WORKBOOK

CHAPTER - 1 : Understanding Dying and a Palliative Approach

1- One key message in the text is that the principles of palliative care can be integrated into
care early in the dying process. Is this a new concept for you? Write about this idea. What are
the benefits of the palliative approach? Do you already follow some of these principles

Yes, this idea is somewhat new for me because I used to think palliative care was only for the very
end of life. Starting it earlier can improve comfort, manage pain, reduce stress, and support both the
client and family emotionally. It focuses on dignity and quality of life, not just the illness. I already try
to follow some of these principles by respecting people’s wishes, listening to them, and offering
comfort and support when they are in distress.

2a. Two key changes:

1. People live longer now, so death often happens at an older age.

2. More people die in hospitals or long-term care homes rather than at home.

2b. Two challenges:

1. Managing multiple chronic illnesses and complex medical needs near the end of life.

Meeting emotional, spiritual, and family support needs while providing quality end-of-life care.

Review the common patterns of decline in Chapter 1 of the text.

Steady Decline
Person: Gradual weakness
Family: Ongoing stress
PSW: Care, pain relief

Stuttering Decline
Person: Ups & downs
Family: Hard to plan
PSW: Support, explain changes

Slow Decline
Person: Very slow loss
Family: Burnout
PSW: Social support, respite

Sudden Death
Person: No prep time
Family: Shock, grief
PSW: Comfort, grief

Using the text, define the following terms

a. Dementia: Decline in memory, thinking, and daily functioning.

b. End of life: Final stage when death is near.
c. Holistic care: Care addressing physical, emotional, social, and spiritual needs.
d. Hospice: Care focused on comfort and quality of life at the end of life.
e. Palliative care: Care to relieve symptoms and improve quality of life for serious illness.
f. Palliative approach: Using palliative care principles early, even before end of life.

The principles of palliative care in simple words:

1. Relieve suffering – Manage pain and symptoms.

2. Improve quality of life – Focus on comfort and dignity.
3. Holistic care – Support physical, emotional, social, and spiritual needs.
4. Respect patient choices – Honor wishes and preferences.
5. Support families – Help caregivers and loved ones.
6. Team approach – Use a coordinated healthcare team.
7. Early integration – Start palliative care alongside other treatments.

6- The best definition is:

The integration of palliative care principles, practices, and philosophy into care for people with
all life-limiting illnesses, early in the disease process, across all care settings.

7- The correct answer is:

c. Physical, emotional, psychosocial, sexual and spiritual needs.

8- Palliative care regards dying as a natural process, considers the person and family as
the unit of care and continues through death and into bereavement. - TRUE

B- Palliative care is active, holistic care exclusively for older individuals with
serious health-related suffering due to severe illness - FALSE

C- Palliative care may improve a person's quality of life through the prevention and relief of
suffering - TRUE
9- When a healthcare professional (HCP) asks the “Surprise Question”—“Would you be surprised
if this patient were to die within the next 12 months?”—it helps identify:

● Whether a patient may be in the last year of life.

● Patients who might benefit from early palliative care.
● The need to plan and discuss future care goals with the patient and family.

10- Here is a clear way to represent an interdisciplinary palliative care team in a long-term
care facility with arrows showing the flow:

│ Patient │

│ & Family │

└─────┬──────┘

┌────────────────┼─────────────────┐

▼ ▼ ▼

│ Nurse │ │ Physician │ │ Pharmacist │

│ (symptoms, │ │ (care plan) │ │ (medications)│

│ daily care) │

│ PSW / │◀────▶│ Social │

│ Care Aide │ │ Worker │

│ (personal │ │ (emotional │

│ care, │ │ support) │

│ assistance) │

│ Chaplain / │

│ Spiritual │

│ Care │

│ (spiritual │
│ & cultural)

