Post-mortem Care

POST-MORTEM CARE Know who does what, and when… Typically, when a patient dies, the nurse calls the patient's physician to pronounce the death. The doctor is usually responsible for completing the death certificate, notifying the family, and obtaining consent for donor services or an autopsy. But that's not always the case. Physicians can delegate the job of calling the family to you, or ask you to get the signature for an autopsy. And in some settings, such as home care or hospice, nurses may be allowed to pronounce death without physician oversight. Confirming the death is the first step in the post-mortem process, whether you or someone else pronounces. First, you'll need to verify the patient's identification by checking the ID bracelet and confirming the identity with family members, if present. Then, try to rouse him by calling his name and gently shaking his hand or shoulder. Don't try (or let anyone else try) to elicit pain by any means, particularly not by twisting a nipple or testicle, or rubbing knuckles into the sternum. Instead, you should look, listen, and feel for a lack of apical and carotid pulses, and the absence of breath sounds. Check to see if the pupils are fixed, dilated, and unreactive to light. Assess the skin's color and temperature. When death occurs, the skin turns pale, waxen, and cool to the touch. Death initially causes the muscles to relax. The jaw falls open, and the sphincters release urine and stool. The eyes often remain open. Document your findings. Be sure to include the patient's condition just prior to death, the presence—or absence—of an advanced directive, who pronounced the death, when the family was notified, and whether donor services were called or an autopsy referral was made. The attending physician is responsible for completing the cause of death on the death certificate, which can be done after the patient is transferred. But the pronouncer, if other than the attending, is responsible for filling out only the patient's name, the month, day, year, and time of death, so that the body can be released to the morgue or funeral director. Autopsies are encouraged at some hospitals as a way to take a critical look at the medical care a patient received. While families can refuse them, and most do, a death by accident, poisoning, homicide, or suicide, is considered a coroner's (or medical examiner's) case, and legally requires an autopsy. For a list of reportable deaths, see the box at the end of this article. Care of the body after death… After the patient is pronounced, you'll prepare the body for viewing by the family and transport to the morgue or funeral home. Keep in mind that once the heart stops, the body generally loses heat (algor mortis) at a rate of about 1.5° F (0.84° C) per hour until it reaches room temperature. While the patient feels cool to the touch, he's still warm enough for bacteria to begin breaking down body tissues. Refrigeration is necessary to slow decomposition, so try not to keep the body on your unit for more than an hour. (Some hospital polices permit a maximum of two hours.) You'll have to juggle the timing of care to accommodate the family. Family members should be given the option of seeing their loved one before or after post-mortem care is provided. If you feel comfortable and your hospital policy allows, you may permit them to bathe the patient or help, depending upon their cultural mores. Gather gloves, a shroud kit, a clean gown and linens, extra underpads, bath items, paper tape, 4 x 4-inch gauze pads, a syringe for deflating a catheter balloon, clamps, and scissors. Bring a clean gown for yourself and a mask or face shield as needed for your protection if the death was caused by a contagious disease. The shroud kit should contain a white vinyl sheet or zippered-bag to wrap the body in, another plastic bag for the patient's personal effects, a chinstrap, tape, ties, and tags. Close the door or draw the curtain for privacy. Move the patient to a private room if necessary. Always preserve the patient's dignity and show respect.

