The purpose of this review is to assist the broad range of health care, first responders, legal, and funerary professionals who may be involved in the management of human remainsFootnote † after traumatic death. This information is presented as events and processes that can occur in the socio-cultural context of largely Western and high-income societies. Traumatic death can include those resulting from road accidents, disaster, terrorism, war, civil disorders, homicide, and suicide. As part of their professional role, many personnel have responsibilities that require them to interact with and help the families of the deceased manage a range of potentially challenging situations. These can include death notification, identification of the deceased, autopsy, decisions about viewing the body, and additional support of family members’ loss-related responses, such as grieving, mourning, and remembering. These events and processes are likely to have an emotional impact on survivors. There are also the obligations of society to care for the remains of the deceased and to attend to the family of the deceased. These include the care of the remains by the responsible authorities and respecting the cultural practices of families. However, these social obligations include a broad range of responsibilities that some professionals seldom understand and may have little experience with. This review describes this range of responsibilities and the challenges that professionals are likely to face in conducting such activities. It also highlights areas that require careful attention as described in the relevant literature and as experienced by the authors.
Methods
A systematic literature review was conducted to identify existing scientific research about the impact of circumstances pertaining to the notification of traumatic death, the viewing of the body, and the outcomes of viewing or not viewing on survivors and professionals. References were obtained through searches of PubMed, Power Search, and Google Scholar, and from references cited in the collected literature. Search terms applied singly and in combination were: death, human remains, bodies, viewing, notification, trauma, disasters, terrorism, forensics, identification, autopsy, children, unexpected, violent, and premature death, emergency department, grief, and bereavement.
Articles were included that reported the process and outcome of notification of traumatic, violent, unexpected, or sudden death, methods of forensic identification, the viewing or not viewing of the body including alternatives to viewing and the relationship of viewing or not viewing to grief, bereavement, and funerals and memorials. All selected articles were in English. Articles were excluded if they were not specifically related to our search criteria or if they duplicated information from more comprehensively written and better-resourced articles.
A total of 1067 articles were identified in our search of the literature databases. A total of 984 were removed from further examination as they were not related to the topics of interest. The 83 remaining articles were evaluated using the inclusion and exclusion criteria. A total of 50 articles were removed because they did not specifically meet the inclusion and exclusion criteria or because the information was duplicated in another article. When an article contained duplicate information, the latest publication was selected. The final manuscript included 33 peer-reviewed articles (1987-2022) (Table 1). The article selection process is presented in Figure 1, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart (PRISMA).
Table 1. Matrix of included studies
Figure 1 PRISMA article selection flowchart.
Using these 33 publications, the authors categorized areas of particular interest to professionals, including death notification, assisting families with decisions about viewing the body and barriers to viewing, actions that survivors can take when remains are not recoverable, forensic challenges in the identification of remains, effects of the COVID-19 pandemic on families’ ability to have access to the remains of their family member, cultural and religious practices concerning the care of remains, and suggestions for research.
Results
Death Notifications
Notification of in-hospital death
If a death occurs in a hospital, notification of the family is usually an obligation of the hospital.Reference Ombres, Montemorano and Becker1 Hospitals may or may not have a protocol for notification procedures and staff may not be adequately trained. When there is a protocol and staff have practiced and used it, the notifier’s performance in the process will typically go more smoothly, although survivors’ reactions may differ.
Provider and staff actions for in-hospital death notification
Clinical practice guidelines are necessary for notification in a hospital following sudden and unexpected death including responding to the emotional and practical needs of the bereaved.Reference Whelan and Gent2 In addition to the skill and sensitivity of the notifier, the notification process requires the support of the staff including doctors and nurses, social workers, religious support providers, and the availability of a private space, which may be used by survivors to process the information, reflect on their situation and meditate or pray.Reference Collins3, Reference Roe4 In addition to providing information during the notification, non-verbal actions of the notifier can affect the survivors’ experience of events. These actions may include the notifier’s attitude and behavior such as posture, gestures, and facial expressions.Reference Klein and Alexander5
Helpful and unhelpful actions by death notifiers
Helpful and unhelpful nursing actions by an emergency department (ED) in Hong Kong were described based upon interviews of family members conducted 50 days to 10 months after the death of their family member.Reference Li, Chan and Lee6 Actions perceived as helpful were receiving written information about what to do following the death, being given the opportunity to view the body in the ED, and respecting individual customs and religious practices. Actions perceived as least helpful were discouraging viewing the body, offering sedation, and providing comfort measures such as a cup of water and tissue paper.
Notification of traumatic death outside the hospital
The notification processes and outcomes of 52 surviving Italian men and women who were notified of a death that occurred under unexpected and violent circumstances were reported. Only about half of the participants stated that they received clear and comprehensive information about the events that led to the death. Most survivors sought or received formal or informal support, but some received none.Reference De Leo, Guarino and Congregalli7 In addition, following notification, families described being confronted by police, legal, medical, and mortuary authorities who sometimes enacted unfamiliar and complex procedures such as identification of the deceased and death investigations, which added to the families’ level of distress.
