cutting.  To remove by cutting, cast cutters, spreaders, and  bandage  scissors  are  necessary.    Cuts  are  made laterally and medially along the long axis of the cast, then widened with the use of spreaders. The padding is then cut with the scissors. THE TERMINALLY ILL PATIENT LEARNING  OBJECTIVE:   Evaluate   the needs of the terminally ill patient. The terminally ill patient has many needs that are basically the same as those of other patients: spiritual, psychological, cultural, economic, and physical. What differs in these patients may be best expressed as the urgency to resolve the majority of these needs within a limited   time   frame. Death   comes   to   everyone   in different   ways   and   at   different   times. For   some patients,  death  is  sudden  following  an  acute  illness. For others, death follows a lengthy illness.   Death not only affects the individual patient; it also affects family and friends, staff, and even other patients.  Because of this,   it   is   essential   that   all   healthcare   providers understand the process of dying and its possible effects on people. Individual’s Perspective on Death People   view   death   from   their   individual   and cultural  value  perspectives. Many  people  find  the courage   and   strength   to   face   death   through   their religious  beliefs.     These  patients  and  their  families often   seek   support   from   representatives   of   their religious faith. In many cases, patients who previously could not identify with a religious belief or the concept of   a   Supreme   Being   may   indicate   (verbally   or nonverbally)   a   desire   to   speak   with   a   spiritual representative. There   will   also   be   patients   who, through   the   whole   dying   experience,   will   neither desire nor need spiritual support and assistance.  In all these  cases,  it  is  the  responsibility  of  the  healthcare provider to be attentive and perceptive to the patient’s needs and to provide whatever support personnel the patient may require. Cultural Influences An   individual’s   cultural   system   influences behavior patterns. When we speak of cultural systems, we refer to certain norms, values, and action patterns of specific  groups  of  people  to  various  aspects  of  life. Dying is an aspect of life, and it is often referred to as the final crisis of living. In all of our actions, culturally approved roles frequently encourage specific behavior responses. For   example,   in   the   Caucasian, Anglo-European culture, a dying patient is expected to show   peaceful   acceptance   of   the   prognosis;   the bereaved  is  expected  to  communicate  grief.    When people   behave   differently,   the   healthcare   provider frequently has difficulty responding appropriately. Five Stages of Death A theory  of  death  and  dying  has  developed  that provides highly meaningful knowledge and skills to all persons involved with the experience.  In this theory of death   and   dying   (as   formulated   by   Dr.   Elizabeth Kubler-Ross in her book  On  Death  and  Dying), it is suggested   that   most   people   (both   patients   and significant  others)  go  through  five  stages: denial, anger, bargaining, depression, and acceptance. The first stage,  denial, is one of nonacceptance. “No, it can’t be me! There must be a mistake!” It is not only important for the healthcare provider to recognize the denial stage with its behavior responses, but also to realize that some people maintain denial up to the point of impending death.  The next stage is anger.  This is a period of hostility and questioning: “Why me?”   The third stage is  bargaining.  At this point, people revert to a culturally reinforced concept that good behavior is rewarded.     Patients  are  often  heard  stating,  “I’d  do anything if I could just turn this thing around.”   Once patients realize that bargaining is futile, they quickly enter  into  the  stage  of   depression. In  addition  to grieving because of their personal loss, it is at this point that patients become concerned about their family and “putting affairs in order.”  The final stage comes when the patient finally accepts death and is prepared for it. It   is   usually   at   this   time   that   the   patient’s   family requires more support than the patient. It is important to remember that one or more stages may be skipped, and that the last stage may never be reached. Support for the Dying Despite the fact that we all realize our mortality, there is no easy way to discuss death. To the strong and healthy, death is a frightening thought.   The fact that sooner  or  later  everyone  dies  does  not  make  death easier. There   are   no   procedure   books   that   tell healthcare providers “how to do” death.  The “how to” will only come from the individual healthcare provider who  understands  that  patients  are  people,  and  that, more  than  any  other  time  in  life,  the  dying  patient needs to be treated as an individual person. 2-23