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Care of the dying

04-05-2020, 07:00 PM
There is never a stage when nothing can be done to help a patient. One may be quite unable to prevent him from dying, but there remains the task of ensuring that he is preserved from suffering and pain, that he has people around him to care for him, and that his dignity as a human being is preserved and respected. If the patient is obviously dying, make sure that he remains tranquil in mind and body during the period of dying. Comfort, companionship, compassion, and the complete relief both of mental and physical suffering, should be the aims.
Signs of death
Never consider anyone to be dead until you and others agree that the following signs are present.

The heart has stopped. No pulse will be felt and no heart sounds will be heard. Put your ear on the left side of the chest near the nipple and listen carefully. If you are not sure what to listen for, listen to the left side of the chest of a live person first. To test that the circulation has stopped, tie a piece of string tightly round a finger. In life the finger becomes bluish, but in death it remains white. Slight pressure on the finger-nail or lip in life will cause the area to become pale, and when the pressure is released the colour is regained. In death, this will not occur.

Breathing has stopped. Listen with your ear right over the nose and mouth. You should feel no air coming out and should see no chest and abdominal movement. A mirror held in front of the nose and mouth will be clouded by the moisture in the outgoing breath in life, but no clouding will occur in death.

The person, looks dead. The eyes become dull and the skin pale. The pupils are large. Shining a bright light into the eye does not make the pupil smaller.

These are the immediate signs of death. Later signs are as follows:

Rigor mortis. This is a stiffness of the body that usually comes on about 3-4 hours after death. The timing will depend to some extent on the ambient temperature. The stiffness lasts for 2-3 days. It is most easily felt in places like the jaw, the elbow, and the knee.

Post-mortem lividity or staining. Blood in a dead body will tend to gravitate. So, if the body was left lying on its back after death, there will be reddish or purplish patches resembling bruises over the back and over the back of the limbs that were downwards. This is called "post-mortem lividity or staining". It is possible to deduce from this, staining what position the body was in after death.

The cornea goes milky. The cornea is the clear window at the front of the eye! It goes milky about 15 hours after death.

Decomposition. Changes due to decomposition can be seen 2-3 days after death and will usually appear first in the abdomen where a greenish colour may be observed. This is a certain sign of death.

While none of the signs described above is infallible in itself, there is usually little difficulty in coming to a decision when they are taken together.

Mistaken death: a warning
A person who has taken large doses of certain drugs, usually sedatives or tranquilizers, or who is suffering from hypothermia, may look dead, but may be alive. Mistakes have been made in this respect. Check carefully for shallow breathing, for a pulse, for heart sounds, and so on, as described above. If you ale aware of the possibilities for error, you are less likely to make a mistake. All the circumstances surrounding the death may help you decide whether drug overdose and hypothermia are possibilities.
Cause of death
It is important to try to establish the reasons for death. Causes of death can be ascribed to two main groups:

- natural causes such as illnesses;
- injuries, which may be accidental or non-accidental.

If the person has been ill on board, records of the nature and progress of the illness and of the treatment given will have been made. These records should be carefully preserved in case any further inquiries are necessary. Similarly, in the case of injuries, the circumstances of the incident that led to the injury or injuries should be investigated and recorded. The record of the investigations, together with the medical records, should be carefully preserved. It must always be remembered that medico-legal inquiries may subsequently be necessary even when there are, at the time, no apparent criminal or suspicious circumstances surrounding a death. If the circumstances of death are unusual, sudden, or unknown, or if there is any suspicion of criminal intent, there should if possible be a post-mortem examination by a pathologist.

