My friend John's first encounter with post-mortem care was on the job. Nursing school did nothing to prepare him, and his facility hadn't provided training. So, like many new ICU nurses, he made mistakes.
The most egregious: He allowed the patient's valuables to make their way to the morgue, because he inadvertently left them on the bottom shelf of the transport cart.
This may not sound like a big deal to you, but it was extremely disturbing to the family. So, too, was another colleague's failure to properly position the chin of a patient who'd just died—leaving his jaw "frozen" open, to his daughter's horror.
What's even more disturbing is that such painful experiences can largely be prevented. Despite the fact that proper post-mortem care is an important nursing function, it's one for which RNs typically receive little or no training. This primer will help you get it right the first time.
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. (To learn more, check out the government's handbook for death certification. Point your browser to http://www.cdc.gov/nchs/data/misc/hb_cod.pdf.
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
MORE ARTICLES IN THIS ISSUE
I am a care manager at a local hospital's satellite office. I report to the satellite DON as well as the Director of Care Management for the health system. The two couldn't be more different, and sometimes it's impossible to find a balance between their two competing directives. It's especially difficult when one asks me to tell the other something. Help!