part of life and part of our job as nurses. But, like families, we grieve when residents pass. Quality care will still be part of their care in the final hours.
This article really hit home to me, as over the past few years, our family has lost many of the older generation members as they have been in either palliative care or at home for their final days. It is hard to fathom how caregivers who face this every day helping out families such as mine can bear the pain and anguish around them.
In spite of that tough mission, I admire how they continue to provide professional, caring, and loving medical and humane treatment to not only those passing but also the survivors surrounding those on their final chapter. No doubt they are underappreciated by many until they find themselves in such a situation and see what they do day in and day out.
Thanks for shedding a bit more light on the job that they do for us all, the caregivers have my utmost respect and admiration. You are right that their chief concern is to let the families grieve, and they do their best to provide that time and space for the affected families. It makes that final chapter so much easier than it might have been.