11-

Urban Rural/Remote First Nation, Inuit, Métis

┌───────────┐ ┌───────────┐ ┌───────────┐

│ Patient & │ │ Patient & │ │ Patient & │

│ Family │ │ Family │ │ Family │

└─────┬─────┘ └─────┬─────┘ └─────┬─────┘

│ │ │

┌───────────┼───────────┐ ┌───────┼─────────┐
┌──────────┼─────────┐

▼ ▼ ▼▼ ▼ ▼▼ ▼ ▼

Nurse Physician PSW Nurse Physician PSW Nurse Physician PSW

│ │ │ │ │ │ │ │ │

▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼ ▼

Pharmacist Social Chaplain Community Health Elders / Social Traditional

Worker Worker Traditional Worker Healers

Healers / Counselors

│ │ │

▼ ▼ ▼

Volunteers / Family & Neighbors Family & Community

Support Groups

12- Two short examples showing how the team followed palliative care principles for Tom:
1. Holistic care: The team addressed Tom’s physical symptoms (pain, stuttering) and
supported his emotional and social needs, including communication with his family.
2. Family involvement: The team included Tom’s family in care planning and decision-
making, respecting their preferences and providing support throughout his decline.

14- Barriers

● Limited services in rural/remote areas

● Lack of awareness
● Cultural/language differences
● Financial or transportation issues
● Staff shortages

Ideas to improve access:

● Community education
● Telehealth/mobile services
● Train more local staff
● Financial/transport support
● Culturally respectful care

15- Four ways a PSW can integrate a palliative approach:

1. Monitor and report symptoms to the care team.

2. Provide comfort and personal care (hygiene, positioning, pain relief).
3. Support emotional and social needs of the person and family.
4. Communicate respectfully about the person’s wishes and preferences.

16- a. Palliative approach: Using palliative care principles early in care for people with
serious illnesses, even before end of life.

b. Palliative care: Specialized care to relieve symptoms and improve quality of life for people with
serious, life-limiting illnesses.

c. Care team: Patient and family, nurses, physicians, PSWs, social workers, pharmacists, spiritual
care providers, and other support staff.

Chapter 2 — Preparing to Care

Self-awareness is knowing your own emotions, thoughts, and behaviors, understanding why you act
a certain way, and seeing how you impact others. It helps you make better decisions and improve
relationships.

2a- An early experience I had related to death was when a family pet passed away. I remember
feeling sad and confused because I didn’t fully understand what death meant at the time. Seeing my
family mourn and saying goodbye to the pet made me realize that loss can be painful and that grief is
a natural response.

2b- The support I received was mainly from my family—they comforted me, explained that death is a
natural part of life, and allowed me to express my sadness. I would have liked more guidance on
understanding and coping with grief, maybe from a teacher, counselor, or someone experienced in
helping children process loss, to help me manage my feelings better.

2c- This experience made me more aware of the feelings of loss and sadness that come with death.
It helped me understand that grieving is natural and taught me to appreciate the time I have with
loved ones. It also made me more empathetic toward others who are experiencing loss.

4] Reflect on which trajectory or pattern of decline you would hope a loved one would
experience when they are dying.

a- I would hope for a gradual decline with comfort-focused care, where a loved one remains
alert and aware for as long as possible, receives proper pain management, and can spend
meaningful time with family and friends. This allows them dignity, connection, and the chance to say
goodbye peacefully.

b- Yes, I might want something different for a loved one than for myself. For myself, I might choose a
very peaceful, comfort-focused approach with minimal interventions. For a loved one, it can feel
harder to choose because I worry about their suffering and hope for more time with them, which
might lead me to consider more aggressive treatments than I would want for myself. Making
decisions for someone else often feels heavier and more emotional because it involves balancing
their wishes with my own fears and hopes.

5} Faces/feelings about working with dying people.

Common feelings: interested, nervous, honoured, and unsure. It’s normal to have mixed emotions —
curiosity plus concern.

6} Baggage to acknowledge and set aside

Examples: “I must always fix things,” religious assumptions, fear of death, or judgments about how
someone grieves. Put these aside by reminding yourself to listen and honour the person’s values.

7} Best practices you might already use

Use open questions, respect routines, ask about cultural/spiritual needs, provide privacy and dignity
during care, and report observations promptly.

8} Fix-It Trap — how to tell you fell into it

Signs: immediately offering solutions, minimizing feelings, switching topic, or saying “don’t worry.”
Instead, sit, listen, reflect feelings, and ask what they need.

9} Strategies for addressing systemic bias/racism

Acknowledge bias, listen to affected people, educate yourself and colleagues, advocate for equitable
policies, and include culturally safe practices in care planning.

