so now that we have discussed end of life death and dying now we need to talk about how do we care for the patient after death post-mortem nursing care death is defined as the permanent cessation of respiratory and circulatory functions and the determination of the cessation of these functions is made through a physical examination that includes auscultation for the absence of indications of respiratory and circulatory functions such as breathing sounds heart tones those kinds of things now the family is allowed and encouraged to spend time with the deceased we have to honor that privacy should be honored allowing them to have that time alone with their family member and cultural rituals should be allowed now procedures postmortem they do vary from state to state and amongst institutions so it's extremely important that you know your facility's protocol especially when it comes to something like autopsy if a patient dies because of known causes and this is verified then as the nurse we remove bandages we remove drains or clip drains oftentimes if the drain is really deep and the tissues we'll just clip it at the skin and put four by four or maybe even abdominal pad over if there's a lot of drainage out of it just to remove all the tubes and the lines for for family viewing now if the death is not because of a known cause leave those tubes and those lines in because there may need to be an autopsy to investigate was it because of displacement of a tube because of infection related to a line so before you just automatically start removing those things know the context of the patient's death and know your facilities protocol always check your policies and of course be very considered of the patients and family's wishes and belief system especially if this was a very traumatic death the family may want to do some bathing but there may need to be some cleanup prior just for their emotional and mental health so we may do some preliminary cleanup but let them finish bathing things like that so we have to be very aware of what the patient and family wants managing the situation within which the patient died and of course being aware of their belief system in the patient's belief system as well so what is that physical assessment this is very important overall General appearance that is only one tiny piece of this because it's happened everywhere in the nation is that people have charted on someone saying that they appear to be sleeping and they were dead for hours so you have to document that's why if you're charting on someone say you're on a night shift or maybe it's the afternoon or it's early in the morning and the patient is they do appear to be sleeping that's very subjective they appear to be sleeping document Signs of Life respiration is even an unlabored skin tone pink and if they have Vital Signs hooked up to them say in the ICU document vital signs of that time as well because when you get to the postmortem nursing assessment General appearance which might drive you to do the assessment to check for signs of life so you have to assess for not only absence of breath and circulatory evidence such as breath sounds and both both an apical and Carotid pulse you have to check for the pulse or the beat of the heart at the heart and then also at the Carotid pulse not radial because sometimes you can have such a diminished heart rate that it's not even felt radial carotid is pretty close to the heart so that's usually pretty reliable but you also have to check apical two to make sure they are truly gone there is complete cessation of cardiac activity at least as far as pumping that can allow for a pulse to be felt there might even be pulseless electrical activity still on the monitor so you have to make sure that you truly do not hear any heart tones you also have to confirm a lack of response to stimuli so they don't respond to you verbally they don't respond to pain a sternal rub I've seen people use a pen light and press it into the bed of the fingernail to elicit a pain response and of course that really hurts so the harder you press if there's no response that is one way to assess for a lack of responsive stimuli you can also do corneal reflex pupillary response open their eyes use a pen light to see if there's any pupillary response and you can also do a corneal reflex sometimes in the textbook you see this done with a cotton swab I think that's kind of mean uh when I was uh working on my masters I did a rotation at St Francis in the ICU and I saw someone take a normal saline flush and just drop a tiny little bit of water in their eye and if they responded that's a corneal reflex and that's much nicer than a cotton swab especially if they are still alive because that's uncomfortable it's like when you get something in your eye it doesn't feel good so maybe just an eye drop using a normal saline flush is a great way to check for or confirm lack of response to stimuli so once you have no response to stimuli you have confirmed an absence of breath sounds and both apical and a Carotid pulse now if you are the primary nurse for this patient you have to have it confirmed by another nurse and or a physician has to confirm death now in most situations with maybe the exception of being a trained and very specific hospice nurse nurses cannot call death Physicians must call death so if I was a primary nurse I would do my assessment I would verify a lack of stimuli breath sounds the heart tones have another nurse come in do the same assessment to verify and