Postmortem Care (Pediatric) - CE/NCPD

ALERT

Immediately after death and before postmortem care activities, place the patient’s body in the supine position and elevate the head of the bed to decrease livor mortis.

OVERVIEW

Experiencing a pediatric patient’s death following a prolonged illness or a sudden trauma is emotionally and psychologically devastating for the family. Postmortem care that is handled with sensitivity and in a manner that is consistent with the family’s religious or cultural beliefs may help the family begin the grieving process. Assumptions that all individuals from the same ethnic group handle death in the same manner should be avoided. A health care team member should discuss with the family the desire to obtain mementos (e.g., lock of hair, handprint, photograph), who they would like present during postmortem care (e.g., family, friends, others), important postmortem rituals (e.g., bathing, dressing), and disposition of the body (e.g., funeral home, coroner, cremation center). 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; algor mortis, which causes a drop in body temperature to room temperature; livor mortis, which causes a purple discoloration of the skin from blood pooling in dependent areas; and rigor mortis, which is the stiffening of the body. 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 1986 Omnibus Budget Reconciliation Act (OBRA) requires that a patient’s survivors be made aware of the option of organ and tissue donation.^{undefined#ref1">1,2} In the case of a heart-beating organ donation (e.g., heart, lungs, liver, pancreas, kidneys), a patient must remain on the ventilator, and fluids and medications that maintain hemodynamic stability must be administered until the organs are surgically removed. The organ procurement process includes identifying potential organ donors, providing care for the donor’s body, and caring for the family throughout the donation process. In a nonheart-beating donation, tissues such as eyes, bone, and skin are retrieved from deceased patients either at the coroner’s office or mortuary. Because of the sensitive nature of making requests for organ donation, professionals from the organ procurement organization (OPO) may assume that responsibility. 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 involves notifying the OPO to determine whether a patient qualifies for organ donation. This conversation should be held in a private place with the custodial parent or legal guardian. 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). This is only legal for pediatric patients who are mature minors or emancipated minors.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 for the emancipated or mature minor. In these situations, the family may receive information about the recipient of the donated organ, if requested.

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. If an autopsy is required, IV catheters and other indwelling tubes and lines should be capped and left in place. Autopsies normally do not delay burial or change the appearance of the deceased, but there may be a cost to families. The patient’s custodial parent or legal guardian 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.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain the procedure and the reason for postmortem care to the family.
• Explain to the family that they can participate in the postmortem care of their child if desired.
• Provide education as needed to protect the family and others from infectious diseases from the patient. In many cases, this includes patients who were on contact, droplet, or airborne isolation precautions. Explain to the family that minimal contact, limited to close family members, and the proper use of PPE is necessary to limit transmission of disease.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the family.
3. Verify the correct patient using two identifiers.
4. Ask the practitioner or other designated team member to establish the time of death and determine if the practitioner has requested an autopsy.
5. Determine if the family has been informed of the death.
6. Identify the custodial parent or legal guardian.
7. Consult the practitioner’s orders for special care directives or specimens to be collected.
8. If not already done, determine if the patient will be an organ donor and notify the organ procurement team per the organization’s practice.
9. Give family and friends a private place to gather, preferably in the patient’s room. Provide an opportunity for them to ask questions.
10. Ask the family if they have requests for the preparation of the body (e.g., position of the body, special clothing, ritual bathing). Determine if they wish to be present or to assist with the care of the body.
11. Assist the family, as needed, with contacting their spiritual care provider or support system.

Preparation

1. Provide privacy for the patient’s body, if possible. If the patient has a roommate, explain the situation to the roommate and roommate’s family and move the roommate to a temporary location.
2. Per the organization’s practice, notify the morgue or mortuary chosen by the family to transfer the patient’s body. Discuss plans with the family for postmortem care.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers.
3. If organs or tissue are being donated, follow the organization’s practice for care of the body.
4. Ensure that the patient has identification per the organization’s practice.
5. Assess the general condition of the body and note the presence of dressings, tubes, and medical equipment.
   1. For patients who require an autopsy, do not remove indwelling devices; disconnect and cap IV lines.

      Rationale: Removal of tubes and lines is contraindicated if an autopsy is planned.

   2. For patients who do not require an autopsy, remove indwelling devices (e.g., urinary catheter, endotracheal tube), per the organization’s practice.
6. If culturally appropriate, use a rolled-up towel under the chin to close the patient’s mouth.

   Rationale: Positioning the mouth in a closed position may be less disturbing to family members.

7. Place a small pillow under the patient’s head.
8. Follow the organization’s practice regarding securing the hands and feet. Use only rolled gauze to secure the limbs together. Position the hands in an elevated position on the abdomen.

   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 postmortem process caused by gravity.³ The condition is minimized if the affected body part is elevated.

