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.

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