Astudy of the literature from Nightingale in. Til Death Do Us Part? The Nurse s Role in the Care of the Dead A Historical Perspective:

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1 Til Death Do Us Part? The Nurse s Role in the Care of the Dead A Historical Perspective: Cynthia Ann Blum, MSN, RN In the immediate hours after a person takes his or her last breath, the nurse has always been present. In the hospital or at home, under hospice care or without warning, the nurse is frequently the last to hold the hand of those transitioning from life to death. The nurse, in assuring the patient and family a peaceful transition, finds her role to include caring for the body with reverence to the religious and cultural concerns that the patient holds sacred. (Geriatr Nurs 2006;27:58-63) Death be the not proud, though some have called thee Mighty and dreadfull, for, thou art not so; For, those whom thou think st thou dost overthrow, Die not, poor death, nor yet canst thou kill me. From rest and sleep, which but thy pictures be, Much pleasure, then from thee, much more must flow, And soonest our best men with thee doe go, Rest of their bones, and soules delivery. Thou art slave to Fate, Chance, kings and desperate men, And dost with poison, warre, and sickness dwell, And poppy or charms can make us sleep as well, And better than thy stroke; why swell st thou then? One short sleep past, wee wake eternally And death shall be no more; death thou shalt die. John Donne ( ) Astudy of the literature from Nightingale in 1859 to the present-day text reveals a topic in which nurses are trained both through written instruction and by the passing on of procedures for caring for the deceased. 1 Isabel Adams Hampton tells the nurse that her duties to her patient do not cease until the body has been decently cared for and the bed and the room have been left in perfect order. 2 This article examines specific areas of care found in the literature describing some of the death rituals followed by the nurse. The historical perspective will help the nurse to formulate implications for present-day care. Nursing textbooks are the primary source of instruction for nurses in performing these duties. Historical Perspective Florence Nightingale, in Notes on Nursing, 3 discussed the complicated state of society in large towns and reveals the cause of death as being less likely to result from organic disease than by a combination of illnesses producing the sum exhaustion necessary for death. She expresses the need for quiet, good food, and good air as assuring continued life to those without organic disease. As Nightingale discussed death, she expressed the nurse s role to advocate for the patient and utilize common sense in all deeds and duties. Nightingale did not discuss the nursing care of the patient who has died but did tells nurses go straight your way to God s work, in simplicity and singleness of heart. 4 In 1873, the first Nightingale model nursing school was opened at Bellevue Hospital in New York. A Manual of Nursing was prepared in 1878 as text for this training school. A notation is made for nurses giving home care that we have no power of ourselves to help ourselves, but that God is ever willing to grant us strength to perform our duties, if we pray to Him in the name of our Blessed Saviour. 4 The care the nurse gives her patient will often decide the question of life or death, but the question of care after death is not addressed. In 1888, instruction to nurses in A Text-Book of Nursing tells us that death is clear; the only condition with which it may be confused is catalepsy, which is most often associated with hysteria. One must be careful not to announce death prematurely as the failure is sometimes so gradual. The attending physician must be notified at once. 5 The role of the physician in confirming death repeats throughout the literature as a first direction for the nurse before disposition of the body. While the body of the deceased patient remains in the hospital, the administration is under duty to maintain the corpse in proper condition. 6 The Nurses Responsibilities A patient is not legally dead until a physician has certified his death, and nothing should be done that would interfere with life, as there is always a possibility of life remaining in the 58 Geriatric Nursing, Volume 27, Number 1

2 body. 7 The physician should be notified of the change in condition, but the nurse should never assume responsibility for being alone with a dying patient. Bertha Harmer published texts on the principles and practice of nursing in 1927, which were revised with Virginia Henderson several times through The text from 1927 states that a very young nurse will never be asked to care for the body alone not because any special skill is required but because actual contact with death is apt to be depressing to the young and inexperienced mind. 8 The sense of duty as a nurse to treat the body tenderly and reverently is the last tender office that can be offered. A stretcher is prepared and the body is lifted gently and reverently to it. 8 These statements did not appear in later revisions of the text. Harmer and Henderson also discuss the use of a screen to afford privacy, which is eliminated from later texts, but privacy, respect, and dignity remain central to care of the deceased. The literature supports the role of the nurse to the family; do not begin preparation for care of the body in the presence of any member of the family, or any visitor. Neither should the nurse show any desire or haste to prepare the body when friends or members of the family are present. Good taste and sympathy should prompt her to alleviate as much as possible the grief of any relatives who may be present at that time. 10 Prolonged family visitation is supported. 