Raise the bed to a working level, and place the patient in a supine position. The idea is to make the body look as natural and peaceful as possible to avoid upsetting the family. Straighten the limbs and gently hold the eyelids closed until they can stay that way on their own. If the eyes will not stay closed, moisten gauze pads and place them over the closed lids until they remain closed without assistance. In any case, do not tape the eyes closed, as this can leave unsightly marks. Rigor mortis, the progressive stiffening of muscles, can begin as soon as 10 minutes after death, beginning with the face. But it may take up to six hours to set in, depending on the size of the patient, the cause of death, and the ambient temperature. For that reason, placing a rolled-up washcloth under the chin can help keep the mouth closed until the jaw stiffens. If the patient wore dentures, putting them in before you close the mouth helps maintain a normal appearance. Place a fresh pillow under the patient's head and raise the head of the bed about 30 degrees. This prevents livor mortis, a deep reddish-purple color, from forming on the sides of the face, earlobes, and neck. It begins about 30 minutes after death, and is caused by blood pooling in the dependent regions of the body. Make-up does not hide the discoloration, so try to keep the head elevated throughout the procedure to prevent it. Cap or clamp all IV lines, nasogastric tubes, and indwelling catheters. Don't remove them unless your hospitals' policy requires you to do so. Leaving the lines in facilitates the autopsy and embalming processes, so when in doubt, don't take them out. Do clip the IV tubing as close to the clamp as possible, however, and cover it with a piece of gauze and tape it down. Use paper tape to prevent injuring the skin. Coil up NG and urinary catheters and tape them down, as well. Leave the hospital ID bracelet on or replace it if it's missing. If you're allowed to remove lines, cover the insertion sites with gauze and secure the dressings with paper tape. Don't forget to deflate the balloon of a urinary catheter before you pull it, and pad the area in case there's residual drainage. Clean secretions from the eyes and wash the face. While a full bath may be unnecessary, you should remove all visible blood and body fluids. Put a fresh gown on the patient, change the linens, and comb his hair. Put a pad under the patient's buttocks, and pad any areas that are draining. Place a clean sheet, or light blanket, over the patient up to the chin. Leave the arms out and at the sides. Clean up the room, and remove soiled linen and any extra equipment so that family members aren't upset by blood spatters or other debris, and have easy access to the patient. Give the patient's clothing to the family. If there's no one available, fold and label the clothing, and place it in a plastic bag. All valuables, including a purse, wallet, watch, or jewelry, should be put in an envelope and sent to the cashier's office if they can't be given directly to the family. Be sure to give the family some space… The death of a loved one is traumatic no matter how much or how little anticipatory guidance a family receives. For many, their first reaction is shock, numbness, and disbelief. Some people get angry, while others weep or scream. Some experience palpitations or shortness of breath, while others develop nausea or faint. Rarely do people take it on the chin. Offer to call the chaplain or other spiritual advisor, or social worker, as needed. Allow family members to talk about the death. “Don't rush them”. Allow them time alone with the body. But remain available to answer questions and provide support. Once the family leaves, summon a cart from the morgue. Tag the body on the toe or ankle per hospital policy. Check your policy for labeling the tag when an infectious disease is involved. Remove the dentures and place them in a cup, if possible, so that they can travel with the body. If you cannot remove the dentures, secure the chin with the strap provided in the shroud kit, assuming your facility's policy allows this. You'll want to take this step because as rigor mortis wears off, the jaw will again relax, and the dentures may fall out.

Wrap the patient snugly in the shroud. Place a tag on chest area. Help move the patient to the cart, taking care not to let the head or limbs fall. Make sure the death certificate or other paperwork accompanies the patient. Finally, check to be sure that you documented the disposition of the patient's personal effects and valuables and any unusual or extreme reaction by a family member. “The most important thing to remember is to be gentle; knowing that your efficient care may, well, be the last memory the family has of their loved one”. Reportable deaths: According to the Centers for Disease Control and Prevention, deaths that should be reported to the coroner or medical examiner's office include:

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Death by homicide, suicide, accident, and other violent deaths such as thermal-, chemical-(including poisonings), or radiation-related deaths, and those caused by criminal abortion Sudden death not caused by readily recognizable disease Death under suspicious circumstances Death of person whose body will be cremated or otherwise disposed of such that further examination can't be done Death of inmates who are not hospitalized Death related to employment (accident or disease) Death related to contagious disease, or other conditions that constitute a threat to public health.

Prepared by:

Mary Cheer G. Chua BSN – 3B