Identification of a dead body*
*These observations relate mainly to the identification a dead body recovered from the sea or the body of a passenger. Usually, there will be no difficulty in identifying the body of a crew-member known to many people on board.
If the ship is near port it may be possible to put the body in a bath with plenty of ice all round- -remember to put some ice in the bath first. It might even be possible, if the ship is not near port, to keep the body in a refrigerator or cold-store set aside for the purpose and to arrange for its examination by a pathologist. If, however, the body cannot be kept and burial at sea necessary, it is essential to examine the body thoroughly and to note down every observation that can possibly assist in subsequent identification. This is a task that must be undertaken by at least two people.
Strip the body of all clothing. Clothing should be removed without tearing or cutting. List each item briefly, and note any initials or names on the garments. Any papers, wallet, money, etc. should be included in the list. Any articles that are wet should be dried and should then be put into a plastic bag, sealed, labeled, and kept in a safe place for handing over to the police or to other authorities at the next port. Clothing must be dried and afterwards suitably wrapped and labeled for handing over. When handing over clothing and other articles, check each item against the list and get a receipt from the person to whom they are delivered.
Examination of the body
Examine the body carefully and record the following data:

- race;
- skin colour;
- approximate age;
- height.

To measure height, straighten out the body with the legs fully extended. Make two marks on the deck, one in line with the heels, the other in line with the top of the head. Measure and record the distance between the lines.

Next note the development of the body (whether fat, thin, wasted, muscular, etc.).

Inspect the head and face: record the length and colour of the hair; note the eyebrows, and describe any facial hair. The complexion should be described (for example: sunburnt, pale, florid, saIlow). Record the colour of the eyes and the shape of the nose. Open the mouth and examine the teeth, noting whether they are sound, decayed, or missing. Dentures should be removed, cleaned, and placed with the other articles kept for future examination.

Inspect the rest of the body: record all birthmarks, moles, scars, or deformities from injuries. Note the exact position of all scars and describe their length and width. A diagram may help. Note whether circumcised or not. Vaccination scars should be noted. Tattoos should be described, and any words or letters noted. Record the size, position, general appearance, and colour of such tattoos. Wounds and bruises should be noted; try to decide whether they could explain the death. Note the exact position, depth, and dimensions of all wounds. Describe the character of the wounds: clean cuts as from a knife, or ragged tears, or bullet-wounds. Note any skin blackening or singeing of clothing around the entrance bullet-wound. Look for the exit wound showing where the bullet left the body (this is always bigger than the entry wound). Feel under the skin for a bullet that may be lodged there and, if there is one, note the position. Look carefully for signs of bruising round wounds or if there has been any escape of blood from wounds, as shown by blood clots, blood-staining of the surrounding skin, blood on the clothing, or blood in the area where the body was found. This will help to distinguish injuries caused during life (which bleed) from those caused after death (which do not bleed). Note also any broken bones. External signs of disease such as boils, ulcers, varicose veins, or skin rashes, should be recorded.

Use of a camera
If the circumstances of death are other than straightforward, photograph the body where it was found and from several angles. When the body is moved, take more pictures of the scene to show any blood on the deck or other evidence. Take general pictures of the unclothed body and special views of any wounds, scars, and injuries. Try to record all observations you think may be of help in identification or of interest with regard to the cause of death. Note why you took each picture and what you intend it to show. Remember to have all your observational notes countersigned, and to make all appropriate entries in the official log book.
The time of death
A note of the time of examination and a record of any of the following phenomena may help in later estimation of the time of death.

Feel the surface of the body. Is the body warmer under the clothing than in exposed areas? Temperature is best felt using the back of the fingers and hand. If possible, take the temperature of the body with an ordinary (not a clinical) thermometer 5 cm inside the rectum.

Look for putrefaction. The earliest change is green or greyish discoloration over the lower part of the abdomen. This discoloration spreads to the rest of the abdomen, to the trunk, up the neck to the head, and into the limbs. Note the extent of discoloration. Late signs of putrefaction show as swelling due to gas in the tissues. The appearance is bloated, and the abdomen is swollen. The skin becomes moist and peels. Bags of reddish or greenish fluid may form on the surface. The odour is very offensive. The pressure of gas may force froth or fluid out of the nose, mouth, and anus. The tongue may protrude. When putrefaction has advanced to this extent, some of the data required for identification cannot be obtained. The features will be much altered by swelling and discoloration, the eyeballs will be bulging or collapsed, and the hair, teeth, and nails will be loose or easily detached.