11,12 The nurse may control the amount of time by quietly suggesting to one who may not be so deeply affected as the others that they remind the family of their obligations to attend to other matters and to allow the nurse to continue her care of the patient. 11,12 The nurse should know the requirements of the hospital regarding care of the body after death. 11,12 Policy regarding the wrists and ankles lying free or bandaged, crossed and tied together, as well as the use of a chin strap are items that may differ according to the institution. The responsibility for care of the body after death is guided by local procedure. Many procedures are in accordance with requests made by local morticians because the way the body is handled can either facilitate or hinder the preparation of the body for viewing. 13 Although many procedures were changed over time, cleanliness of the body and proper identification were common instructions throughout the literature. The Nurse as Person As far as the public is concerned, nurses have succeeded in conveying the impression of being always unperturbed and even lacking emotion. The remark that even the nurse cried at the death of someone s child illustrates this fact. 14 Ujhely 14 describesthenursewho,whilecaringfor dying patients since the age of 18, may by the age of 25 have built a thick armor to shield herself from repeatedly experiencing such overwhelming situations. The nurse was advised to exhibit a degree of control of her emotions. Students were encouraged to observe and then participate in providing postmortem care under conditions that provide support and encouragement to minimize the possibilities of a traumatic aftermath. One student Quint 15 interviewed felt that her religious upbringing had a lot to do with how she handled the procedure. Students expressed surprise at how the body would feel as well as feeling shocked at an orderly who handled the body in a rough manner. The student stated, In nursing school we are taught to protect the body. 15 The difficulty in allowing others to handle the patient in a rough manner was of concern. 1 Depersonalization, joking behaviors, and the use of the body for teaching purposes disturbed the inexperienced nursing student. Yet nurses might handle high levels of anxiety by laughing, joking, or casual conversation with other staff members therefore depersonalizing the body. Referring to the corpse as it or wearing an unnecessary gown and gloves also keep the nurse from the conscious reality of death. This behavior denies the body the respect and dignity it deserves. 16 Interviews with nurses tell of identifying with the patient as one of their family when giving postmortem care. Personal memories of deaths of loved ones related to the nurse enabled the nurse to personalize the event. 1 Dehumanizing behavior around the deceased may result from embarrassment or not knowing how to act. 17 Telling the person responsible for the behavior something about the patient is a way to minimize the crudeness and humanize the care. Nurses frequently have vivid recollections of their first experience with death. Likewise, they Geriatric Nursing, Volume 27, Number 1 59

3 often have difficulty giving postmortem care to a patient with whom they have become attached. One nurse shared a story of being unable to wrap the head of a woman who had suffocated and whose face appeared scared after death. Others have difficulty placing the patient s hands inside the shroud as both the hands and the face have defining, uniquely human characteristics and aspecial meaning. 1 The major roles of the nurse in caring for the body after death are carrying out legal requirements, protecting the body tissues, and discharging the body to an appropriate area for claim. Family members are usually given one more opportunity to see the body, so it should be made to look as familiar as possible. 16 Ifthe patient dies at home, directions to guide the family are similar to the actions of the nurse today. Treating the body with respect, cleaning and dressing based on your needs, and closing the eyes and the mouth if aesthetically appropriate are suggested to the family. 18 Many specific areas of care emerge in the literature. An abbreviated summary follows to trace aspects of sacred space, religious concerns, and cultural considerations. The Patient s Sacred Space The literature repeatedly tells the nurse to leave the patient room clean and devoid of medicines and medical equipment. Dust the room and make everything tidy and pretty is a direction given in the Trained Nurse in The window shades should be drawn to a few inches below the middle sash and the window should be open afew inches. 