Active Dying After Death

An unattended death occurs when the person who died was alone and was not under direct care or medical supervision at the time of death. This can include deaths in which the causes are known or unknown, although deaths of unknown causes will generally require further investigation by a medical examiner. Due to the nature of unattended deaths, most are discovered only after a significant period of time has passed. Depending on the circumstances, the body of the person who died may be found unintentionally by friends, family, neighbors, landlords, or during a welfare check conducted by law enforcement officials. 

The circumstances surrounding unattended deaths can vary. Although unattended deaths frequently include deaths due to natural causes among those living alone, or those affected by the widespread epidemic of loneliness and isolation, other causes of death can be involved as well. For example, unattended death can include those resulting from accidents, homicides, or suicides if no one else witnessed the death. Deaths that occur in nursing homes, hospitals, or long-term care facilities are not considered to be unattended, even if the deaths weren’t witnessed, since the person who died is considered to be under the care of a physician in these settings.

When an unattended death of an unknown cause occurs, an investigation is usually conducted by law enforcement. The purpose of these investigations is to confirm the identity of the person who died, determine the cause and manner of death, and rule out any suspicions of foul play. The cause of death will be determined during an autopsy, which is conducted by a medical examiner or coroner. Not all unattended deaths require an investigation, especially if the cause of death is already evident; however, sometimes people find that having additional insight into the cause of death provides a sense of closure. 

Sources

“Okla. Admin. Code § 445:10-1-4 – Unattended death”. Cornell Law School. https://www.law.cornell.edu/regulations/oklahoma/OAC-445-10-1-4

“Sudden or unattended death investigations”. Anne Arundel County Police Department. https://public.powerdms.com/aac/documents/286 

“What is an “unattended death,” and why are they investigated?”. KRTV News. https://www.krtv.com/news/what-is-an-unattended-death-and-why-are-they-investigated 

“Attended versus Unattended Death”. American Institute of Crime Scene Integrity. https://aicsi.com/blog/attended-versus-unattended-death/ 

Being present at the death of someone you care deeply about is a profound and sometimes life-changing experience. Thus, it’s impossible to predict how any one person will react. According to Medscape’s “The Last Hours of Living,” emotional reactions of loved ones include everything from numbness to disbelief to abject despair. What’s important to remember is that any of these reactions is normal and expected and perfectly OK. 

With that being said, for many people who have witnessed the pre-active and active dying phases of someone they love, the first emotion they feel is relief. They know the person is no longer suffering and no longer hovering in the unknown space between life and death, and that is a very comforting thought. Later, relief may be followed by a period of intense sadness, often accompanied by emotions such as fear, anger, guilt and despair. Some people feel as if their loved one has abandoned them; others simply feel terribly alone. Much of this depends on your relationship with the person who died and how emotionally connected to them you are. 

Physical reactions are also not unusual following the death of someone you love. You may feel a hollowness or “pit in your stomach,” or a tightness in your chest, and your heart may race uncontrollably. You may even feel dizzy, as if you are about to faint. These are perfectly normal reactions to extreme emotional and physical stress, so try not to let them frighten you. Take slow, deep breaths to calm your nerves, and leave the area if you need to take a break. Death is not an emergency. Take some time to collect your thoughts and experience what you are feeling, gather with loved ones and process your initial grief. (Learn more in our section on grief and loss.)

Sources

“The Last Hours of Living: Practical Advice for Clinicians”. MedScape. https://www.researchgate.net/profile/Linda-Emanuel-2/publication/267839765_The_Last_Hours_of_Living_Practical_Advice_for_Clinicians_The_Last_Hours_of_Living_Practical_Advice_for_Clinicians_CMECE/links/55045eeb0cf2d60c0e66e52c/The-Last-Hours-of-Living-Practical-Advice-for-Clinicians-The-Last-Hours-of-Living-Practical-Advice-for-Clinicians-CME-CE.pdf

A death certificate is a legal document filed with the government that states the time, date, and manner of a person’s death. It is required when you make arrangements for burial or cremation, request life insurance benefits or apply for survivors’ benefits with Social Security. It is also necessary when probating a will, or settling property or estate matters of the deceased. State and federal governments also use the information in death records to track leading causes of death and to inform healthcare policy.

A death certificate may be filled out by anyone who is familiar with the person who died. However, only a healthcare professional, coroner or medical examiner can legally certify the death. The U.S. Standard Certificate of Death, which is the form used in most states, requires the following demographic data:

• Full legal name
• Date of birth
• Age
• Occupation
• Race
• Educational level achieved
• Residence address
• Military service (yes or no)
• Spouses name
• Father’s name
• Mother’s name

The form also asks for the address where the death occurred and the method of final disposition. 

These details can be filled out by the next of kin, but are usually handled by the funeral director if a funeral home is involved. In some states, even if the form is filled out by the family (as in a home funeral) a funeral director must certify that the information is accurate and complete. 

