Erika Nelson, M.S.W., is a mortuary science licensee in Ann Arbor, Michigan, who is also a home funeral consultant. When Holly Stevens, director of the manual project, queried a listserv for home funeral advocates about conditions that make long vigils at home impractical without embalming, she responded at length.
With Nelson’s permission, we are including the information here, because we believe it will be useful to home funeral committees as they begin to encounter a variety of challenges in their work.
Warning: her post contains graphic information about body care that may not be of interest to everyone who visits this website. Please do not continue if you are not interested in this subject matter.
--The Home Funeral Committee Manual Publishing Group
It is true that many bodies have the potential to leak fluids; however, if you use protective garments, as you would on an incontinent person, the clothing/bedding will be protected. My experience with things like small cuts or tears in the skin and IV needle holes, etc, is that you can simply bandage them tightly, as you would to prevent bleeding on a living person. Use medical tape and cotton squares on effusive wounds. As far as things like bedsores, my experience as a home health aid for a hospice taught me about DuoDerm bandages, which I believe would be sufficient to seal a decubitus ulcer. DuoDerm bandages are very expensive, but they are something that places like Rite Aid or Walgreens carries, so when a local Rite Aid closed to move to another location and was getting rid of old inventory, I picked up a whole bunch of DuoDerm patches at 90% off. Some are 12" x 12"—large enough to cover and seal in even the most gruesome bedsore. They are also things that families may have left over when a hospice patient dies. Hopefully, the body with the bedsore was having it treated by a nurse, who would have access to the left over Duoderm pads.
Obesity can cause complications for an at home funeral. Not only would the extra weight make moving or turning the body that much more difficult, but dry ice may not be as effective at cooling the internal organs. People tend to hold their fat deposits on the front of the body, so dry ice underneath should work, but it depends on the size of the person. With a very, very obese person, it should go without saying that proper cleansing of all of the skin surfaces, in all of the skin folds, is important.
Since pre-existing fungal infections and small tears in the loose skin folds could be a problem, something like a medicated anti-fungal powder, cream or spray, like for athlete's foot, might be helpful to prevent odor or additional break down or cracking of the area. When moving the body, extra care must be taken not to put too much stress on any one area of skin, as tearing could be an issue—use one of those quilted bed pads or a sheet (or a couple of sheets to increase strength) to move or turn the body, rather than the relatively small pressure points of using hands on the body directly (think snowshoe rather than high heeled shoe).
As far as edema is concerned, if you see that fluid is building under the skin in blisters, you can drain the blisters simply by lancing them and soaking up the fluids. Wrapping the area (usually lower legs or arms) with an absorbent material for some time and then replacing the covering and using a wrapping of Saran wrap or other plastic covering to prevent wicking of the fluids onto the clothing should be sufficient. Again, with proper cooling, the area should not decompose all that much more rapidly than any other area. Changing the absorbent material every few hours as needed would also help.
This is going to sound strange, but when I was looking over the 90% off stuff at that Rite Aid, I stumbled across a manual breast pump, with its wide aspiration surface and thought "this would be great for suctioning edema blisters or other wound effluent off of skin." So, let necessity be the mother of invention.
Tissue gas is commonly known as gangrene. The symptoms are blackening of the skin, strong odor and distention of the skin as gases created by the bacteria swell under the skin. The skin "crackles" a bit like tissue paper when you touch it because the gas underneath is moved around by your touch. There is no way to prevent the spread of the bacteria when it gets started, other than blocking it with the injection of embalming chemicals; therefore, if the darkening of the skin or the swelling of the skin start to become apparent, it is important to begin plans to move directly to the disposition. This infection spreads very quickly, with unpleasant effects becoming obvious within two to six hours.
Tissue gas is a concern, especially, if there is a perforation in the bowel. The ironic thing is that most cases of tissue gas are actually caused by perforating the bowel with the trocar during embalming and then spreading the infecting organism, C. Perfringens, with the dirty trocar into areas that are not followed with adequate chemical infusion. Anyway, C. Perfringens comes from the bowel (we all have it inside us at any given time) or from soil or other surfaces in the environment. Cases where the body experienced an injury on the ground, like "road rash," are especially likely to have infections of such bacteria. The scraped skin should be properly disinfected and dressed, as if the person were alive, in order to prevent those bacteria from causing problems.
JerriGrace Lyons told me about having an experience with this infection—she just explained to the family what was going on and that she recommended skipping the vigil period to proceed. They understood.
Some skin infections, like MRSA or other staph infections, could be infectious and would need to be properly disinfected. Disinfectants, like hydrogen peroxide or iodine can also be used and should be allowed to work on the site for at least a few minutes, so a compress or basin should be used to keep the disinfectant on the site until the bacteria is surely destroyed. Afterward, the area should be tightly bandaged and dressed. Obviously, disposable gloves and gowns should be used to protect the caregiver from exposure or transmission to others.
The CDC put out this information about disinfection in cases in of MRSA: http://www.cdc.gov/ncidod/dhqp/ar_mrsa_Enviro_Manage.html#8
As far as HIV goes, you can only contract HIV through exchange of body fluids, just as when the person was alive. If the bathing is done with gloves, a gown and some common sense, then after any leaking is sealed with protective bandages and garments, the risk is no longer an issue. Obviously, the caregiver should use extreme caution if he or she has any cuts or wounds and should ask someone else to care for the body if the cut or wound is not protected by an impervious dressing, glove or the like.