Disposal of the body

Retention for burial ashore or post-mortem examination
Wherever possible, a body should be retained for post-mortem examination or for burial ashore. For the sake of the deceased person's relatives and to preserve the body in the best possible condition, thoroughly wash and dry the body all over. Comb out and part the hair, and give attention to the fingernails. Straighten the arms and legs, and interlock the fingers over the thighs. Tie the ankles together to keep the feet perpendicular. With forceps, place a good plug of cotton wool well up in the rectum. Pass a catheter tube into the bladder and empty it completely; if this is impracticable, make a firm tie around the root of the penis. A plug of cotton wool may be passed into each nostril. The body should then be put in a body bag; and kept in a refrigerator or cold store set aside for the purpose. Packing in ice in a bath is an alternative near port.
Burial at sea
If there is no suspicion of foul play, if for a reason it is not possible to retain the body, or if so requested by next-of-kin, the body may buried at sea. In this case, it is not necessary do more than to lay the body on a flat surface, straighten the legs and arms, and interlock the fingers over the thighs. The hair should be brushed off the forehead, the face washed, and the jaw secured by passing a bandage under the chin and over the top of the head, where it may be tied or clipped.

For burial at sea, the body has traditionally been sewn into a length of canvas of standard width and about 4.5 metres in length, weighted by fire bars sewn to the canvas on either side of the legs below the knees. It is probable that these items may not be available on a modern ship. In seeking substitutes, bear in mind that the shroud needs to be made of a very strong material and the weights sufficiently heavy to ensure rapid sinking and permanent submersion of the body. There should be three or four slits or openings in the material to allow the gases of decomposition to escape and prevent flotation due to trapped air. Burial should not take place in soundings any part of the world.

After preparation, the body should be placed upon an improvised platform resting on the ship's side-rail and a suitable trestle or other support, covered by a ship's flag, secured to the inboard edge of the platform. Wooden blocks screwed under the platform and resting against the ship's side-rail will prevent the platform slidding outboard when the inboard end is raised to allow the body to slide from under the flag into the sea. It is very important to ensure that the whole operation proceeds smoothly and respectfully without unseemly mishaps. If the ship is small and there is a heavy sea, precautions must be taken to ensure that the body will not prematurely lost and will not fail to drop cleanly into the sea at the right moment. This may warrant fastening guide-rails on the platform. The seamen allocated to perform the disposal must be carefully briefed. On receipt of a discreet signal, they must raise the inboard end of the platform to allow the body to slide from under the flag into the sea.

When the family is notified that the remains were committed to the deep, the Ship's Master should indicate the longitude and latitude where this took place. Also, the master should find out if the next-of-kin wants the flag sent to the family with the personal effects of the deceased.

Religious Rites
Here follows two short forms of service approved by the Church of England and the Roman Catholic Churches respectively for the Burial of the Dead at Sea.
A short form of Protestant service
MASTER: Let us pray.

We brought nothing into this world, and it is certain we can carry nothing out. The Lord gave, and the Lord hath taken away; blessed be the Name of the Lord.

The Lord is my shepherd; therefore can I lack nothing, He shall feed me in a green pasture, and lead me forth besides the waters of comfort.

He shall convert my soul; and bring me forth in the paths of righteousness, for His Name's sake.

Yes, though I walk through the valley of the shadow of death, I will fear no evil; for thou art with me; thy rod and thy staff comfort me.

Thou shalt prepare a table before me against them that trouble me; thou hast anointed my head with oil, and my cup shall be full. But thy loving kindness and mercy shall follow me all the days of my life; and I will dwell in the house of the Lord for ever.

MASTER: For as much as it hath pleased Almighty God to take unto himself the soul of our dear brother/sister here departed, we therefore commit his/her body (ashes) to the deep in sure and certain hopes of the Resurrection to eternal life, through our Lord Jesus Christ.