10} Definitions:
a. Culture — shared beliefs, values, customs and ways of living of a group.
b. Cultural safety — care that recognizes power imbalances and respects a person’s identity
and needs.
c. Cultural humility — ongoing self-reflection and willingness to learn from others.
d. Cultural sensitivity — awareness of cultural differences and a respectful attitude.
e. Cultural awareness — recognition that culture shapes experience and choices.
f. Cultural protocols — specific practices or customs to be followed respectfully.

11} Therapeutic boundaries — (a) signs you’re not maintaining, (b) steps to set boundaries
a. Signs: over-sharing personal life, doing favours outside role, emotional dependence.
b. Steps: clarify role limits, use supervision, set consistent professional behaviours, and get
support when boundaries feel blurred.

12} Four common roadblocks to communication

Examples: advising/solving, minimizing, changing the subject, and giving unsolicited reassurance
(e.g., “Don’t worry — it’s not that bad”).

13} When trauma-informed care is important & steps

It’s important when people have past abuse, loss, or violence. Steps: recognize trauma signs,
prioritize safety, ask permission, avoid re-traumatizing procedures, and refer to supports.

1. Sympathy or Empathy?

● “I feel so sorry for you.” → Sympathy.

● “I hope you feel better soon.” → Sympathy.

● “I can hear the sadness in your voice…” → Empathy.

● “I am here for you if you want to talk…” → Empathy.

● “I feel so badly that your mother died.” → Sympathy.

● “It sounds like you are overwhelmed… How can I help?” → Empathy.

15. Which PSW activities are appropriate (a–d)?

a. Yes — provide brochures.
b. Yes — share observations at care conferences.
c. Yes — suggest family write questions/goals to share.
d. No — PSWs should not advise changing medication doses; report concerns to nurse/MD.

16. Group discussion prompts — short guidance

a. Self-awareness similarities: we all fear loss; differences: how we cope.
b. Share personal experiences briefly to build empathy.
c. Feelings: pride, anxiety, sadness — normal and useful to reflect on.
d. Baggage: name it, reflect where it came from, and commit to putting it aside during care.

17. Ways to incorporate Indigenous Wellness Framework

Ask about cultural needs, invite Elders or community support, allow traditional practices,
use Two-Eyed Seeing (combine Indigenous and Western approaches), and ensure
respectful communication.

18. Vision board — sample best practices & skills

Put “listen actively,” “ask cultural questions,” “support family rituals.” Skills to develop: gentle
curiosity, language access, and trauma-informed responses.

19. Judgement story — how to avoid judging

Recognize assumptions, ask nonjudgmental questions, learn person’s story, and practice curiosity:
“Tell me more about that,” rather than assuming.

20. TRC call to action — PSW actions

Educate staff about local calls, create welcoming spaces for Indigenous practices, invite community
liaisons, and support cultural safety training.

21. Role-play exercise steps

Person A shares a concern; Person B first uses a roadblock, then practices open-ended questions;
reflect on how each felt and create a list of helpful open questions.

22. What you’d want the team to know when caring for you
Personal values, preferred comfort measures, spiritual/cultural wishes, who to contact, and whether
you want a family present — brief and clear.

23. Characteristics of a good/bad death

Good death: pain controlled, dignity preserved, family present, wishes respected. Bad death:
 uncontrolled symptoms, isolated, choices ignored.

24. Dignity question — what team needs to know about you (example)
What comforts you, privacy preferences, spiritual/cultural rituals, preferred language, and any “do not
do” items.

25. Two-Eyed Seeing — what & how to integrate

It’s combining Indigenous and Western knowledge; integrating by asking about traditional healing,
collaborating with Elders, and respecting both knowledge systems.

26. Systemic bias option — brief action plan

Map who’s affected locally, create staff training, build partnerships with community groups, and
report inequities up the chain.

Chapter 3 — Using Standardized Tools

1. Working with the team — two strategies to feel confident

Prepare clear notes before meetings, practice concise reporting (SBAR), and ask for feedback after
conferences to improve communication.

2. Palliative Performance Scale (PPS): five things it measures

Ambulation, activity and evidence of disease, self-care, intake, and level of
consciousness. 826008541-Integrating-a-Palliat…

3. Describe a person with PPS = 20%

Mostly bedbound, requires extensive assistance with self-care, limited intake, reduced
consciousness or drowsiness, and high care needs.

