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Applying the Nursing Process to Death Investigation:
The Nursing Process and the Family/Survivors
I Part three in a series.
By Rae Wooten, BSN, RN, ABMD
 It’s now two o’clock in the morning and it is cold
and misting rain. I wade through the thick, wet underbrush as I leave a wooded
area where crime scene investigators continue to work with the help of portable
lights. I joined police earlier and each of us performed our respective jobs ...
each one important and wrapped in sadness. I found the victim lying face down,
wearing blue jeans, a T-shirt and athletic shoes. While I busied myself
photographing and documenting the scene, I was hoping that I would find ID in
the victim’s clothing. In the meantime I was making notes of every piece of
identifying information possible.
For purposes of discussion, let’s assume that picture identification was
found in the victim’s right jeans pocket and that the condition of the body is
such that I feel comfortable that the decedent is the individual on the ID card. I now turn my attention to the second component of the nursing process as it
relates to death investigation — notification of the death to the family and
other survivors. This task often leaves me wondering where to begin. The weight
of the responsibility is daunting as I prepare to give loved ones news that will
change their lives forever.
This is an appropriate time to point out that the nurse death investigator
may be the person responsible for making notification of the death. When you
combine a nurse’s knowledge of grief and grieving, defense mechanisms,
communication skills, etc. with her caring, empathetic approach, I believe that
you have a basis for why nurses do it best. Every case is different, with unique
challenges and dynamics. Every case deserves our best effort in every regard,
but nothing is more important than identification and notification. Not
only is there huge liability associated with misidentification and erroneous
notification, but I can hardly imagine the emotional pain and suffering
inflicted on families when such a tragedy occurs.
Let us now return to the case at hand. I am fortunate that I have been able
to identify the victim immediately. In many cases that will not be true, and
only after you have identified the decedent can you identify their next of kin.
After you have identified those to whom you must make notification, you must
locate them. Sounds straightforward, but is it? The processes of identification
and subsequently notification are also built on the nursing process.
For the purpose of discussion, let’s assume for a few minutes that the body
in the wooded area had no ID on it. I then must assess the death scene not only
for the purpose of determining the cause and manner of death but also with
attention to collecting data necessary to identify the deceased. I will note
such things as hair color, length and style. I will pay special attention to
clothing, especially the shoes, belt and any jewelry. I know that every freckle,
mole, scar and tattoo will be incredibly valuable in the identification process.
Then a plan is made to accomplish the task of identification, such as
fingerprinting, securing picture identification, obtaining X-rays, etc. and the
plan or plans are implemented with the results being evaluated to determine
success or failure and the possible need for a new plan. Once we know who the
decedent is and identify and locate family, the actual notification starts a new
and rapid fire round of assessment, planning, implementation and evaluation. I liken this to a tennis match in which you never know where the ball will
land or how quickly or hard it may be returned.
Not unlike the assessment of the death scene, assessment in relation to
notification begins when you identify the location to which you’ll respond and
perhaps the individuals you believe you will notify. Many times you will have
little information other than the location and information you gain as you
approach the house including such things as children’s toys in the yard, a
baby seat in a car or a wheelchair ramp to provide you with valuable clues.
After knocking on the door, the nurse death investigator may be met with any
number of situations that provide pieces of assessment information. For example,
the person opening the door may be a child, an elderly person on oxygen, or
non-English speaking. Obviously each of the situations requires a different
approach.
Additionally, each person’s response to your presence will vary. Some may
be immediately fearful, asking you what’s wrong. Some may be curious about why
you knocked on their door and quietly wait for an explanation. Others, upon
hearing that you work with law enforcement, may immediately respond with the
question, “Is he in trouble again?” Those assessment findings demand the
quick formation of nursing diagnoses and plans followed by deliberate, careful,
sensitive implementation of those plans, culminating in the news of the death.
Beyond the actual notification, which may be followed by emotions and actions
ranging from hysteria to absolute denial, fainting and fleeing, again the
nursing process will guide the nurse death investigator’s actions. Do the
survivors need immediate medical attention, spiritual support, or assistance in
notifying other family members? Will they need referral to a support group
later?
Nursing involvement with the survivors does not end with the notification. It
continues through the days, weeks and even years to come as we strive to assist
the survivors in healing. Healing can involve many things from repeated
discussions of the death and the circumstances surrounding it to just being a
shoulder to cry on. It may involve providing autopsy reports to survivors and
answering their questions or helping them with necessary legal and insurance
paperwork.
Access to someone who has intimate knowledge of the death is often so
important; after all, who else can answer those questions about how the decedent
was found, whether or not death was quick or whether they suffered? The death
investigator, because she is a nurse, understands grief and provides a safe
sounding board for those grieving family members, allowing them to shed their
tears, vent their anger and perhaps even share their guilt.
It seems appropriate to touch on some likely nursing diagnoses. They will
vary as greatly as the individuals who survive the deaths. Some anticipated
diagnoses may be as simple as grieving, altered nutrition or sleep pattern
disturbances; other less obvious diagnoses may include such diagnoses as risks for altered
development, compromised family coping, helplessness, powerlessness and
knowledge deficit. Whatever the diagnoses, the implementation of the nursing
process will benefit the survivors.
We have now examined two of the three components of the nursing process as it
relates to death investigation, investigation of the death proper and
notification and interaction with family and survivors. In the next and final
article I will discuss the nursing process and death investigation as it relates
to the community or society. Hopefully you are beginning to see how these components are interrelated and
dynamic and spiral and twist like a DNA helix.
Rae Wooten,
BSN, RN, ABMDI, is the deputy coroner for the Charleston County, S.C. Coroner’s
Office.
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