|
Applying the Nursing Process to Death Investigation: The Nursing Process and the Decedent
By Rae Wooten, BSN, RN, ABMDI
Part two in a series.
 The phone rings or your pager goes off; the message is,
“We are on scene with a DOA.” The assessment begins.
When the DOA is an elderly man found in an abandoned building at 3 in the
morning and it is 20 degrees outside, the investigator might wonder about the
possibility of foul play, hypothermia or natural causes. On the other hand, when
the DOA is a 20-year-old female who was found dead in bed in a college dormitory
with no apparent trauma, the investigator may ponder the possibility of a drug
overdose or an undiagnosed illness. The time of day, the location of the death,
the weather ... all have assessment value.
Individual pieces of assessment information are valuable; however, they are
often more valuable when they are “sewn” together like a quilt. Each piece
is interesting in its own right, but when connected or pieced together with
others, the result has even greater value.
For example, you respond to a death where the decedent is lying face down on
the floor of his bedroom. While assessing the body you observe a 1-inch
laceration on his forehead. You also note that there is a small amount of blood
on the floor under the decedent’s head. You have made two significant
observations. As you continue to investigate the scene you find that the
decedent was on Coumadin. Now you have a third significant observation. Initially you might ask, “Why is there so little blood from a 1-inch
laceration that is in a highly vascular area?” Add the Coumadin and more
questions arise: “Why was he prescribed Coumadin?” “Was the decedent compliant in taking it?” “Had his heart stopped
beating effectively; possibly v-fib or sudden asystole — or had he suffered a
sudden rupture of an aortic aneurysm?” You count the Coumadin tablets and
compare your findings to the dispensing information. You note the name of the
doctor; his or her input will be very important. Dig further and you find copies
of medical records that reflect that the decedent was scheduled for a pacemaker
insertion the following week.
As you can see, any one piece of this assessment information is important,
but when pieced together, the whole scenario provides new insight. This is one
reason why a nurse death investigator has such an advantage. Law enforcement
personnel simply are not as equipped to recognize what is important, evaluate
what it means and determine its significance.
Assessment related to the actual death applies not only to the body and the
immediate environment but also to the more general or global environment.
Information gleaned from other sources such as family, friends, witnesses,
medical records and so forth, is invaluable in the assessment process.
Let’s return to the aforementioned DOA. The nurse death investigator enters
the immediate environment where the death occurred or the dying process began.
Beyond the yard and front door there are endless bits of assessment information
that the death investigator might gather before ever reaching the body. Some of
these may be as simple as the indoor temperature, the food found in the
refrigerator and cabinets or the presence of crutches. Other bits of information
may be more complex, such as prescription medications or blood spatter.
Frequent findings that provide valuable assessment data include such things
as ashtrays full of cigarette butts, bottles of antacids and appointment cards
for various doctors’ appointments. As we move to the body our initial
visualization reveals even more. We can assess the location and position of the
body (i.e., lying in bed, on the toilet or on the floor with the telephone lying
nearby). We note the status of lights, the TV, fans, etc. All of these things
provide us with more information about the death.
Finally, we assess the body proper to include body temperature, lividity and
rigor mortis. A head-to-toe assessment of color, skin integrity, wounds/trauma,
scars, weight and so forth provide additional valuable information about the
decedent, but we are far from through. We have yet to gather assessment data
through interviews with family, friends and healthcare providers; additionally
we will review medical records and potentially autopsy findings.
Out of assessment grows a plan, implementation and evaluation. It is not difficult to see that based on the assessment findings the plan
will vary. The plan may be to have the body transported to a funeral home, held
at the morgue until the investigation is more complete or to have the body
autopsied. As any one of these plans is implemented, new assessment data may
become available which may lead to the development of a new plan. The assessment
process is continual and the planning stage is ever evolving. For example, if
after the initial assessment, a body is sent to the funeral home for preparation
for burial and new information is discovered that raises questions about
possible drug abuse, the plan will change. As a second example, the body of an
elderly man is sent to the morgue after he is found dead in his car following an
accident. Your assessment reveals no significant damage to the vehicle and
witnesses report that the decedent slowly drifted off the road without any
evidence of braking and struck a tree. When his medical history is evaluated and there is no evidence of trauma, the
remains may be released to a funeral home in light of a history of severe
coronary artery disease with complaints of chest pain just prior to the
incident. In this case, what initially appeared to be an accidental death was in
fact a natural death.
This component, the investigation of the death proper, is the first of three
components of the nursing process approach to death investigation. In the next article I will explore the second component, which is related to
family and/or survivors. I will demonstrate how I believe these components twist
and spiral in a way that impacts each one. Later I will add the third component
to complete the interrelated, dynamic model that I envision.
Rae
Wooten, BSN, RN, ABMDI, is the deputy coroner for the Charleston County, S.C.
Coroner’s Office.
More News
|