4. Describe a person with PPS = 10%

Totally bedbound, minimal intake, possibly semi-conscious or unresponsive, needs full care and
close symptom management.

5a) What does increasing CSHA frailty score mean?

Higher value = more frailty, greater vulnerability to stressors, reduced function and higher risk of
adverse outcomes.

5b) Benefits when frailty is 4–7

Targeted supports like physiotherapy, mobility aids, nutrition and individualized care planning can
improve comfort and function.
 6. When to use the Symptom Framework for PSWs
Use whenever you need to assess a symptom (pain, nausea, dyspnea, anxiety) to collect onset,
provoking/palliating, severity, and treatment details.

7. PAINAD limitation
PAINAD can detect behavioural signs of pain but cannot always identify the cause or precise
source
of the pain.

8. Psychosocial Assessment Tool — PSW role

Be open, ask about rituals, document values, facilitate spiritual/traditional practices, and respect
differences without judgment.

9. SBAR report for Eileen

S: This is deepanu, I’m calling about Eileen, age 98 — sudden abdominal pain and distress this
morning.
B: She has COPD, on oxygen, opioids for breathlessness, usually able to get up but today refusing
and moaning.
A: She has abdominal spasms rated up to 8/10, tender on palpation, short of breath, unsure of last
bowel movement.
R: Could you please assess today and advise pain treatment and bowel management; request
nurse review/physician as needed.

10. Group tool practice —

Rotate roles (observer/person/PSW) and note unclear questions so you can refine the tool wording
for real situations.

Chapter 4 — Supporting Physical

Comfort
1–3) Reflection on pain/opioids/comfort basket
Family beliefs shape how people accept medications; be aware of biases about opioids. A comfort
basket should include favored snacks, lip balm, a warm blanket, favorite music, and items that
provide meaning and sensory comfort.

4. Principles guiding support of physical comfort Apply: a (focus on goals), b (individualize comfort),
d (monitor & report), e (educate family). Option c (use meds only when death is imminent) is false.

5. Principles for medication decisions (a–f)

a True: team sets pain goals. b False: regular dosing is often needed to prevent baseline pain. c True:
breakthrough doses for recurring symptoms. d True: combinations sometimes needed. e True: record
side effects. f True: comfort measures are also important.
6. Opioids commonly used for pain / dyspnea?
True — opioids are commonly used for moderate-to-severe pain and to ease breathlessness in
palliative care.

7. Four common side effects of opioids (correct set)

Nausea/vomiting, constipation, drowsiness, confusion. (option d).

8. Four common fears/misunderstandings about opioids

a) Addiction — rare when used for symptom relief under supervision.
b) Respiratory depression — monitored but uncommon at appropriate doses.
c) Hastening death — appropriate titration aims for comfort, not to shorten life.
d) Constipation — common and preventable/ treatable with laxatives.

9. Why give meds regularly (around the clock)?

Regular dosing prevents pain from recurring and avoids cycles of uncontrolled pain, improves sleep and
function, and reduces need for large breakthrough doses.

10. Most common concerns: constipation & addiction?

True — constipation is common and treatable; fear of addiction is common but usually unfounded in
palliative contexts.

11. Consequences of not providing meds regularly

Uncontrolled pain, increased distress, decreased mobility and appetite, greater agitation, and reduced
quality of life for the person and family.

12. Preparing to support traditional healing (five steps)

Ask respectfully about wishes, make space/time for ceremonies, involve community/elders, document
preferences, and coordinate with the care team.

13. Why include complementary/alternative therapies (three reasons)

They can reduce anxiety and symptoms, support cultural/spiritual needs, and improve perceived quality
of life alongside medical care.

14. “Profound Truths of Nutrition” — simple explanation

Eating is for comfort and pleasure; forcing food often causes distress; weight loss at end of life is
common and not always reversed by more feeding; focus on comfort and meaningful food experiences.

15. Yetta — (a) what she did; (b) five PSW actions
a) Yetta likely prioritized favorite small portions, ate socially, and eased family expectations
about weight.
b) PSW actions: offer small frequent favorite foods, ensure pleasant environment, provide oral
care, educate family about normal appetite changes, liaise with dietitians.
16. Support for family of person with anorexia/cachexia
Provide clear education about why eating changes happen, reassure that hunger may not be present,
suggest meaningful ways to connect (touch, music), and arrange dietitian or spiritual support.