The last part of a death certificate is filled out by the healthcare professional (doctor, nurse practitioner, coroner or forensic pathologist) who certifies the death. It includes the date and time death was legally pronounced, the immediate cause of death (e.g., heart attack), the underlying cause of death (e.g., coronary artery disease) and the manner of death (e.g., natural accident, suicide, homicide or undetermined.)  If additional information surrounding the person’s death becomes known later, most states allow the certificate to be amended. 

When all information is complete, he doctor, nurse practitioner, coroner, or forensic pathologist who completes the form signs it to certify the death. The completed death certificate is then filed with the Bureau of Vital Statistics in the location where the death occurred. This may be done electronically or via a paper copy of the certificate depending on the location where the person died. 

Obtaining a certified copy of a death certificate

A family member or eligible person over the age of 18 can apply for a certified copy of the death record, or certificate. The certificate will have a raised seal of the office issuing the record. A photocopy will not be accepted for any official or legal use. It’s best to request several copies, as you may need to submit them to various entities, including the deceased person’s banking institutions, credit card companies, life insurance companies, Social Security, and more. 

Policies about who can obtain a certified copy of a death certificate, the cost of the copies and other requirements vary by state. Search the interactive database on the website of the National Center for Health Statistics to learn about specific statutes in your state. 

Sources

“How to probate a will: A step-by-step guide”. FreeWill. https://www.freewill.com/learn/how-to-probate-a-will 

“U.S. Standard Certificate of Death”. CDC: National Center for Health Statistics.  https://www.cdc.gov/nchs/data/dvs/death11-03final-acc.pdf 

“Where to Write for Vital Records”. CDC: National Center for Health Statistics. https://www.cdc.gov/nchs/w2w/index.htm

Although there is no rush to call anyone immediately after your loved one dies, you will at some point need to contact a health care provider to certify the time of death. If your loved one was in hospice, that should be your hospice provider; the hospice nurse will come to your home and certify the death. If the person was not receiving hospice care, call their attending physician and inform them that your loved one has died. If you can’t reach their physician or the physician isn’t available to come to the home, you will need to call 911. As long as you have a pre-hospital DNR order or POLST available, emergency responders will not perform CPR. Nor will they attempt resuscitation if the person is obviously deceased (for example, if the body is cold and rigor mortis has begun). In some locations, a paramedic may certify death at the scene; in others, the body will need to be taken to the Emergency Room, where a physician will pronounce the person dead. 

After the death is certified by a healthcare provider, you may call the funeral home (if you’re using one) at any time. Most funeral homes have someone available 24/7 to come to your home or the hospital to pick up the body. However, some will want the death certificate completed and signed by a qualified health care provider before transporting the body, so be sure to check with your selected provider in advance. 

Keep in mind, too, that you can notify the funeral home that your loved one has died but choose not to have their body removed right away. For example, some families opt to perform natural death care rather than leave the act of caring for their loved one’s body to a funeral home. You may also choose to have a visitation and funeral in your home, with or without the help of a home funeral guide. 

Although the days and hours leading up to a person’s death are often difficult, the moment of death is usually peaceful. The person will typically take a final breath, which may be preceded by a period of irregular respirations known as Cheyne-Stokes breathing, in which they take several fast, deep breaths and then stop breathing for a time (apnea), then repeat the cycle of rapid, deep breaths followed by no breathing. This can go on for several hours. 

After the person’s last breath, you may hear an audible sigh as air escapes from the lungs. At that time, you should feel for a pulse at the side of the neck or, if that’s not possible, in the groin. (The pulse in the wrist may be absent even if the person is still alive.) Wait a full minute. If you don’t feel any pulse, the heart has almost certainly stopped. 

When the heart stops beating, circulation stops, and the person’s skin will become very pale and cool to the touch. Their eyes may be open or closed. If they are open (or if you open them), you’ll notice that the pupils (the dark part of the eye) are quite large and “fixed,” meaning they no longer change size in response to light. If you touch the eye gently, the person will not blink. The eyes will also begin to cloud over and develop a semi-opaque film. This usually happens an hour or two after death, but can occur more quickly.

When a person dies, the muscles relax, including the sphincters in the bladder and rectum. As a result, urine and/or stool may be released from the body shortly after death. The jaw will also become very slack and the mouth may fall open, especially if the person is lying on their back.

After some time (usually 2 to 4 hours), the muscles of the eyes, neck and jaw will begin to stiffen, a condition known as rigor mortis or postmortem rigidity. This stiffness will gradually spread to the entire body, peaking about 12 hours after death. After some time (usually 24 to 48 hours after death), the muscles will relax again. 

Sources

“Rigor Mortis”. ScienceDirect. https://www.sciencedirect.com/topics/medicine-and-dentistry/rigor-mortis#

“Cheyne-Stokes breathing: Definition & how to treat”. Resmed. https://www.resmed.com/en-us/sleep-health/blog/what-is-cheyne-stokes-respiration-a-brief-cheyne-stokes-definition/