9. Close the patient’s eyes by gently pulling the eyelids over the eyes.
10. Wash soiled body parts. If the family is assisting with washing the body and providing postmortem care, assist them with donning gowns and gloves for protection from splashing of bodily fluids.
11. Remove soiled dressings and replace them with clean dressings, securing them in place with paper tape or rolled gauze bandaging.

    Rationale: Paper tape minimizes skin damage when tape is removed. Rolled gauze can be wrapped around the limb, with no adhesive.

12. Place an absorbent pad under the patient’s buttocks.

    Rationale: Relaxation of the sphincter muscles at the time of death causes the release of urine and feces.

13. Dress the patient in a clean gown or preferred clothing provided by the family.
14. Brush and comb the patient’s hair. Remove any clips, hairpins, or rubber bands.

    Rationale: Hard objects damage and discolor the face and scalp.

15. If the family wishes, obtain a lock of hair and place it in a plastic bag or other container for the family.
16. Facilitate photography, footprints, or handprints, if available and desired by the family.
17. Identify which of the patient’s belongings are to stay with the body and which ones the family wishes to take with them.
18. Ensure that the family has ample time alone with the patient’s body.
    1. Encourage the family to say goodbye with any preferred rituals.
    2. Remain accessible to address needs and answer questions.
19. Place the patient’s body in a shroud provided by the organization.
    1. Place an identification label on the outside of the shroud per the organization’s practice.
    2. Follow the organization’s practice for marking a body that poses an infectious risk to others.

       Rationale: The shroud protects against injury to the skin, avoids exposure of the body, and provides a barrier against potentially contaminated bodily fluids. Labeling ensures proper identification of the body. Marking a body reduces exposure of the morgue and mortuary staff to contamination.

20. Ensure timely transportation of the patient’s body to the organization’s morgue.
21. Dispose of all soiled dressings, supplies, or single-use equipment in a waterproof bag.
22. Remove PPE and perform hand hygiene.
23. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Provide support to family and friends as needed. Include child life specialists, if available, to support younger siblings.

EXPECTED OUTCOMES

• Body is prepared and bathed without causing new skin damage.
• Body is prepared properly for autopsy, if required.
• Body is prepared properly for tissue donation, if applicable.
• Family members are allowed to stay with their child and participate in postmortem care as desired.

UNEXPECTED OUTCOMES

• New skin damage is caused by bathing and preparation of the body.
• Body is not properly prepared for autopsy, if required.
• Body is not prepared properly for tissue donation, if applicable.
• Family members are not allowed to stay with their child and participate in postmortem care as desired.

DOCUMENTATION

• Time of death
• Description of any resuscitative measures (if applicable)
• Name of the practitioner certifying the death
• Any special preparation of the body for autopsy or organ and tissue donation
• Presence or absence of first-person consent if the patient was a mature or emancipated minor
• Consent for organ donation by the custodial parent or legal guardian
• Name of person who made the request for organ and tissue donation, if applicable
• Name of OPO representative
• Name of mortuary
• Personal articles left on the body (e.g., glasses, favorite blanket), jewelry taped to skin, or tubes and lines left in place
• Appearance and condition of the patient’s skin during preparation of the body
• Actions taken to secure valuables and personal belongings and name of parent or guardian who received them
• Time body was transported and its destination
• Location of body identification tags
• Unexpected outcomes and related interventions
• Education

REFERENCES

1. Callison, K., Levin, A. (2016). Donor registries, first-person consent legislation, and the supply of deceased organ donors. Journal of Health Economics, 49, 70-75. doi:10.1016/j.jhealeco.2016.06.009 (classic reference)* (Level VI)
2. Donate Life America. (2021). 2021 Annual update. Retrieved July 26, 2023, from https://donatelife.net/wp-content/uploads/2021DonateLifeAmericaAnnualUpdate.pdf
3. Van Grinsven, T. and others. (2017). Postmortem changes in musculoskeletal and subcutaneous tissue. Journal of Forensic Radiology and Imaging, 10, 29-36. doi:10.1016/j.jofri.2017.07.004 (classic reference)* (Level VI)

ADDITIONAL READINGS

Kukora, S. and others. (2019). Thematic analysis of interprofessional provider perceptions of pediatric death. Journal of Pediatric Nursing, 47, 92-99. doi:10.1016/j.pedn.2019.05.002

Medani, S., Brierley, J. (2021). End-of-life issues in the paediatric intensive care unit. Paediatrics and Child Health, 31(6), 245-249. doi:10.1016/j.paed.2021.03.004

*In these skills, a "classic" reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Clinical Review: Sarah A. Martin, DNP, MS, RN, CPNP-AC/PC, CCRN

Published: September 2023