See: CDC Recommendations for Prevention of Transmission of HIV in Health_Care Settings
I don't understand what makes some funeral providers think that blood borne pathogens suddenly become airborne after death. With airborne illnesses like the flu or TB, it is important to place a cloth or surgical mask over the mouth and nose of the body while turning or compressing the chest of the body at all. This will express the air in the lungs, which will be caught in the cloth or mask, rather than being breathed in by others. The danger is that disease will be included in droplets of moisture expressed with the air and inhaled by others. Dispose of the cloth or mask when all of the air has been expressed.
The family should be especially careful about this, even if there was no diagnosed TB or flu, if the person was coughing, sneezing, hacking, wheezing, etc in life. They probably would have been exposed to any illnesses already, just through the caregiving relationship, but if the caregivers in death are different than the caregivers in life, then the protective measures make sense. Also, the room should be kept as ventilated as possible—open windows and doors, and turn on fans to reduce the concentration of droplets in the air to be inhaled. The concentration of droplets is what makes transmission likely, not simply the presence of diseased droplets, so spreading the air out doesn't spread the disease further, it decreases the likelihood that anyone will inhale a high enough concentration of droplets to get sick. See CDC Guidelines for the Prevention of Transmission of Tuberculosis in Health-Care Settings.
In talking with Char Barret, a funeral director and home funeral guide in Seattle, I heard the story of a woman who had a skin infection and horrible odor as the result of a large tumor that had broken through her skin when she died. The caregivers were very concerned about the odor and didn't know if a home wake would be possible. Char literally froze the area by creating a dry ice compress, which eliminated the odor. The area was simply kept frozen for the duration of the wake and the odor was not an issue. The offensive bacteria were frozen, so they were not able to create to odorous gases.
That being said, a whole body infection, like septicemia, could be a real problem. I've embalmed bodies with septicemia, a virulent blood infection, and I can tell you that I would have concerns about the odor and the rate of decomposition. If you have ever had or cared for person with a bad urinary tract infection and smelled that infection odor from the urine, you know what the entire body smells like with an advanced septicemia patient. The blood looks like diarrhea, yellow-brown, and the odor is horrible. Other than a massive trauma or burn case, or tissue gas, septicemia is probably the least appropriate case for wakes at home, in my opinion.
As far as chemotherapy or medications causing rapid decomposition, I honestly don't know. All we ever learned about that in school is that the chemicals could lessen the effects of the formaldehyde, so use more formaldehyde. I would think that the dry ice would be effective in delaying the decomposition either way; after all, bacteria cause decomposition, right, so shouldn't the chemotherapy chemicals deter the bacteria? I don't know.
I think that probably the one thing that people might forget about which could make a real difference as far as odor is the cleansing of the mouth. I suspect that swabbing the mouth with antiseptic mouth wash, especially after any purging of fluids, and making sure that the teeth and tongue are thoroughly cleaned would make a big difference with odor. A baby aspirator can be used to suction fluids from the nose or mouth.
I'm sure you know some of this, but one of the interesting tips that JerriGrace taught me was about taking the cotton from a Q-tip, rolling into a very thin twist and placing it under the eyelid, to provide a little bit of grip or resistance for the eyelid and eyeball, acting like a gentle version of an eyecap. Genius!
Also, her partner, Mark, mentioned that he had used a small piece of dry ice to help "set" the jaw muscle of a mouth that didn't want to close. He cooled the muscle enough that it stayed in place and he says that it stayed that way even after it must have warmed back up to room temperature.
For wound closure in the funeral home, we use a drying powder in the wound/cut before sewing and rubber cement to seal stitching in the skin. I realize that unembalmed bodies would leak more when gravity is bringing fluids out of the underside of the body, but for the top surface of the body, where gravity is actually working for us, and wicking into clothing is the issue, I would imagine that cornstarch and a seal of rubber cement might help.
I understand what some funeral service folks say about being suspicious of home funeral guides without much training trying to take on funeral service. There are unexpected situations that arise. To me, it comes down to two things: expectation and payment. I think that things get blown out of proportion for funeral directors because the public expects a perfect service—they are professionals after all. With home funeral guides, the expectation is that things will be more casual, with more room for flexibility for both blunders and serendipity.
I get nervous about someone making a living off of payment as a funeral service provider without earning the licensing that funeral directors earn simply because there is nothing to lose if the person is incompetent—they don't have a license on the line that can be taken away due to malpractice. The people that I have met so far in this realm are not anyone that I am concerned about, but if it ever becomes a profitable business to get into, who knows who will try to make a living at it? What kinds of consumer protection are available when the service provider is unregulated? Market forces, I suppose. If they burn people, no one will call on them.
As far as formaldehyde and embalming go, I just hope that some people decide to become more informed about why embalming is used, what it actually involves, and what the alternatives are. I don't think that most people realize that a dead body can actually be beautiful without being "restored" to a life like appearance, just as a newborn baby is beautiful even before that pink or blue cap is placed on its little head.
Erika Nelson, M.S.W., Ann Arbor, Mich.