Government regulations at both state and federal level require hospitals to establish policies and procedures to certify death; to identify potential donors; and to care for a body after death. If organ donation is anticipated, respiratory and circulatory support must be maintained until vital organs can be harvested. It must be clearly communicated to the family that the devices used to maintain organ perfusion no longer keep the patient alive, but are merely supporting the organs in anticipation of transplant.
Vital organs requiring support are:
heart
liver
lungs
kidneys
pancreas
KEY TERMS
Algor mortis—Reduction of body temperature with loss of skin elasticity.
Livor mortis—Discoloration of skin in dependent areas.
Rigor mortis—Stiffening of the body, developing within two to four hours of death.
Such non-vital tissues as the cornea, skin, long bones, and middle ear bones do not require support after death.
If the patient had an infectious disease, the body must be labeled in accordance with established policy.
Before rigor mortis develops, the nurse should position the body in a normal alignment and close the eyelids and mouth, inserting dentures if necessary. Because of the reduction in body temperature and loss of skin tone (algor mortis) after death, it is important to gently remove all tape and dressings to prevent tissue damage. The skin or body parts should never be pulled on. The head of the bed should be elevated to prevent purplish discoloration (livor mortis) of the face. The body must be stored in a cool place to slow bacterial formation after death.
Equipment
A commercial morgue pack, if available, will contain gauze or string ties, chin straps, a shroud, and three identification tags. In addition to these items, the nurse should gather the following:
Before placing the body in a supine position with arms at sides and head on a pillow, the nurse should put on clean gloves. The head of the bed should be slightly elevated. At this time, the nurse can insert the patient's dentures, if worn, and then close the mouth. By placing a fingertip on each eye, the nurse should gently close the patient's eyes. If the eyes will not remain closed, moistened cotton balls can be placed on the eyelids for several minutes, and then a repeated attempt to close the eyes can be made. A folded towel should be placed under the chin to keep the mouth closed. All catheters, tubes, and tape can be removed, but adhesive bandages should be applied to puncture sites.
At the time of death, the patient's survivors become the focus of concern, and the nurse must then be able to offer comfort and support to the living. All the patient's belongings can be gathered for the family to take. If a ring cannot be removed, the nurse can cover the ring with gauze, tape it securely, and tie the gauze to the wrist to prevent loss.
Before the family views the patient, the body is cleansed, using soap, water, and washcloths. To absorb any rectal drainage, one or more ABD pads is placed between the buttocks. The body is covered up to the chin in a clean sheet, with the arms placed outside of the sheet if possible. Then the room must be prepared for receiving the family and friends by removing all trash and providing lower light in the room. If there are unpleasant odors present in the room, a room deodorizer can be used before allowing the family to return.
The nurse can then offer family members the opportunity to view the body, but not force them, letting them know that either viewing or not viewing is acceptable. This is the time to ask family members if they prefer that any jewelry be left on the body. The nurse should clearly document whether personal items are remaining with the body, or to whom the items were given. The nurse can allow survivors privacy in viewing the body, but not leave them alone until it is ascertained that they are comfortable remaining with the body. The nurse can encourage the family to touch and talk as a way to say goodbye to the deceased.
When the family has left, the towel can be removed from under the chin, placing an ABD pad under the chin and wrapping chin straps under the chin, with the straps tied loosely on top of the head. Padding the wrists with an ABD pad prevents bruising, and then the nurse ties the wrists together with gauze or soft string ties; the ankles should be padded and tied in the same manner. It will be necessary to fill out three identification tags with the deceased's name, room and bed number; date and time of death; and the physician's name. One tag will be tied to the big toe, hand, or foot. Another identification tag must be attached to the shrouded body, and the third identification tag attached to the personal belongings. The nurse must ensure that the patient's identification bracelet is not removed.
Aftercare
A family member should take all the patient's personal belongings. The body will be transported to the morgue or funeral home.
Complications
If organ donation is planned, failure to maintain support for vital organs will mean that organs cannot be harvested.
Results
The patient's family will have the opportunity to view the body, if they wish, in order to begin the grief process. Emotional support of the survivors will be provided by trained staff members.
Health care team roles
Physicians must certify the death. If the death occurred in unusual circumstances, an autopsy may be requested. Staff members, pastoral care, or other personnel should remain with the family during preparation of the patient's body for viewing. Nursing is responsible for coordination of all postmortem care. Trained staff members will provide information to the family regarding organ donation.
BOOKS
Ambrose, Marguerite, and Frances Quinless. "Fundamental Procedures." In Nursing Procedures, 3rd ed. Springhouse, PA: Springhouse Corporation, 2000.
Potter, Patricia. Fundamentals of Nursing, 5th ed. St Louis, MO: Mosby, 2001.
ORGANIZATIONS
American Academy of Hospice and Palliative Medicine (AAHPM). 4700 W. Lake Avenue, Glenview, IL 60025-1485. (847) 375-4712. <http://www.aahpm.org>.
Hospice and Palliative Nurses Association. Penn Center West One, Suite 229, Pittsburgh, PA 15276. (412) 787-9301. <http://www.hpna.org/>.
Last Acts National Program Office. Partnership for Caring, 1620 Eye Street NW, Suite 202, Washington, DC 20006.(202) 296-8071. <http://www.lastacts.org/>.