17. Two strategies to help prevent constipation

a) Encourage fluids and fibre as tolerated. b) Encourage mobility and follow bowel protocols
(stool softener/laxative as ordered).

18. Constipation table

● Observed: reduced bowel movements, hard stools. Ask: “When was your last bowel movement?”
Comfort measures: encourage fluids, prune juice, gentle abdominal massage. Support family:
explain causes and planned interventions.
(Repeat similar short rows for additional observations like bloating, discomfort.)

19. Dehydration table

● Observed: dry mouth, low urine output. Ask: “Are you thirsty? Any difficulty swallowing?” Comfort:
oral swabs, sips, moistening wipes; Support family: explain benefits/limits of IV fluids and comfort
focus.

20. Delirium (Mrs. Marsh) table

● Observed: pacing, confusion, refusal meds. Ask: “When did this start? Any pain or new meds?”
Comfort: reorientation, quiet room, familiar items, cover pain. Support family: explain delirium is
common and often reversible; invite family to re-assure.

21. Delirium vs Dementia

● Causes: Delirium = acute medical cause; Dementia = chronic neurodegeneration.

● Onset: Delirium = hours–days; Dementia = months–years.

● Brain changes: Delirium = often reversible; Dementia = generally permanent.

● Caused by body changes: Delirium = yes; Dementia = usually not primarily.

● Anxiety/paranoia: More common and fluctuating in delirium.

22. Tools to use in isolated community for delirium care plan

Use SBAR, Symptom Framework, PPS, medication list, Confusion Assessment Method (CAM), family
interviews, and phone consults with palliative specialists and cultural supports.
23. Risk factors for depression with life-limiting illness
Loss of function, chronic pain, social isolation, prognosis uncertainty, prior mental health history.

24. Primary risk factors (a–e)

a) Past depression or mental illness, b) Social isolation, c) Persistent uncontrolled symptoms, d)
Major losses (function/roles), e) Poor social support.

25. Depression table (sample row)

● Observe: low mood, withdrawn. Ask: “Have you felt hopeless or lost interest in things?” Comfort:
encourage routine, involve social supports, consider referral for psychiatric assessment. Support
family: provide education and referral info.

26. Dyspnea straw exercise —

a) Felt panicky, tight chest, and effortful breathing.
b) Thoughts: fear, urgency, “I can’t get enough air.”
c) If sudden, I’d worry about serious illness and want immediate help; I’d try to sit upright and
use calming strategies.

27. Breathing difficulties table

Prevention: manage anxiety, optimize COPD meds; Observe: increased work of breathing, use of
accessory muscles; Ask: “Does anything make it better/worse?” Comfort: upright position, fan, oxygen
as ordered, calm presence.

28. Fatigue (PPS 40%) strategies

Prioritize important tasks, schedule activity at best energy times, use assistive devices, plan rest
breaks, and enlist help for demanding tasks.

29. Mouth discomfort table

Observe: dry cracked lips, difficulty swallowing. Ask: “Do you have mouth pain or dryness?” Comfort:
frequent oral care, sips of fluid, saliva substitutes, lip balm.

30a) Nausea Symptom Framework

Onset: began yesterday after chemo/meal; Provoking: strong smells, movement; Quality: queasy, sick;
Region: upper abdomen; Severity: 6/10; Treatment: tried ginger and small sips; Understanding: thinks
it’s meds; Values: wants relief to enjoy company.

30b) SBAR verbal report for nausea (example)

S: This is deepanu about patient. She reports ongoing nausea.
B: Started yesterday, associated with smells after meals, tried ginger and sips. Has a history of
[relevant hx].
A: Severity ~6/10, affecting intake, not relieved by non-drug measures.
R: Please advise antiemetic order or nurse assessment and whether to hold oral intake until seen.
31. Pain role-play — Mr J (role-play A) sample Symptom Framework & SBAR

● Onset: pain began yesterday after fall. Provoking: movement, transfers. Quality: constant
aching/spasm. Region: left hip. Severity: 7/10. Treatment: usual meds help briefly; rubs help.
Understanding: thinks fall caused hip injury. Values: wants relief to move and sleep.

● SBAR: Ask nurse/MD to assess for fracture, consider analgesic review, and assistance with
safe transfers.

