Last responders: Deathcare workers in the age of COVID-19

By Jules Murtha
Published February 7, 2022

Key Takeaways

  • Medical examiners and other “deathcare workers” have toiled behind the scenes to provide compassionate care for COVID-positive bodies, with little recognition or acknowledgment.

  •  Government regulations discouraged autopsies on COVID-positive decedents, potentially eliminating learning opportunities about the deadly virus.

  • Forensic pathologists can better manage their emotional and physical health by implementing behavioral changes and reaching out to colleagues for support.

Throughout the COVID-19 pandemic, the heroism of healthcare workers such as physicians, first responders, and those in critical care medicine has garnered rightful widespread recognition.

Less celebrated, however, are the so-called "deathcare" workers.

Medical examiners (MEs) have shouldered the dangerous responsibility of caring for COVID-positive decedents while navigating substantial death counts and enduring their own mental health challenges—all without the applause.

The ME’s role in COVID-19

Simply put, MEs are licensed physicians who investigate the nature of an individual’s death. Postmortem examinations provide epidemiological insights regarding a person’s cause of death, which could yield important discoveries when performed on COVID-positive bodies.[]

But government regulations have discouraged autopsies on the bodies of COVID-positive individuals, according to an article published by Forensic Science, Medicine and Pathology.[] Understandably, the US government aims to reduce risk of transmission by limiting contact with decedents who had confirmed or suspected cases of COVID.

MEs who feel it necessary to perform a postmortem examination on a COVID-positive decedent—the findings of which could shed light on early warning signals—must reconcile several risk factors.

First, dissection of a COVID-positive body entails risk of transmission through air particles and on surfaces. To reduce the odds of contracting COVID, medical examiners wearing PPE must perform autopsies in rooms with airborne isolation precautions in place. The rooms must have negative pressure, and the air must be changed between six to 12 times per hour.

Despite these obstacles, medical examiners can provide information that could be the key to disease management and prevention.

Dealing with crushing caseloads

At times, the sheer number of bodies accounted for by MEs was overwhelming. An article published by the American Journal of Clinical Pathology details a difficult scene: Hospitals at capacity were forced to place bodies in warehouses and trucks.[] The makeshift morgues weren’t private or secured, and often lacked proper cooling mechanisms.

In Michigan, the MEs caseloads grew by 50% from April 2019 to April 2020. From April 1 to April 27, 2020, Washtenaw County alone saw a 200% increase compared with average seasonal case numbers of previous years. Still, autopsy personnel treated bodies with respect and dignity throughout examinations.

Their compassion extended to decedents' families, too.

When guidelines suspended in-person funerals, pathologists quickly took to providing artful photos of decedents’ hands to their loved ones to aid in the grieving process. Images of fingerprints and tattoos and impressions of handprints and footprints were available to family members who couldn’t host a service. The authors of the AJCP article mention the importance of such actions.

"It is hard to measure the impact of this simple measure. One grieving father replying to an email sent in response to his request for photographs said, ‘having these helps me considerably.’"

Myers, et al.

Another challenge faced by forensic pathologists was how to determine whether a patient died of COVID or with COVID, according to the Association of American Medical Colleges. Because COVID generally initiates a cascade of symptoms that could kill, it’s difficult to pinpoint exactly what qualifies as a COVID death.[]

To clarify, the CDC requires deaths be documented as COVID-related if COVID was listed in parts I (immediate cause of death) or II (conditions leading to immediate cause) of death certificates. This documentation is typically completed by a ME or another doctor.

Emotional impact on deathcare workers

Forensic pathologists may suffer from severe stress associated with COVID. A behavioral health guide published by the National Association of Medical Examiners notes that novel stressors linked to the pandemic could have a “pronounced effect” on deathcare workers. Such conditions call for behavioral intervention.[]

According to the guide, forensic pathologists can lessen the negative impacts of the pandemic by depersonalizing their work. Limited exposure to a decedent’s hands, face, and personal effects is crucial to mitigating emotional identification. Doing so lessens compassion fatigue among deathcare workers in the long-term.

Examiners are also encouraged to reach out to colleagues who have military or other mass casualty experience for personal tips on reducing emotional identification with patients.

In terms of personal safety, examiners can communicate with leadership regarding safety concerns. COVID-positive bodies must be handled accordingly—implementing COVID infection control procedures can lower risk of contracting the disease, as well as alleviate stress and anxiety.

Mood swings, feelings of emptiness, and alcohol and drug abuse are just a few identifiers of stress in death service workers. When these symptoms surface, forensic pathologists can cope individually by journaling, making healthy choices, and pursuing behavioral health services via telehealth.

Stress symptoms can also be addressed by forging meaningful connections with trusted colleagues. Deathcare professionals can offer each other solidarity and support.

Healthcare leaders have the ability to mitigate stress among medical examiners, too. Physicians can voice their evolving needs to leadership, who can facilitate peer support networks and provide information on behavioral health resources.

What this means for you

Between the physical and emotional risks associated with caring for a plethora of bodies, deathcare workers have faced immense strain throughout the pandemic. Strict regulations regarding autopsies only compound difficulties for forensic pathologists. To combat the stress and potential burnout due to COVID, MEs can reduce emotional identification with bodies, as well as seek support from leadership and colleagues.

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