8.3 Mental Health, Depression, & End-of-Life Care

Mental Health, Depression, & End-of-Life Care

Caring for residents with mental health needs or at the end of life requires clinical sensitivity, empathy, and strict protocol. CNAs support both physiological comfort and psychosocial well-being for residents and families. This content overlaps Utah's Basic Nursing Skills and Mental Health domains—especially observation of depression, suicide risk, dying signs, and dignified postmortem care.

Mental Health, Depression, and Anxiety in Older Adults

Mental health disorders are not a normal part of aging. Long-term care residents face elevated risk from chronic pain, loss of independence, bereavement, and isolation.

• Clinical depression: A mood disorder beyond temporary sadness. Signs include persistent social withdrawal, refusal to eat or participate in care, worthlessness or excessive guilt, sleep changes (insomnia or hypersomnia), loss of interest in previously enjoyed activities (anhedonia), and frequent crying. Never dismiss these as "just getting old."
• Anxiety: Excessive worry, restlessness, irritability, hand-wringing, pacing, hyperventilation, and elevated pulse.
• Suicide risk: Older adults—particularly older men—have high suicide rates. Warning signs include giving away treasured possessions, statements such as "I won't be around much longer" or "I wish I could sleep and never wake up," stockpiling medications when able, and a sudden unexplained lift in mood that may mean a plan has been made.

CNA Action for Suicide Risk: Never leave the resident alone. Stay with them, call for help, and report immediately to the licensed nurse. Do not promise to "keep it a secret," bargain about whether they "really mean it," or leave to finish other tasks first.

Encourage participation in activities the resident still enjoys, report appetite and sleep changes, and use therapeutic listening without false reassurance. CNAs do not diagnose mental illness or counsel as therapists; they observe, support, and escalate.

Hospice Care vs. Palliative Care

• Palliative care: Comfort-focused management of pain, symptoms, and stress at any stage of serious illness, and it may continue alongside curative treatment.
• Hospice care: Specialized comfort care for terminal illness with a prognosis of six months or less. Curative treatment stops; the focus is pain control, emotional and spiritual support, and preserving dignity and quality of life.

Advance directives (living wills, durable power of attorney for health care) guide decisions when the resident cannot speak. CNAs follow the care plan and report if a family member asks for care that conflicts with documented wishes—they do not interpret legal documents independently.

Physical Signs of Approaching Death

As active dying begins, body systems slow. Recognize changes to guide comfort and family preparation:

1. Sensory changes: Hearing is the last sense to go. Even unresponsive residents may hear. Speak before care, explain what you are doing, and encourage family to keep talking to their loved one. Never make inappropriate remarks at the bedside.
2. Skin and circulation: Extremities cool; skin may turn pale, gray, or cyanotic. Mottling is purple, bruise-like discoloration from pooling blood, often starting in the feet, knees, and legs.
3. Respiratory changes: Irregular breathing may include Cheyne-Stokes respirations—deep, rapid breathing that slows into temporary apnea. A wet "death rattle" can occur when secretions pool because the swallow reflex is lost; repositioning and oral care (per care plan) may help comfort, but the sound itself is usually more distressing to families than to the resident.
4. Elimination: Output falls (oliguria); urine darkens. Incontinence appears as sphincters relax.
5. Musculoskeletal changes: Muscles relax; the jaw may drop and the face appear slack.

Provide frequent mouth care, keep the room calm and at a comfortable temperature, manage odor and incontinence promptly, and offer presence. Pain and dyspnea are reported immediately so the nurse can adjust the comfort plan.

Grief, Family Support, and Cultural Beliefs

Families may show anticipatory grief before death and acute grief afterward. Allow quiet time, offer tissues and chairs, and avoid rushing viewing. Support spiritual and cultural practices without judgment:

• Some cultures specify who may touch the body, how it is positioned, or which direction the bed faces.
• Report requests for clergy or spiritual leaders promptly.
• Handle rosaries, scriptures, amulets, and sacred clothing with care per family instruction.

Postmortem Care Procedure

Postmortem care is care of the body after death is declared. Perform it with dignity:

1. Wait for the nurse to pronounce death and give permission to begin.
2. Ask visitors to step out briefly while you prepare the resident.
3. Use standard precautions—pathogens may remain in body fluids.
4. Place the body supine with the head slightly elevated on a pillow to prevent facial blood pooling and dark discoloration (lividity).
5. Gently close eyes and mouth; use a rolled towel under the chin if needed. Insert dentures promptly per policy before rigor mortis (muscle stiffening, often within 2–4 hours) makes placement difficult.
6. Bathe soiled areas; apply a clean gown.
7. Place a clean incontinence pad under the buttocks for leakage as muscles relax.
8. Do not remove IVs, catheters, or tubes—the nurse does this, and tubes often stay if autopsy is planned.
9. Comb hair, tidy linens, pull the sheet to the shoulders (never cover the face), clean the room, and set chairs for family.
10. Inventory belongings, bag and label them, and give them to the family per facility policy.

Clinical Scenarios and Common Exam Traps

Exam Trap: Hearing is the last sense lost. Never whisper gossip or speak as if the resident cannot hear, even when unresponsive.

Another Trap: Elevating the head during postmortem care prevents facial discoloration—not airway management or slowing rigor mortis.

Scenario: A resident tells the CNA, "When I leave this place, it will be in a box—I've already given my watch to my grandson." The CNA stays in the room, activates the call light for help, and reports the statement and gift-giving behavior to the nurse immediately. Safety and timely reporting come before finishing the bed bath.