Multiple notifications of remains recovery
Immediate and extended family members (454) of persons who died in the 9/11 terrorist attack in New York City were asked to respond to a questionnaire about their experiences regarding the number of notifications they received (none, once, twice, or more). Those who received two or more notifications of the identification of fragments of their loved one’s remains had more severe grief and posttraumatic symptoms. In cases where the potential exists for multiple notifications, forensic procedures should be considered in relation to the potential consequences of providing a continual stream of distressing information to families.Reference Cozza, Fisher and Hefner16
Viewing Remains
Factors affecting the decision to view
Decisions about viewing the body can involve complex issues that are often faced by bereaved family members. The choices are typically complicated by such factors as the cause of death, severity of injuries, disfigurement, lack of preparation for the viewing, and the presence or absence of supporting persons.Reference De Leo, Guarino and Congregalli7 Those who conduct the notification are often challenged by responding to survivors’ questions about whether or when it would be appropriate to view the body. Opportunities to view the body may be encouraged, discouraged, or forbidden by the authorities who have custody. Evidence of whether survivors should be encouraged to view the body after a traumatic death is mixed, as is addressed in the following paragraphs.
Benefits of viewing. Possible benefits of viewing the body are (1) confirming the reality of death, (2) seeing that the condition of the body is less distressing than in fantasies, (3) giving the viewer the chance to say goodbye, and (4) having an image of death that may be helpful in grief work.Reference Cathcart8, Reference Chapple and Ziebland13 There can be differences in the value and meaning of early viewing, such as in a hospital or a forensic facility, and later viewing, such as in a funeral home. Early viewing allows survivors to confirm the reality of the death, to be with their loved one after the transition from life, to know the circumstances of the death, and to begin to get over the shock. Viewing in a funeral home allows for final goodbyes and the final separation from the physical body.Reference Harrington and Sprowl9
Drawbacks of viewing. Viewing the deceased is a personal experience for the viewer. Some reactions that have been expressed are that viewers were discomfited that the body did not appear as expected. Some were disturbed by the coldness of the body, distress related to disfigurement, such as in a case in which a relative had died in a fire and the body was unrecognizable, and the family member was unprepared for the viewing.Reference Chapple and Ziebland13
Barriers to viewing. Families are sometimes advised not to see the body of the deceased after a traumatic death.Reference Dix19, Reference Reny, Root and Chreiman20 This advice can be prompted by well-meaning authorities who do not want to further traumatize the survivors. Viewing might also be discouraged by care providers when they are uncomfortable with their own intense emotions as well as the emotions that could be displayed by family members.Reference Harrington and Sprowl9
Survivors can themselves feel victimized when they are advised against seeing or are not allowed to see the body. Dix reported that after her brother was killed in the Lockerbie air crash over Scotland, no information was given to the families about the state of the bodies.Reference Dix19 Undertakers were advised by the Scotland authorities to recommend that families not see them. Families were distressed when they were only allowed to see the deceased through a window but were not allowed to touch them or be with them.
Policies that do not permit contact with the body can cause severe distress and anger among family members who want to spend time with the dead.Reference Mowll, Lobb and Wearing10, Reference Mowll, Bindley and Lobb21 Due to the many policies for public health protective measures, such as self-isolation, people are not able to gather to be physically present with the sick or dying, religious rituals cannot be performed, families cannot say goodbye, funerals cannot be held, and mourning rituals cannot be performed. All these restrictions have complicated the process of dying, viewing, burial practices, and grieving.Reference Corpuz22 Restrictions could also lead to psychopathologic conditions, such as persistent complex bereavement disorder in vulnerable individuals.Reference Diolaiuti, Marazziti and Beatino23
Possible consequences of not viewing. Persons who chose not to view the remains, when viewing was possible, gave a variety of reasons. Among these were that they did not want to see a body that had been disfiguredReference Cathcart8 or they wanted to remember the person as they were.Reference Chapple and Ziebland13 Some who chose not to see the body later wondered if they had made the right decision. For some, not viewing seemed to prevent a lack of closure about the death.Reference Chapple and Ziebland13 Among other consequences of not viewing the body include a survivor’s continuous mental searching for the deceased, feeling that the reality of the death was not recognized or realized, not satisfying emotional needs of holding or touching the deceased, having no opportunity to say goodbye, and not fulfilling the need to find meaning in the death.Reference de Mönnink15
Sensory impact of remains on viewers. There are many possible and often unpredictable sensory experiences associated with viewing the deceased. In addition to the sight of the body, other sensory experiences associated with this exposure include touch and smell. The experiences of touching or holding the body can be components of the viewing process. The coldness of the body, unexpected odors, or an altered appearance from life can serve to confirm the reality of the death but can also add complexity to the experience. Notably, the viewing can produce a long-lasting sensory experience and be the subject of recurrent intrusive images.Reference Mowll, Lobb and Wearing10
Smell differs significantly from other sensory modalities in that the perception of odors has the unique ability to trigger memories of episodes significantly associated with smell in a person’s life. The strength of the association with these memories depends on the significance of the experience in the person’s life. However, and sometimes fortunately, smell memories are based on recognition and not on memory. In other words, smells are recognized, but cannot be generated by the mind through imagination or command.Reference Engen11 The sudden and unanticipated strong emotions associated with smell may be upsetting and disorienting. There are few ways to prepare for the emotions evoked by smells. However, professionals who prepare survivors for the viewing should describe the state of the remains and what they may expect to see, smell, and may feel during the viewing.
