Death: Another Point on the Continuum of Care
By Catherine A. O'Brien, RN, MS, CNA, CLNC, D-ABMDI

Death was certainly not a motivating factor in my decision to become a nurse. I wanted to make a difference in the quality and quantity of my patients' lives. But today I find myself a registered medicolegal death investigator. How did I get to this point in my career continuum?

Several unconventional encounters with death in my early years as a staff nurse in the hospital setting may have had a subconscious influence on me. These experiences, laden with forensic implications, were not appreciated at the time. The attempted homicide of a known gangster under my care on an acute medical unit by someone dressed like a respiratory therapist left me shaken. As I turned the corner and approached the room with the sounding call light, I observed a male figure, dressed in white pants and lab coat, come out of the room and walk down the hall in the opposite direction. Although one of my patients in that room was on oxygen therapy, I recall thinking it odd and too early in the night for respiratory therapy to be making routine rounds. My patient told me he heard muffled, moaning sounds that awoke him. Simultaneously, coughing sounds could be heard from the other side of the curtain. When able to speak, the roommate told me of a suffocation attempt on his life that was interrupted by the ringing call light. How devastated I was that any patient under my direct care was victimized. I regretted not having had the foresight to anticipate this possibility due to the patient's personal history, but after all, hospitals were supposed to be safe environments. I regretted not following my gut instinct about the untimely presence of someone unfamiliar in the environment. Had I been more observant of this male figure, I might have been able to provide law enforcement a more detailed physical description. Perhaps had I verbalized an inquisitive remark to this individual, it may have provided an opportunity to get a glimpse of his face, hear a verbal response or generate a reaction to share with the police in order to make a valuable contribution to the subsequent investigation.

A few more experiences: The contorted body lying on the annex roof outside my patient's room window as I went to pull the shade was frightening. Was this a patient or someone dressed in patient clothing? Did he jump from a higher floor? Was he pushed? What happened and why? As the investigation unfolded, this would become my first encounter with suicide. Feelings of confusion surfaced as I wondered if our healthcare community somehow failed this patient while in an institution committed to quality care, patient safety and dignity for life.

The day my ventilator dependent patient was disconnected from respiratory support while I participated in change-of-shift report was suspicious and could not have been accidental. During report, I focused on a distant but constant alarm, which I immediately recognized. I rushed to a private room, finding the door only slightly cracked open and the curtain pulled around the bed. The machine was connected to the endotracheal tube but not ventilating and appeared to be malfunctioning. The visitor chair, occupied 15 minutes earlier by the patient's daughter, was now empty and she was nowhere in sight. The patient was in acute distress and as resuscitative efforts ensued, I frantically tried to determine what had gone so terribly wrong. Just prior to report, a physical assessment had been performed with stable findings and ventilator settings double-checked. The patient had been resting comfortably in the company of his daughter. I instructed her to call if anything was needed and said I would be in report. As other team members responded to the code, it was soon determined the ventilator was unplugged from the wall outlet behind the headboard. The prospect that his daughter was involved or responsible for his expiration left me stunned, saddened and feeling professionally violated. While I empathized with the family's plight, should I have been more suspect of a family distraught and divided over a loved one's ventilator dependent state? Or did someone unauthorized entered the room who was familiar with unit routines, aware staff would be clustered in report and not in close proximity to the room? Could the plug of this older model machine just happen to fall out of the outlet causing it to lose power? For weeks thereafter, I searched for clues I might have missed and struggled with feelings of guilt in failing my responsibility to keep my patient safe from harm, even if that included members of his own family which was an inconceivable thought to me at that point in my career.

My death experiences as a pediatric intensive care nurse were tragic. Traumatic deaths due to gun shot injuries, blunt trauma injuries, patterned injuries, burns, neglect and battering, accidents were common denominators in the demise of many of my vulnerable patients. It was during this decade of my career that collaboration on numerous cases with law enforcement, child protective services, organ procurement teams, hospital general counsel and the legal process came to the forefront. The intersection between medicine and law in each instance broadened my perspectives, taught numerous lessons and strengthened my advocacy for victim's legal, civil and human rights. The value of meticulous initial and ongoing assessments, detailed and factual documentation as well as testimony presentation cannot be understated. This was particularly evident in one case that involved a toddler in isolation who was under the care of a registered nurse each shift. Periodically, there was a need to leave the room to obtain refrigerated medications, which sometime occurred while the parents were present. On several occasions, my colleagues and I observed that after the parent's departure, the child's behavior often would become agitated with increased vital signs and other unusual findings for no apparent reason. We verbalized our suspicions to the attending physician. A chemical assault was confirmed by toxicology reports finding the presence of phencyclidine (PCP) that was injected into the intravenous line by the child's father.