19 Ifthe family is delayed in reaching the hospital, the nurse should place a screen between the bed and the door, all lights should be turned off except the one at the bedside, and the door to the room should be closed. 11 Low lights in the room soften the appearance of the corpse. Family members should come away with the perception that their loved one died easily and without pain. 16 Generally, the nurse is responsible for care of the patient room. In 1954, calling the housekeeping department to clean and prepare the room foranotherpatientwassuggested. 11 Asancillary personnel became available, references in the literature after this date delegate the cleaning of the room to a person other than the nurse. The nurse of today is acutely aware of the patient s surroundings as sacred space. Tidiness in the room suggests to the family a peaceful death and provides a way for the nurse to comfort those who come to visit. Religion-Based Traditions Every nurse owes it to her profession to acquaint herself with the rituals and fundamentals of all faiths so that she may serve her patient to the best of her ability. 20 Last sacraments for the Catholic or Protestant patient are tobereceivedbeforedeath. 21 WhiletheRoman Catholic patient should properly be involved in the Sacrament of Last Anointing so that they might join in the prayers, it can be given conditionally for some time after the patient ceases to breathe. 20 The Catholic patient should be baptized if it has never been done before. Prayers for the Dying should be offered as well. 22 Inthe event of a sudden death, the priest should be called, and anointing with oil and viaticum or final communion should be administered if at all possible. The priest will also lead the family in prayers. 23 Protestant rituals vary based on specific faith and personal feelings of the patient and family. Last sacraments and prayers may be appropriate. Christian funeral practices vary from simple observances to elaborate rituals. 24 If the patient is of the Jewish faith, Beruch Dayan ha-emet (Blessed Is the Judge of Truth), Glory to God, or the chant Om may be appropriate. Others of this faith chose silence. 25 Goses is the name given to a dying person, and in the Talmud, different rules apply to a goses than to a living person. The goses should not be touched for fear that his departure might be inadvertently hastened. Furthermore, the goses should not be left alone, and it is a great mitzvah to be present at the departure of the soul. Candles are usually lit at this time to symbolize the flickering of the human soul. 25 Ifthe patient is an Orthodox Jew, do not touch the body until the rabbi has arrived to perform the final rites. 22 After death, a son or relative closes the eyes and mouth of the deceased and washes and dresses the body. 24 Organ donation, autopsies, and cremation are often resisted by those of the Jewish faith. Reality and simplicity are characteristic of a Jewish burial, in clear contrast to many American funeralrituals. 24 Thenurseshouldsupportthese 60 Geriatric Nursing, Volume 27, Number 1

4 rituals in keeping with the Jewish faith as she facilitates care for the dead. In 1988, Zane Robinson Wolf authored Nurses Work, The Sacred and the Profane. In her interviews of nurses from a selected floor of a large urban hospital, she asked their feelings about postmortem care. The passing down of rituals from nurse to nurse emerged as a common theme. One such occurrence involved the crossing of arms about which the nurse said, With the Jewish patient, you don t cross their arms. With patients of other religions, it is customary to cross the arms and tie them. 26 This specific direction was not found in any other literature. 25 Muslims spend their remaining time praying and reading the Koran (Islam s holy book). The dying person should be turned toward Mecca. Only other Muslims should touch the dead body of another Muslim. Non-Muslims should put on rubber gloves before touching the dead body. After death, the body is bathed at the mosque or at home and often wrapped in white cotton. Muslims are not cremated and are often buried within 24 hours of death. 24 Buddhists believe in reincarnation and that the last thoughts of a person before death determine the rebirth condition. After the person dies, the body is washed, dressed in new clothes, and then cremated. Hindus view death as mortality of the body but not of the soul. After death, the body is washed, anointed, and dressed in burial clothes. Hindus believe that cremation is the best way for the soul to begin its journey. 24 Religious rituals and ministry are a lifetime journey. At the end of life and the hours after, those of faith should be offered a ministry consistent with their beliefs. This offering may provide comfort to the individual, to those left behind, and to the team that provides end-of-life care. Because travel has increased and cultures have collided, the nurse of today should bring an awareness that was not required in the less mobile society of the past. Cultural Concerns Class or Ethnicity The nurse should use common sense and a genuine consideration for others when adapting to the customs and culture present in the home environment. The student nurse should be aware that her work will probably bring her in contact with every social class. She should cultivate habitual courtesy and familiarize herself thoroughly with all of the niceties of cultured people. 