(The body is then lowered into the sea, or the ashes are scattered)

I heard a voice from heaven saying unto me: from henceforth blessed are the dead which die in the Lord; even so saith the Spirit; for they rest from their labours .

Let us pray.

Most merciful father we beseech thee of thine infinite goodness to give us grace to live in thy fear and love and to die in thy favour, that when the judgement shall come we may be found acceptable in thy sight through the love of thy Son, our Saviour, Jesus Christ. Amen.

PRESENT: Our Father which art in heaven, Hallowed by Thy name, Thy Kingdom come, Thy will be done on earth as it is in heaven, give us this day our daily bread. And forgive us our trespasses, as we forgive them that trespass against us. And lead us not into temptation; but deliver us from evil. Amen.

MASTER: The grace of our Lord, Jesus Christ, and the love of God, and the fellowship of the Holy Ghost, be with us all evermore. Amen.

A short form of Roman Catholic Service from the Catholic Seafarers Prayer Book 1977
MASTER: Let us pray.

It is our solemn duty to commit to the sea this mortal body (these ashes). As we do so, we call trustfully upon God from whom all creation has life. May He in due time, by His power, bring to resurrection with all the saints, the body of this our brother /sister, may God unite his/her soul with those of all the saints and faithful departed, may he/she be given a merciful judgment, so that redeemed from death, freed from punishment, reconciled to the Father, carried in the arms of the Good Shephered, he/she may deserve to enter fully into everlasting happiness in the company of the eternal King together with all the saints.

(There follows a short period of silent prayer)


From the depths I call to you Lord, Lord listen to my cry for help!
Listen compassionately to my pleading!

If you never overlooked our sins Lord,
Lord, could anyone survive?
But you do forgive us;
And for that we revere you;

I wait for the Lord, my soul waits for him,
I rely on his promise, my soul relies on the Lord
more than a watchman on the coming of dawn.

Let Israel rely on the Lord,
as much as the watchman on the dawn!
For it is with the Lord that mercy is to be found,
and a generous redemption;

It is he who redeems Israel from all their sins.

(The body is then lowered into the sea, or the ashes scattered)

It has pleased Almighty God to call our brother/sister from this life to himself. Accordingly we commit his/her body (ashes) to the sea. Since Christ, the first fruits of the dead, had risen again and will refashion our frail body in the pattern of His glorious risen body, we commend our brother/sister to the Lord. May he embrace him/her in his peace and bring his/her body to life again on the last day.

May his/her soul and the souls of all the faithful departed rest in peace. Amen

PRESENT: The Our Father

Our Father, who art in heaven Hallowed by thy name.
Thy Kingdom come, Thy will be done on earth as it is in heaven.
Give us this day our daily bread, And forgive us our trespasses, As we forgive them who trespass against us,
And lead us not into temptation
But deliver us from evil. Amen.

MASTER: Grant, O God, that while we lament the departure of this Your servant, we may always remember that we are most certainly to follow him/her. Help us to prepare for that last hour by a good life that we may not be surprised by a sudden and unprovided death, but be ever watching that when you call we may enter into eternal glory. Through Christ our Lord. Amen.

In ships which are manned by foreign crews there may be some objection to the use of Christian rites. In such cases, the senior members of their community on board should be consulted and their wishes complied with.

Note: Burials at sea are very uncommon nowadays because of the need for a coroner's report, and the majority of corpses are flown home for burial.
Scattering ashes at sea
If ashes are consigned to the ship to be scattered at sea the wishes of the consignors should be complied with as reverently as possible. The Commital service has already been performed by the appropriate religious body and does not need to be repeated. However, if it is generally felt that there should be some acknowledgement of the solemnity of the occasion and in the absence of other instructions there is no objection to the use of the burial services.

It is sometimes overlooked that on ships with high superstructure there is a considerable turbulence caused by the wind and a proportion of the ashes might well, under certain conditions, carried back on board. This must be guarded against. If the casket or urn is also to be disposed of it should be placed in a weighted and perforated bag before being consigned to the sea.
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