Mr K (role-play B) — similar structure: onset overnight increase, sharp/shooting pain to legs, severity 8/10,
concerned about fracture, request nurse/MD review and possible imaging/treatment.

32. Annette (page 134) —

a) Identified by change in behaviour (grimace, guarding) and reduced activity.
b) PSW repositioned, used pillows, offered comfort measures and reported to the nurse.
c) Verbal report: concise SBAR noting onset, observed guarding, pain rating, and request assessment.
d) Sample chart entry: “Follow-up 1hr after analgesia: pain decreased from 8/10 to 3/10, sitting
upright, tolerating small sips; family informed.”

Chapter 5 — Providing Psychosocial Care

1. Priority boxes exercise — Large box: family, friends, faith, music; Medium (3 months): travel,
reconcile with people, meaningful visits; Small (3 days): loved ones present, favourite foods,
comfort. These scale down from long-term meaning to immediate priorities.

1d–1f) Feelings & decision process:

Large box: gratitude and concern; medium: urgency to repair relationships; small: focus on intimacy
and comfort. Decisions narrow to what’s essential and meaningful.

2. Dialysis discontinuation scenario a) Feelings: sadness, concern, maybe disagreement.

Questions: about goals, prognosis, and patient’s reasoning.
b) Appropriate to discuss with supervisor, nurse, social worker, or clinical educator — not
confront family or force views.
c) Best practice interactions: listen nonjudgmentally, ask open questions, respect autonomy, and
check understanding.
d) To show compassion: “I’m here with you,” offer practical help, sit quietly, and honour their
choice while ensuring symptom support.

3. Why psychosocial care is holistic

Because it addresses emotional, social, spiritual, and practical needs alongside physical symptoms,
 recognizing the whole person and their relationships.

4. Supporting someone through transitions

Communicate honestly, involve family, manage symptoms proactively, revisit goals of care, and
support practical and spiritual needs.

5. Four key points about dying with dementia

a) Communication becomes harder; rely on behaviors and nonverbal signs.
b) Trajectory is often prolonged and unpredictable.
c) Early ACP is critical.
d) Comfort and routine are priorities; involve family in decision-making.

6. Culturally safe communication for imminent death

Use respectful language, ask how the family wants information shared, involve interpreters/Elders,
allow space for rituals, and avoid assumptions.

7. PSW actions to support psychosocial needs

a) Listen and be present, b) facilitate family contact, c) support spiritual practices, d) encourage
routines that bring comfort, e) advocate for the person’s wishes.

8. Three formal assessment processes

a) Psychosocial/spiritual assessment (e.g., PAT), b) Advance care planning documentation, c)
Cognitive assessments or standardized family interviews.

9. Eight ways PSWs support advance care planning

a) Encourage conversations, b) Share observations with the team, c) Help with practical steps
(contacting SDM), d) Provide info brochures, e) Support family meetings, f) Record preferences, g)
Prompt ACP discussions early, h) Respect and reinforce documented wishes.

10. Can a PSW sign legal documents?

False — PSWs should not sign legal documents like wills or formal contracts.

11. Five things about grief

a) Grief is unique and non-linear, b) It affects body and mind, c) Cultural norms shape grieving, d)
Anticipatory grief can occur, e) Support and rituals help heal.

12. Supporting children whose loved one is dying

Use age-appropriate language, encourage expression through play/art, maintain routines, include them
in rituals if appropriate, and provide trusted adult support.

Chapter 6 – Caring in the Last Days and Hours

1. Feelings about caring for someone in their last days and hours:I feel honoured to be present
at such an important time, but also a bit nervous about doing everything correctly. I sometimes feel
sad knowing the person will die soon, but I also feel motivated to provide comfort and dignity.
Compared to Chapter 2, I am now more confident and less fearful because I have learned what to
expect.

2. Feelings about caring for the body after death: I see caring for the body as a final act of respect.
At first, I felt uncomfortable and a little anxious, but now I understand its importance for dignity and for
the family. If I feel unsure, I would ask a colleague or supervisor for guidance so I can learn and feel
more comfortable.