Death, under any circumstance in the pediatric ICU, was always a somber experience. There were those heart-wrenching encounters with devastated parents regarding consent for autopsy who questioned exactly what the procedure would entail. I found myself inept in formulating a response that was truthful and informative, yet compassionate and sensitive since I had never witness the procedure. A day in pathology observing autopsies guided me in subsequent parental encounters. It was also during this period, as a critical care nurse, I experienced cognitive dissonance relative to my scope of practice and death. Critical care nursing is dedicated to the prevention of and intervention in life-threatening situations. Caring for a patient with a diagnosis of brain death was in direct conflict with this mission. Curious about the feelings of other colleagues, this became my graduate thesis subject matter.

The administrative arena was my next career phase, which distanced me from dealing with death directly. However, several leadership positions underscored the responsibility to ensure staff knowledge and compliance with various forensic principles. Removal of evidentiary matter in the ambulatory surgery setting was becoming more frequent which highlighted the need for staff education on the chain of custody. An outpatient program for forensic evaluation under anesthesia for children of alleged sexual abuse was developed. Care of the patient under custodial care, drug diversion of controlled substances, assessment for elder abuse were other forensic subject matters which emphasized the need for current policies and procedures, availability of expert consultative resources, effective reporting processes, and relevant educational endeavors all designed to provide leadership to clinical staff when needing to maneuver in unfamiliar medicolegal terrain. Death was a frequent byproduct of the active level-one trauma center and knowing the forensic value of a dying declaration and demonstrating competence in standards of evidence collection and preservation was unmistakable in certain settings. The dreadful infant abduction by an authorized visitor to the nursery that culminated in homicide was too high a price to pay for a wakeup call reiterating our obligation to prevent harm to those who trust in us. While not under my purview, this tragedy was a defining event for me that shaped my desire and focus to become a medicolegal death investigator.

Training has consisted of many facets. Courses in criminal justice administration, legal nurse consulting and numerous forensic education sessions have provided a foundation for principles, processes, techniques and skills. Time spent with the Chicago Police Forensic Services Unit and Miami-Dade Crime Scene Investigation Unit allowed for death scene investigation outside the walls of a hospital as we responded to gang shootings, natural deaths and suicide. Participating with the multifaceted team and learning the delineation of roles was important as we secured and analyzed the scenes, photographed, conducted the physical exam, processed the evidence and completed all associated documentation. Participating in numerous scene investigations with a child death investigator, whose style of interview, skill in body language interpretation and seasoned knowledge of human behavior has been invaluable. This relationship has exposed me to investigations for SIDS, failure to thrive, pediatric homicide, and deaths deemed suspicious which result in requests by the forensic pathologists for a scene investigation. The number of deaths annually associated with firearms drove my desire to experience handling a loaded gun, understand safety mechanisms and evaluate the ease or difficulty in pulling a trigger. A visit to the firing range with a supportive colleague allowed me such experience, firing rounds from a 9 mm semiautomatic and 38-caliber revolver. As I aimed at the target of a human figure, I will not soon forget the overwhelming feeling of empowerment which was laced with sinister feelings of control that I sense may fuel much of the domestic and gang related shootings seen in the community.

Time with a forensic pathologist has taught me a tremendous amount in the area of estimating time of death, external and internal examination, identification of traumatic injury vs. artifact, antemortem injury and postmortem artifact. The value of a well-documented scene report to augment clinical findings was appreciated. As I observed numerous cases, my reverence for the fragility of life and finality of death was renewed. The autopsy of an 18-month-old boy, weighing only 1.5 pounds more at death than at birth, was very disturbing. This child was the offspring of 24-year-old parents from affluent families who had "discarded" their son almost immediately after birth. The teary eyes of hardened pathologists all consulted around the cold steel table as law enforcement and I waited anxiously for the decision as to the cause and manner of death. In this very somber environment, there was a fascination in watching the medical and legal systems traverse as starvation and homicide was ruled which promptly resulted in first degree murder charges announced in the press that same day. Another intense experience was the autopsy of a 17-year-old female who had been brutally beaten, strangled, shot and stabbed multiple times, her body dumped in a swampy are of the county. Finding she was pregnant, her uterus was removed, photographed, specimens taken and cut open. There lie a male fetus of an estimated 16 weeks gestation. At that moment, the dichotomy between innocence and evil, safety and violence, life and death was dramatic and profound for me.

These personal experiences and shared reflections have all taught and influenced me in my quest to become a competent forensic nurse and qualified death investigator. A more seasoned practitioner today, I maintain a much higher index of suspicion at all times and wear much tougher skin. Situations exist all around us, both in the hospital setting and the community at large, with forensic implications relevant to the living and the dead. Death, all too often, is the outcome of reckless human behavior or tragic unintentional circumstances. Nurses, in all professional practice segments, must be educated and astute to acts with criminal or civil forensic implications. Surround your practice with behaviors that question and do not assume, exhibit curiosity not apathy, challenge instead of yield, assert instead of submit. From my perspective, this is of paramount value in perusing truth in life and truth in death along the continuum of care for the betterment of humanity.

Catherine A. O'Brien, RN, MS, CNA, CLNC, D-ABMDI is a forensic nurse and registered medicolegal death investigator with the American Board of Medicolegal Death Investigators.

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