4.5 Postmortem Care

End-of-life care begins long before the moment of death. The CNA's role is to provide dignified comfort, support the family, and after death prepare the body in a way that honors the resident and the family's beliefs. NC CNAs are expected to recognize the signs of approaching death, deliver comfort measures, and follow facility postmortem procedure.

The Five Stages of Grief (Kübler-Ross)

Elisabeth Kübler-Ross's 1969 model — still the most-tested grief framework on the NNAAP — describes five emotional stages that dying residents and their families may move through. Stages can occur in any order, be skipped, or be revisited.

CNA response: listen, do not argue, do not falsely reassure ("You'll be fine"). Use therapeutic communication (open questions, silence, reflection) — see Chapter 3.

Signs of Approaching Death

In the hours to days before death, the CNA may observe:

• Cheyne-Stokes respirations — alternating periods of rapid, deep breathing and apnea (no breathing), repeating in a cycle.
• Mottled, bluish, or pale skin (mottling) — especially on knees, feet, and hands, as circulation shifts to vital organs.
• Cool extremities, particularly fingers and toes.
• Decreased urine output, often dark and concentrated.
• Decreasing level of consciousness (LOC) — drowsiness, difficulty rousing, eventually unresponsiveness.
• Loss of swallow reflex — choking on small sips; the nurse may advise stopping oral fluids.
• "Death rattle" — gurgling breath sounds from secretions pooling in the throat.
• Loss of bowel/bladder control.
• Restlessness or "terminal agitation," sometimes followed by stillness.
• Fixed, dilated pupils and absence of pulse/respirations at death.

Hearing is often the last sense to fade — speak gently to the resident, explain every action, and assume the resident can still hear even when unresponsive.

Comfort Priorities (Before Death)

Postmortem Care Procedure

After the licensed nurse pronounces death (in NC, only an RN, NP, PA, or physician can pronounce; CNAs never pronounce), proceed when the nurse and family are ready.

1. Verify family's wishes and religious/cultural practices before touching the body. Some traditions require that the body not be touched by non-family or non-clergy. (See cultural notes below.)
2. Apply gloves and any PPE indicated (isolation precautions remain in effect after death).
3. Lower the bed to a working height; raise the side rail on the far side.
4. Position the body supine with the head of bed elevated about 30° to prevent facial discoloration and fluid pooling.
5. Close the eyes by applying light pressure to the closed lids for about 30 seconds — do not tape.
6. Insert dentures while the jaw is still pliable (within an hour). If they will not fit, place them in a labeled denture cup that goes with the body.
7. Close the mouth by placing a small rolled towel under the chin if needed.
8. Remove tubes, catheters, and IVs only as directed by the nurse. In suspected coroner cases (sudden, unexpected, or traumatic deaths), leave all lines and tubes in place — the coroner needs them.
9. Bathe the body gently, comb the hair, place clean linens, and dress in a clean gown.
10. Remove soiled linens and personal trash; tidy the room so the family can return for goodbyes.
11. Place identification tags per facility policy — most facilities use two tags: one on the big toe and one on the wrist or shroud. The funeral home/coroner uses these to prevent misidentification.
12. Wrap the body in a shroud when the funeral home is ready for transport.
13. Inventory and gather personal belongings; release them to the family with a signed inventory list.
14. Document the time of death (per nurse), care provided, items released, and the time the body left the facility.

What CNAs Do Not Do at Postmortem

• Do not pronounce death.
• Do not remove lines or tubes in suspected coroner cases.
• Do not discuss cause of death with family — refer to the nurse or physician.
• Do not photograph or share information on social media (HIPAA continues after death).

Cultural and Religious Considerations

Religious and cultural practices around death vary widely and must be honored.

Always ask the family: "Is there anything we can do, or anything we should not do, that would honor your loved one's beliefs?" This single question prevents most cultural mistakes.

Grief Support for the CNA

Long-term care CNAs form deep bonds with residents; their grief is real. Use the facility's Employee Assistance Program (EAP), attend memorial services if offered, and talk with peers and supervisors. Self-care is not optional — burnout harms the next resident.