3. Physical Changes and Comfort Measures

Physical Changes in the Last Days/Hours:

● Sleeping more, very weak

● Eating and drinking very little or not at all

● Confusion, agitation, or restlessness

● Breathing changes (irregular, pauses, “death rattle”)

● Skin cool, mottled, or bluish

● Eyes dry, half-open

● Little or no urine, possible incontinence

● Becoming unresponsive

Comfort Measures for the Dying Person:

● Keep them clean, dry, and warm

● Provide gentle repositioning for comfort

● Offer mouth care and small sips if safe

● Speak softly and provide a calm environment

● Use comfort medications if prescribed

● Support their dignity and privacy

 Comfort Measures for the Family:

● Explain that these changes are normal

● Reassure them the person is not usually suffering

● Encourage them to talk to and touch their loved one

● Offer tissues, water, and chairs

● Allow time and space for rituals and presence

● Keep them informed and involved in care

4. Preparing to provide best care

a. Ensure care plan is updated and comfort measures are ready
b. Communicate with team and family about changes
c. Prepare supplies and environment for calm, dignified care

5. Responding to “What changes can I expect?”

a. Explain gently that breathing patterns may change
b. Mention that the person may sleep more or stop eating
c. Prepare them for skin colour and temperature changes
d. Offer reassurance that comfort will be maintained

6. Physical signs death is very near

● Irregular or Cheyne-Stokes breathing

● Cool, mottled skin

● Decreased urine output

● Loss of responsiveness

● Congested or gurgling breathing

7. Tasks when a person is found not

breathing Home:
a. Confirm death per care plan
b. Notify nurse/doctor and family
c. Follow DNR orders
d. Provide respectful body care
e. Document time of death
f. Support family and offer time to say goodbye

Long-term care:
a. Notify nurse immediately
b. Follow facility procedure
c. Assist with post-mortem care
d. Prepare room for privacy
e. Support family
f. Document as required

Support for family (all locations):

a. Offer quiet time with the body
b. Provide tissues, water, chairs
c. Listen without rushing them
d. Offer to call spiritual/cultural support
e. Provide information about next steps

8. DNR status
True – Knowing DNR status helps PSWs respond correctly in an emergency and avoid unwanted
resuscitation.

9. Supporting family after death

a. Allow time for viewing and rituals
b. Offer emotional support and listening
c. Provide practical information (funeral home, belongings)
d. Notify other staff members who were involved in care

10. Respecting different traditions

a. Ask about their customs and follow them when possible
b. Provide space for rituals or prayer
c. Avoid judgment and be supportive even if unfamiliar

11. Coroner’s role

Confirm the identity of the person and the probable cause and manner of death.

12. Reasons to explore family’s understanding

a. Ensure they have accurate information and realistic expectations
b. Provide emotional support and prepare them for what is coming
 Chapter 7 – Caring for You!
1. Activities that help you refuel and re-energize:

● Spending time with family/friends

● Exercise, walking, yoga

● Listening to music

● Journaling or creative hobbies

● Reading or watching something uplifting

● Quiet time or meditation

● Spending time outdoors

2. Reflection on “self-care”:

Self-care means taking time to look after my own physical, emotional, mental, and spiritual
well-being so I can stay healthy and avoid burnout. Reflecting on it made me realize I sometimes
put others first too much. I need to be intentional about resting, eating well, setting boundaries,
and doing things that bring me joy.

3. Compassion fatigue reflection:

“Compassion fatigue happens when I care for others so much that I start feeling emotionally
drained or numb. It can make me feel tired, irritable, and disconnected. Writing about it made me
realize how important it is to take breaks, talk with colleagues, and find balance so I don’t lose my
ability to be present with clients.”

b. Zones (Red / Yellow / Green):

● Green if you feel balanced, energized, connected

4. Maintenance Self-Care Plan:

Include at least one strategy in each category:
● Physical: Regular sleep, healthy food, exercise, stay hydrated

● Emotional: Journaling, counselling, gratitude practice

● Spiritual: Prayer, meditation, connecting with nature

● Professional: Debrief with team, attend education sessions, take breaks

● Social: Spend time with supportive friends/family

● Creative/Play: Hobbies, music, laughter

5. Emergency Self-Care Plan:

● Take deep breaths, step away if possible

● Call a supportive colleague or supervisor

● Use grounding techniques (counting, slow breathing)

● Remind yourself the situation is temporary

● Do something small that soothes you (walk, music, prayer)

● Seek professional support if stress continues