27 Great cultural differences exist in the way bodies are prepared for their ultimate disposition. Even today, the burial practices one culture thinks comforting, important, or even necessary to the welfare of the body, the spirit, or the memory of the departed may be thought primitive, barbaric, or superstitious by another culture. White Americans are more likely to avoid contact with the corpse and the funeral process than other ethnic groups. 24 The nurses awareness of the cultural concerns of the patient and their family as well as self-awareness demonstrates acceptance of others. Death Rituals of the Present As nursing responsibilities have changed and with the emergence of hospice care, the process of determining death has fallen to nurses in many states. Specific state and county regulations as well as institutional procedure must be consulted. In hospice home care, the nurse who determines a lack of vital signs will generally call the physician who verbally agrees to sign the death certificate. Specific items to identify, assessment to be done, and documentation are discussed in Textbook of Palliative Nursing. 28 Health care institutions are required to have policies related to potential organ donors. The nurse may require training and certification to offer this promise of hope to the family. Current literature repeats that the body of the deceased needs to be treated in a way that respects the sanctity of the human body. Nursing care includes maintaining privacy and preventing damage to the body. The physiologies of nursing actions are defined. Algor mortis, the lack of skin elasticity due to a decreased body temperature, mandates why we are careful when removing tape to avoid skin breakdown. Liver mortis is the name for the bluish discoloration that is a by-product of red cell destruction that appears in pooled blood and is to be avoided through proper positioning. Rigor mortis causes stiffening of the body by contractures of skeletal and smooth muscles 2 to 4 hours after death. 29 Geriatric Nursing, Volume 27, Number 1 61

5 The scientific rationale for the ritualized nursing procedures rests on knowledge of the physiological changes after death. 30 Nursing actions after a death include closing the eyelids, inserting dentures and closing the mouth, positioning the body naturally, and removing all tubes to prepare the body for the family to view. Understanding the action of algor mortis helps the nurse to explain to the family the fragility of the skin. The nurse will explain that the family may wish to kiss the hair of the patient instead to decrease the chance of trauma. Dressings are best wrapped with a circular bandage or paper tape due to algor mortis. Placement of pillows decreases the coloring of liver mortis. Rigor mortis lasts for up to 96 hours after death, usually within the timeframe of a final viewing and funeral. Positioning of the patients limbs, jaw, and eyelids increase the chance of a natural and comfortable appearance of the body after death. 31 In some situations the nurse may be the one responsible for certifying the death. Her knowledge of the physiology that contributes to the possibility of a final sigh after death, temperature changes of the skin, sweating, and color changes will help the family to understand these as normal and expected occurrences, unrelated to signs of life. Although postmortem care is no longer required to be done by nurses in some institutions, nurses continue to lead the care and provide support to the family. They may consult the hospital s policy and procedure manual or pass along the procedure to the neophyte by action and word. Just as they learned to care for the dead, they will teach others. Reverence for the person who has died and his or her family and friends who may be suffering is an inherent quality for today s nurse. Respect for the dead and attention to the person and his or her sacred space is a caring act toward others. Summary and Implications for Education and Practice Death sometimes terminates the stay of the patient in the hospital or inevitably the stay of somepatientsmustendindeath. 32 TheRitesof Passage incorporate 3 stages as identified by Arnold van Gennep in describing the deathwatch in the 19th century. The first phase, separation, included rituals of moving the bed chairs, closing the windows, and lighting the candles the creation of sacred space. Transition involves confessionals, forgiveness, and words said outside the normal boundaries of social intercourse, a time of change and of confusion. Reaggregation is the third phase accompanied by symbolic acts: closing the eyelids, covering the face, and reciting prayers to send the soul on its way. 33 Nurses have followed many rituals over the years as the rites of passage have been experienced by the dying. Today s nurse has a strong understanding of physiology and can explain to others the natural body occurrences during the dying process. They are grounded in a cultural and religious