then I would contact The Physician because we confirmed death and then they would call death officially so some overall considerations once we have confirmed death and and death has been called by The Physician now we have to notify pertinent parties of course the family the coroner the morgue and then of course funeral home if prior arrangements have been made to transport them there foreign there are some special considerations in relation to organ donation and we've already talked a little bit about autopsy but we're going to revisit it here because it is so important with organ donation if someone dies because of trauma and certain organs are not affected at all like you hear the really sad stories of young people in a car accident and they still have functioning you know kidneys and hearts and whatever organ was not affected and so those organs will be donated sometimes if that's what the patient in the family desires but there are some contraindications to this and you have to contact the the transplant organization with whom you work or your organization is connected with because sometimes if they're very old if they have some kind of infectious disease like tuberculosis or HIV maybe a cancer or any kind of systemic generative disease like mycena gravis or a mess oftentimes organ donation is no longer possible because with that donation May Come infection or a poorly functioning organ with autopsy we have to know what caused the death and whether or not it was because of something that we anticipated like a patient who was on hospice due to terminal cancer or if because they came in uh admitted for pneumonia ended up in the Ico in a ventilator and died because of that they need to know there may be an autopsy to determine is it truly because the patient just could not physiologically recover or was it something that we did and then lastly any cultural or religious considerations which we've already briefly discussed so what are the the nuts and bolts of actually caring for a patient post-mortem they need to be bathed give them a sponge bath comb their hair change bandages especially if they're soiled again removal of tubes and drains only per policy they may need to stay in place for an autopsy even if there's an autopsy the patient will still come in or I'm sorry the family will still want to come in typically speaking and visit with the patient before they go off to the morgue and then autopsy and then the funeral we talked about skincare already maybe replacing or adding bandages bowel and bladder management at the end of life they lose both rectal and urethral tone and so they may have sphincter relaxation and eliminate both fecal matter and urine so we want to make sure there's an absorbent pad beneath the patient positioning is very important limbs eyelids jaw and proper alignment sometimes you can put a a wash rag or a towel up beneath the jaw because often when patients expire their jaw Falls open it's just the body is totally relaxed so they don't end up in rigor mortis with an open mouth which can be very upsetting for family we want to place that jaw in proper alignment and prop it up with a towel make sure they have their dentures in prop their face and their shoulders up just put them in a very peaceful position uh so that when rigor mortis does set in or before it sets in they are not in a position that is upsetting to the family and also disrespectful to the patient and then lastly clean up the room get rid of bedside commodes get rid of urinals trays any and all medical equipment especially disconnect the EKG or ECG because sometimes patients still have pulseless electrical activity in the heart they don't have a beat anymore they have been declared dead that electricity is still sort of discharging and slowly resolving itself that can really upset family members they think that they're still signs of life so remove that ECG EKG get that out of the room the body starts to change immediately at the time of death immediate decomposition begins and you can see bruising and body softening related to the breakdown of red blood cells there is also now bacterial liquefaction beginning that breakdown of bacteria that is now going to be sort of overwriting the body's processes that used to keep that bacteria in check so we want to keep the room cool to slow down this process that's also why the morgue is is very cold so algar mortis is when the body temperature drops pretty rapidly until it reaches room temperature there's a loss of moisture and elasticity makes the skin very fragile so you have to be very careful that you don't cause postmortem skin tears and then of course rigor mortis which we're pretty familiar with that begins four hours after death and it's because of the depletion of glycogen stores and that results in the body's inability to make ATP your energy and then that leads to an exaggerated contraction in the muscles the good news is it resolves after 96 hours but that's four days and oftentimes funerals happen relatively quickly after death so that's another reason why it's so important that we put our patients into a respectful peaceful position and here are just some pictures there's that liver mortise where the body starts to bruise and red blood cells start to break down and then there's a picture of rigor mortis that's how stiff the body can become so that's again why it's so important we put them in an appropriate position before rigor mortis sets in thank you so now after the the family or friends have