End-of-Life and Post-Mortem Care

Palliative vs. Hospice Care

As an LNA, you will frequently care for residents nearing the end of their lives. It is important to distinguish between palliative care and hospice care.

• Palliative Care focuses on relieving symptoms, reducing pain, and improving the quality of life for individuals with serious illnesses. It can be provided at any stage of a disease, even while the resident is actively receiving curative treatments (like chemotherapy).
• Hospice Care is a specialized form of palliative care reserved for residents who are terminally ill, typically with a physician's prognosis of 6 months or less to live. When a resident enters hospice, curative treatments stop. The entire focus shifts to maximizing comfort, managing pain, preserving dignity, and providing psychosocial support to both the resident and their family.

Physical Signs of the Dying Process

Death is a natural process, and the body exhibits specific physiological changes as it begins to shut down. Recognizing these signs helps you adjust your care and alert the nurse and family.

• Decreased Intake: The resident will lose their appetite and stop drinking. The body no longer needs or can process food and fluids. Never force a dying resident to eat or drink, as this can cause choking and aspiration.
• Circulatory Changes: Blood circulation slows down and centralizes to protect the vital organs (heart and brain). As a result, the hands, feet, and lower legs become cold to the touch. You will often observe mottling—a blotchy, purplish, or bluish marbling of the skin caused by poor blood flow. The pulse becomes weak and rapid, and blood pressure drops significantly.
• Elimination: Urine output decreases drastically and may become dark and concentrated. Loss of bowel and bladder control is common as sphincter muscles relax.

Respiratory Changes and Comfort

Breathing patterns change dramatically during active dying. You may observe Cheyne-Stokes respirations, a distinct pattern characterized by alternating periods of slow, irregular breathing, followed by rapid, shallow breaths, and culminating in periods of no breathing at all (apnea) that can last up to 60 seconds.

Another common symptom is the 'death rattle.' As the resident loses the ability to swallow or cough, normal throat and lung secretions begin to pool. As air passes through these secretions, it creates a loud, gurgling sound. While this can be very distressing for the family to hear, it is generally not painful for the resident. The LNA can help alleviate this by gently turning the resident's head to the side or elevating the head of the bed to allow gravity to drain the fluids.

Emotional and Spiritual Support

Providing emotional support is as critical as physical care. Hearing is widely considered the last sense to leave the body. Even if a resident appears completely unresponsive or comatose, you must assume they can hear and understand you. Always knock before entering, explain what you are doing before touching them, and speak in a normal, gentle tone. Encourage family members to talk, sing, or read to their loved one.

Respect the resident's cultural and religious practices. Some religions require specific positioning of the bed, the presence of clergy, or specific rituals regarding who can touch the body. Facilitate these needs without judgment. Provide a peaceful environment by dimming harsh lights, minimizing alarms if possible, and offering chairs and tissues to grieving family members.

Post-Mortem Care

Post-mortem care is the care of the body after death. Death must be officially pronounced by a licensed nurse or physician before post-mortem care begins. The goals are to prepare the body for viewing by the family and eventual transport to the funeral home, while treating the deceased with the utmost dignity and respect.

Standard precautions apply heavily here, as the relaxation of sphincter muscles often causes the body to release urine, feces, and other fluids.

1. Positioning: Care must be done promptly before rigor mortis (the stiffening of the body's muscles) sets in, which typically begins within 2 to 4 hours. Position the body in normal anatomical alignment (supine, legs straight, arms folded across the abdomen or resting at the sides).
2. Head Elevation: Critically, elevate the head and shoulders slightly on a pillow. This prevents blood from pooling in the face, which would cause discoloration (livor mortis) and upset the family.
3. Eyes and Mouth: Gently close the eyes by pulling the lids down. If the facility policy dictates, insert dentures into the mouth to maintain the shape of the face, or place them in a labeled cup to go to the funeral home. Support the jaw with a rolled towel if it remains open.
4. Bathing and Dressing: Bathe any soiled areas of the body. Place a clean incontinence pad under the perineal area to catch escaping fluids. Dress the body in a clean hospital gown and gently comb the hair.
5. Tubes and Dressings: Leave all IV lines, catheters, and feeding tubes in place unless the nurse specifically instructs you to remove them. Facility policy and state law dictate what must remain for the medical examiner.
6. Final Steps: Tidy the room, remove medical equipment if possible, adjust the lighting, and allow the family as much private time as they need.