awareness that surpasses their own. Is it a slight thing to be able to lessen the amount of human suffering? was asked of the nurse in The more recent advent of hospice has offered an understanding of the need for rituals specific to the family. This may include grieving with the family and allowing shared participation in the care of their loved one. The education of nursing students and practicing nurses needs to include respect for traditional rituals of death with reverence for the sacred space, religious, and cultural concerns that comfort the family and demonstrate respect for the deceased. It is imperative to educate nursing students and prospective nurses about the rituals associated with death, respectful postmortem care, and the physiological signs of dying. New nurses and nursing students should spend time with experienced nurses to learn postmortem care. Exposure to hospice care will comfort and educate nurses in the care of the dying and should be included in nursing curricula. Bury me if you can catch me. Socrates References 1. Wolf ZR. Nurses work, the sacred and the profane. Philadelphia: University of Pennsylvania Press; 1988, pp. 85, 126, 128, 137, Hampton IA. Nursing: its principles and practice. Philadelphia: W. B. Saunders; 1898, p Nightingale F. Notes on nursing: what it is and what it is not. New York: D. Appleton and Company; 1860, p Geriatric Nursing, Volume 27, Number 1

6 4. Nightingale F. Notes on nursing: what it is and what it is not. Facsimile of 1st edition. London: Harrison; 1859, p Weeks CS. A text-book of nursing. New York: D. Appleton and Company; 1888, p Hayt E, Hayt L, Groeschel AH, et al. Law of hospital and nurse. New York: Hospital Textbook Company; 1958, p Harmer B, Henderson H. The principles and practice of nursing. 4th ed., revised. New York: Macmillan; 1939, p Harmer B. The principles and practice of nursing. New York: Macmillan; 1927, p Harmer B, Henderson V. Textbook of the principles and practice of nursing. 5th ed. New York: Macmillan; 1955, p Rothweiler EL, Coulter JS, Jansey FM. The science and art of nursing. Philadelphia: F. A. Davis; 1936, p Price AL. The art, science, and spirit of nursing. Philadelphia: W.B. Saunders; 1954, p Price AL. The art, science, and spirit of nursing. 3rd ed. Philadelphia: W.B. Saunders; 1965, p Fuerst EV, Wolff L. Fundamentals of nursing. 3rd ed. Philadelphia: Lippincott; 1964, p Ujhely GB. The nurse and her problem patients. New York: Springer; 1963, p Quint JC. The nurse and the dying patient. 3rd printing. New York: Macmillan; 1969, p Saperstein AB, Frazier MA. Introduction to nursing practice. Philadelphia: F.A. Davis; 1980, p Henderson V, Nite G. Principles and practice of nursing. 6th ed. New York: Macmillan; 1978, p Duda D. Coming home. Santa Fe, NM: John Muir; 1984, p , Cited by Wolf ZR. 1 Trained nurse, 1890, p McClain ME, Gragg SH. Scientific principles in nursing. 5th ed. Saint Louis: C.V. Mosby; 1966, p Stoney EAM. Practical points on nursing for nurses in private practice. Philadelphia: W.B. Saunders; 1914, p Wood LA. Nursing skills for the allied health sciences. Volume 2. Philadelphia: W.B. Saunders; 1972, p Castles MR, Murray RB. Dying in an institution: Nurse/ patient perspectives. New York: Appleton-Century- Crofts; 1979, p Doka K. editor. Living with grief: loss in later life. Washington, DC: Quality Book; 2002, p Harmon L. Fragments on the deathwatch. Boston: Beacon Press; 1998, p Several Rabbis were consulted by clergy at Hospice of Palm Beach County (FL) in March 2004, and not one had heard of this practice or was aware of any religious base for not crossing the arms of the Jewish patient. Discussion speculated on the crossing of arms as symbolizing the cross of Christian faiths as a possible reason for this ritual as practiced by Wolf s subjects. 27. Smith MR, general editor; Broadhurst J, science advisor. An introduction to the principles of nursing care. 2nd ed. Philadelphia: J.B. Lippincott; 1939, p Ferrell BR, Coyle N. Textbook of palliative nursing. New York: Oxford University Press; 2001, p Delaune SC, Ladner PK. Fundamentals of nursing: standards and practice. 2nd ed. Clifton Park, NY: Delmar; 2002, p Pennington EA. Postmortem care: more than ritual. Am J Nurs 1978;75: Smeltzer SC, Bare BG. Textbook of medical-surgical nursing. 9th ed. Philadelphia: Lippincott, dewitt, Delaune and Ladner, Ferrell and Coyle, Perry and Potter, and other contemporary authors discuss current nursing care and postmortem rituals. 32. Tracey MA. Nursing-an art and a science. St. Louis: C.V. Mosby; 1938, p Harmon L, 25 p , cites The Rites of Passage as identified by Arnold van Gennep. 34. A Manual of Nursing, prepared for the training school for nurses attached to Bellevue Hospital [author unknown]. New York: G. P. Putnam s Sons; 1878, p. 8. CINDY BLUM, MSN, RN, is a clinical instructor at Christine E. Lynn College of Nursing, Florida Atlantic University, and a PhD student in their doctoral program. ACKNOWLEDGMENTS The author thanks Dr. Terri Touhy for her assistance, encouragement, and coaching through the process of writing this first publication /06/$ - see front matter 2006 Mosby, Inc. All rights reserved. doi: /j.gerinurse Geriatric Nursing, Volume 27, Number 1 63