Procedures for death pronouncement vary from state to state and sometimes within the individual state as well.   Your institution will have a set protocol for you to follow at the time of death that conforms to the regulations in your area.

No matter your role in death pronouncement, a final nursing assessment should be performed and documented.  Documentation regarding the death of the patient may include:

The patient’s name, time of physician contact, and death pronunciation

Those present at the time of death- health care personal, family members, and friends

The time of the assessment

General appearance

Lack of reflex or response to stimulus including pupils that are fixed and dilated

The absence of breathing and lung sounds

The absence of both apical and carotid pulse

Any other pertinent details from the physical examination

Time the physician assessed the patient or was notified

Identification of all parties notified of the death

Special plans for disposition- organ donation, autopsy, or cultural/religious needs

After death, the body should be prepared in order to give a clean, peaceful impression for those family members who desire an opportunity to say good-bye before funeral home removal.  Kindly caring for the body shows the family empathy and concern, the continued value of the deceased, as well as modeling grief facilitating behaviors for others present.  Religious or cultural practices the family may find comforting should be encouraged.  It is also appropriate to invite them to participate in the preparation of the body.

There are three categories of change that will occur in the body after death.  These are algor mortis, postmortem decomposition, and rigor mortis.

Algor mortis occurs from a lack circulation.  The hypothalamus stops functioning and the body’s core temperature begins to drop by about 1.8 degrees every hour until it reaches a stasis at room temperature.  The skin begins to lose its natural elasticity as the body cools.  If a high fever was present at the time of death, the person may lose excess fluid through the skin causing the skin to feel moist, or giving the appearance of sweating even after death.  This loss of moisture and elasticity causes the skin to become more fragile and easily damaged.  The body should be handled gently, avoiding excess pressure or traction on the skin.

Unless otherwise indicated by protocol or the need for autopsy, any tubes, drains, and other medical devices should be removed.  Bandages should be applied as fluids may still be expressed as the body loses elasticity.  Because the skin can be so easily damaged, these dressings should be applied with a wrap or paper tape.

Postmortem decomposition refers to bruising and softening of the body that is largely related to the breakdown of red blood cells.  As these cells breakdown, hemoglobin is released resulting in a staining effect on the vessel walls and surrounding tissues.  This mottling or bruising most frequently appears on dependent parts of the body as well as any areas of the body having experience recent trauma such as puncture wounds from invasive procedures.  The face most often appears purple in color when death is the result of cardiac complications.  The remainder of the body takes on a gray hue.  This discoloration can spread very rapidly.  The nurse should assure family members that this bruising process is a normal.

Rigor mortis begins within four hours of death, as adenosine triphosphate (ATP) is no longer synthesized due to the depletion of glycogen stores.  ATP effects muscle fiber relaxation. Its absence causes an exaggerated contraction of the muscle fibers and immobilizes the joints.  Rigor begins in the involuntary muscles of the heart, gastrointestinal tract, bladder, and arteries.  It then progresses through the muscles of the head, neck, trunk and lower limbs.  However, after approximately 96 hours the muscle activity totally ceases and the rigor passes.  Those with large muscle mass may experience more pronounced rigor mortis.  On the other hand, frail individuals are less prone toward to rigor mortis.

Post-death positioning to minimize the effects of rigor mortis should include placing the limbs and hands are in proper body alignment.  The eyelids and jaw should be closed and dentures should be in place in the mouth. A waterproof pad or incontinence brief underneath the body is also helpful for containing body fluids that may be expressed during this process.  However, the practice of packing the vagina or rectum is unnecessary. 

Other common courtesies include washing the body and combing the hair.  The nurse or family may also consider dressing the body in something normalizing rather than hospital attire.  It should also be noted that the body may “sigh” as it is rolled. The movement causes the lungs to compressed and expel air.  When family members are involved in the care, they should also be notified of this possibility.

Family and friends should not be rushed during the initial grieving process.  If the area is kept cool, the decomposition process will be slowed allowing the family time to grieve. 

Next Month: Coping with Death and Dying

Ferrell, B. R., Coyle N. Textbook of Palliative Nursing.  Second Edition. New York: Oxford University Press, Inc. 2006.

 

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