Too often the process of death has had such frightening aspects that people have suffered alone. Today there has been a vast change in attitudes; death and dying are no longer taboo topics. There is a growing realization that we need to accept death as a natural process. Elisabeth Kübler-Ross has written extensively on the process of dying, describing the stages of denial ("not me"), anger ("why me?"), bargaining ("yes me—but"), depression ("yes, me"), and acceptance ("my time is close now, it's all right"), with implications for the helping person.

1. CONCEPTS AND PRINCIPLES RELATED TO DEATH AND DYING:
1. Persons may know or suspect they are dying and may want to talk about it; often they look for someone to share their fears and the process of dying.
2. Fear of death can be reduced by helping clients feel that they are not alone.
3. The dying need the opportunity to live their final experiences to the fullest, in their own way.
4. People who are dying remain more or less the same as they were during life; their approaches to death are consistent with their approaches to life.
5. Dying persons' need to review their lives may be a purposeful attempt to reconcile themselves to what "was" and what "could have been."
6. Three ways of facing death are (a) quiet acceptance with inner strength and peace of mind; (b) restlessness, impatience, anger, and hostility; and (c) depression, withdrawal, and fearfulness.
7. Four tasks facing a person who is dying are (a) reviewing life, (b) coping with physical symptoms in the end stage of life, (c) making a transition from known to unknown state, and, (d) reaction to separation from loved ones.
8. Crying and tears are an important aspect of the grief process.
9. There are many blocks to providing a helping relationship with the dying and bereaved:
1. Nurses' unwillingness to share the process of dying—minimizing their contacts and blocking out their own feelings.
2. Forgetting that a person who is dying may be feeling lonely, abandoned, and afraid of dying.
3. Reacting with irritation and hostility to the person's frequent calls.
4. Nurses' failure to seek help and support from team members when feeling afraid, uneasy, and frustrated in caring for a person who is dying.
5. Not allowing client to talk about death and dying.
6. Nurses' use of technical language or social chitchat as a defense against their own anxieties.
2. ASSESSMENT OF DEATH AND DYING:
1. Physical:
1. Observable deterioration of physical and mental capacities—person is unable to fulfill physiological needs, such as eating and elimination.
2. Circulatory collapse (blood pressure and pulse).
3. Renal or hepatic failure.
4. Respiratory decline.
2. Psychosocial:
1. Fear of death is signaled by agitation, restlessness, and sleep disturbances at night.
2. Anger, agitation, blaming.
3. Morbid self-pity with feelings of defeat and failure.
4. Depression and withdrawal.
5. Introspectiveness and calm acceptance of the inevitable.
3. ANALYSIS/NURSING DIAGNOSIS:
1. Terminal illness response.
2. Altered feeling states related to fear of being alone.
3. Altered comfort patterns related to pain.
4. Altered meaningfulness related to depression, hopelessness, helplessness, powerlessness.
5. Altered social interaction related to withdrawal.
4. NURSING CARE PLAN/IMPLEMENTATION:
1. Long-term goal: foster environment where person and family can experience dying with dignity.
2. Short-term goals:
1. Express feelings (person and family).
2. Support person and family.
3. Minimize physical discomfort.
3. Explore own feelings about death and dying with team members; form support groups.
4. Be aware of the normal grief process.
1. Allow person and family to do the work of grieving and mourning.
2. Allow crying and mood swings, anger, demands.
3. Permit yourself to cry.
5. Allow person to express feelings, fears, and concerns.
1. Avoid pat answers to questions about "why."
2. Pick up symbolic communication.
6. Provide care and comfort with relief from pain; do not isolate person.
7. Stay physically close.
1. Use touch.
2. Be available to form a consistent relationship.
8. Reduce isolation and abandonment by assigning person to room in which isolation is less likely to occur and by allowing flexible visiting hours.
9. Keep activities in room as near normal and constant as possible.
10. Speak in audible tones, not whispers.
11. Be alert to cues when person needs to be alone (disengagement process).
12. Leave room for hope.
13. Help person die with peace of mind by lending support and providing opportunities to express anger, pain, and fears to someone who will accept her or him and not censor verbalization.
14. Health teaching: teach grief process to family and friends; teach methods to relieve pain.
5. EVALUATION/OUTCOME CRITERIA:
1. Remains comfortable and free of pain as long as possible.
2. Dies with dignity.