seen the patient spent time with the patient now it is time to tag them sometimes on the toe sometimes on the wrist usually on the toe because that's how they're put into the more gets easy for the mortician and and hospital employees that work in the more to identify them the way the morgue is set up they need to be put in a body bag or a shroud and then transported to the morgue and sometimes it's directly to a funeral home if those arrangements are made but that Transportation has happened very very discreetly there's usually a large metal Gurney that has a shroud over it that allows plenty of space for any size of body discreetly nurses will take it into the patient's room we move the patient onto that to that Gurney we cover them up and then take back elevators down to the morgue during the time of the funeral and even after the time of the funeral there's some really key Concepts that we have to understand ourselves and then also understand what our patients families and friends and loved ones may be going through so here are some key terms to to differentiate grief is your own personal feelings that a company that that anticipated or an actual loss people can start to already experience grief before the patient has died just an anticipation of losing them morning is could be individual could be a family could be a group could be just overall cultural it's a general expression of grief and there's also Associated Behavior so you can see mourning you can't necessarily see grief grief is a personal feeling you might see it some people may hide it but mourning is typically something that is expressed and you can see so when we drive you know in a long line to uh to the funeral behind the hearse it used to be that at funerals everyone used to wear black we have a wake people bring food those are cultural expressions of mourning and then lastly bereavement that is the period of time during which mourning for a loss takes place you can have leave for bereavement and that's also why during bereavement if the patient had hospice that hospice nurse stays with the family up to 13 months after the patient's death because that one year anniversary can be very painful and so that's the expected period of time where people need the most support now bereavement especially if it's complicated grief and mourning can last for years especially with people that you are really close to and and really important relationships that may leave a void thank you when someone is experiencing grief morning and bereavement as nurses what are some interventions that we can provide support the expression of those feelings and sometimes they need referral to a grief counselor to a mental health counselor but those feelings those emotions those thoughts they need to be expressed and processed and sometimes with the help of a professional so we need to assess what is their social support what are their coping skills and are there any signs of that complicated grief and mourning do they need to go to a counselor do they need to have further support because maybe that person that died was their social support maybe they're not showing signs of having good coping skills or their grief is so deep that sometimes despite having had good coping skills before those coping skills are no longer accessible now most of us have heard of Kubler Ross's five stages of grief these are not necessarily linear doesn't mean you're going to start at number one go to number two and work to three and so on and so forth people can skip stages people can get stuck in a stage people can go from denial to depression to acceptance to anger to bargaining back to acceptance so it's not so much that there is a true progression but instead it's it's a highly individualized process but these are the five most common stages that may be seen within grief thank you so we have talked a little bit about personal grief morning and bereavement helping patients and family members and Friends deal with it but nurses we also have to deal with it as well and again that's why you have that life self-reflection for yourself to address your thoughts and your emotions related to end of life and death and dying because it can of course be very challenging and very heavy so it's really important especially if you are a nurse who's working in an arena like especially in patients something like ICU or maybe you'll end up being a hospice nurse or oncology nurse where there's a lot of deaf and dying or maybe you're in a long-term care facility you need to express your feelings frustration sadness anger share coping skills ask how other people COPE in a healthy way learn what your coping skills are what you need to process emotions and to feel better and and sometimes you just have to disconnect from it for a while give your your nervous system a break share how affected by the lives of patients who have died I shared that I became really attached to a patient that died on spcu and I had to process a lot of my own feelings and thoughts attending Memorial Services celebrate the lives of the patients that died you know support the family and it's also for closure for you too especially if you've really gotten attached to them and the family and then of course caring for yourself that ties back in nicely to the very beginning of this unit where we have to try to eat right try to exercise get some good sleep reduce our stress take that self-responsibility for providing ourselves with those pillars of Health that can promote resiliency