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Don appropriate PPE based on indications for isolation precautions.
Turning a recently deceased body to the side sometimes causes the flow of exhaled air. This is a normal event and not a sign of life.
Postmortem care, which can be provided in the home and in health care facilities, involves caring for a deceased patient’s body with sensitivity and in a manner that is consistent with the patient’s religious or cultural beliefs. As society becomes more culturally diverse, health care team members should be familiar with the ethics of death and dying, and sensitive to the patient and family members’ cultural practices.3 Maintaining the integrity of rituals and mourning practices gives families a sense of some familiarity and control in the face of death. Individual variations exist within cultural and religious groups (Box 1). Assumptions that all individuals from the same ethnic group handle death in the same manner should be avoided. The family’s unique needs must be considered when performing postmortem care.
After death, the body undergoes many physical changes, including loss of skin elasticity and change in body temperature (algor mortis), purple discoloration of the skin (livor mortis), and a stiffening of the body (rigor mortis). Postmortem care should be provided as soon as possible to prevent tissue damage or disfigurement. To prevent livor mortis of the face, the head of the bed should be elevated and a clean pillow placed under the head immediately after death before beginning other activities. The health care team member should provide a peaceful presentation of the patient for individuals who desire an opportunity to grieve and view the patient.
Two legal considerations arise at the time of death. First, the 1986 Omnibus Budget Reconciliation Act (OBRA) requires that a patient’s survivors be made aware of the option of organ and tissue donation. In the case of vital organ donation (e.g., heart, lungs, liver, pancreas, kidneys), a patient must remain on life support until the organs are surgically removed. The organ procurement process includes helping to identify potential organ donors, providing care for the donor’s body, and caring for the family throughout the donation process. Many family members need help understanding what “brain death,” the irreversible absence of all brain function including the brain stem, means for a person who has died. Patients appear to still be alive because life support keeps the deceased’s organs functioning until they can be retrieved. Tissues such as eyes, bone, and skin are retrieved from deceased patients not on life support. Because of the sensitive nature of making requests for organ donation, professionals educated in organ procurement assume that responsibility in most cases. They inform family members of their options for donation, provide information about costs (there is no cost to the family), and inform them that donation does not delay funeral arrangements.
The donation request process sometimes involves notifying the local donor registry to determine whether a patient qualifies for organ donation. The conversation should be facilitated by providing a private place and by helping to identify the family member or surrogate to be involved in the request. Explanations of the procedure should be reinforced and the family should be notified about how the deceased’s body will be cared for. Above all, the family’s cultural and religious practices concerning organ and tissue donation must be honored and their final decision supported. Many donor families report that donating organs helped them in their grief and that they felt positive about the experience.
First-person consent does not require the family’s permission to procure certain organs, provided the patient documented the donation decision (e.g., donor card, driver’s license). The legislation and registry responsibility vary by state. To date, most states have implemented donor registries and passed legislation recognizing first-person consent for organ donation.1 The Donate Life Registry allows individuals to register for organ donation and is a supplement to existing state registries.2 An advance directive or living will may also be used to indicate donor status. In these situations, the family may receive information about the recipient of the donated organ, if requested.
The second common procedure of legal and medical significance performed after death is an autopsy, or postmortem examination. An autopsy, the surgical dissection of a body after death, helps determine the exact cause and circumstances of death, discover the pathway of a disease, or provide data for research purposes. An autopsy is not performed in every death. Individual state laws determine when autopsies are required, but they are usually performed in circumstances of unusual death, such as violent trauma, or unattended, unexpected death in the home. Some states have legislation that requires an autopsy if death occurs shortly after admission to a health care facility. Autopsies normally do not delay burial or change the appearance of the deceased, but there may be a cost to families. The patient’s legal representative and the practitioner or designated requester must sign a consent form. If appropriate, an explanation regarding the value that autopsies have for advancing medical knowledge may be necessary.
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Rationale: Following a death, grieving persons have difficulty focusing on details and may need guidance. Being informed increases their sense of control.
Rationale: Removing IV catheters allows fluids to leak out. Mortuary personnel remove lines after embalming. Removal of tubes and lines is contraindicated if an autopsy is planned.
Rationale: Dentures give the face a more natural appearance. Jaw muscles relax after death, making it difficult to keep dentures in place. Mortuary personnel remove dentures to clean and seal the mouth.
Rationale: Positioning the mouth in a closed position may be less disturbing to family members.
Rationale: Some organizations require securing appendages to prevent tissue damage when the patient’s body is moved. Accumulation of fluid called hypostasis, is a normal post-mortem process caused by gravity.
4 The condition is minimized if the affected body part is elevated.
Rationale: For some, closed eyes convey a more peaceful and natural appearance, but some cultures prefer that the eyes remain open.
Rationale: The goals are to present the patient in his normal appearance and to honor cultural or religious preferences.
Rationale: Some cultural practices require that family members cleanse the patient's body.
Rationale: Paper tape minimizes skin damage when tape is removed.
Rationale: Relaxation of the sphincter muscles at the time of death causes the release of urine and feces.
Rationale: Hard objects damage and discolor the face and scalp.
Rationale: The patient's body is covered to prevent exposure of body parts.
Rationale: Removing medical equipment provides a more peaceful, natural setting.
Rationale: Compassionate care provides family members with a meaningful experience during the early phase of grief.
Rationale: The shroud protects against injury to the skin, avoids exposure of the body, and provides a barrier against potentially contaminated body fluids. Labeling ensures proper identification of the body. Marking a body reduces exposure of the morgue and mortuary staff to contamination.
Adapted from Perry, A.G., Potter, P.A., Ostendorf, W.R. (2018). Clinical nursing skills & techniques (9th ed.). St. Louis: Elsevier.
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