Viewing the body in a forensic setting. A relative is sometimes called by forensic authorities to visually identify the body for a medico-legal death investigation.Reference Blau, Graham and Smythe12 Exposure to a body in a mortuary may be especially traumatic, as it may not have been prepared for viewing. Thus, it is important for the forensic authorities to have training in preparing the remains for the family to view for the identification process. Authorities must be educated about the importance of sensitivity in communicating facts about the death, how the body will be handled, and any legal procedures that could delay release of the body.Reference Whelan and Gent2
A qualitative analysis was conducted based on interviews of 80 people who were bereaved due to suicide, homicide, or other forms of traumatic death. Interviews were conducted to learn why and how survivors decided to view or not to view the body and the emotional reactions of those who chose to view the body. Forty-nine participants (61%) chose to view the body. Of those who viewed the body, 35 (71%) reported that it was the right thing to do, which included feeling an obligation to do so, 9 (18%) had mixed feelings, 3 (6%) did not comment on their feelings, and 2 (4%) regretted it. Eight (10%) declined to view the body, and 11 (14%) were not given the opportunity. Three (4%) who had found the dead after a suicide chose to see the body again and reported that they were glad they did so. The authors’ conclusion was that it should not be assumed that people will be harmed by seeing the body.Reference Chapple and Ziebland13 Clearly, decision-making about viewing the deceased is complex and needs to reflect an understanding of circumstances and the individual needs and capacities of individual family members.
Alternatives to viewing remains
Viewing photographs of the remains. An alternate option to viewing remains in a forensic setting includes allowing the family to review the case file, which may include photographs, diagrams, or a virtual 3-dimensional reconstruction of the remains.Reference de Boer, Roberts and Delabarde14 Photographs can help family members decide whether they wish to be physically present to view the remains. Viewing photographs also gives the bereaved time to ask questions of the authority who has charge of the remains.Reference Cathcart8, Reference de Mönnink15 Photographs can also prevent unnecessary exposure of family members from overwhelming sensory overload, such as is likely to occur in large scale disasters if families are required to file by rows and rows of remains to identify their loved one.
When intact remains cannot be recovered. When remains are commingled, decomposed, burned, or fragmented, or intact remains cannot be recovered, there can be severe challenges for identification. When the identification process is likely to be lengthy, such as over a period of weeks or longer, families are prevented from having access to the remains for viewing or final disposition. Families may wish to be kept informed as each fragment is identified or to be informed at the end of the process, with the option to change their mind over time.
In mass fatality events, family members may gather for long periods of time awaiting word of their loved one’s remains. In many cases of such gatherings, family support centers are set up to assist the families and the authorities. In these settings, families can have protection from the often-intrusive media, receive verified information, experience shared interactions or privacy, and have ready access to religious and behavioral health support and medical assistance.
Visiting the site of death. When remains cannot be recovered, including as a result of disasters or terrorism, one alternative is to go to the site of death. Relatives who were bereaved by the deaths of family members due to a tsunami in Southeast Asia in 2004 visited the site of death. Following the visit, they reported that they gained an increased understanding of what had occurred and experienced a feeling of closeness to the deceased.Reference Kristensen, Weisaeth and Heir17 After a visit to the site of a terrorist attack in Norway, relatives of the deceased reported that the visit had helped them process their loss.Reference Kristensen, Dyregrov and Weisaeth18
Effects of the COVID-19 pandemic on handling bodies. Recently (2019-2022), the COVID-19 pandemic severely disrupted policies and procedures for handling the bodies of those who had died from or were suspected to have died from COVID-19.Reference Lowe, Rumbold and Aoun24 Social distancing in communities affected by the pandemic had a significant impact on the families of people who have died in hospitals. Often, the person in a hospital suffering from COVID-19 died alone or without family present. Social distancing prevented families from being allowed to view the bodies of their deceased loved ones.Reference Pearce, Honey and Lovick25 Grief responses of persons whose relatives died of COVID-19 or from natural death or unnatural death were compared within the 6 months after the death. The inability to say goodbye to the decedent was associated with higher levels of grief during the bereavement period compared to those whose relatives died from natural causes.Reference Eisma and Tamminga26
Viewing the body of a deceased child. Parents who suffered the death of a child were asked to describe helpful actions of professionals related to viewing the body.Reference Janzen, Cadell and Westhues27 It was helpful when nurses prepared the parents for seeing the body and parents were provided adequate time and privacy. Access to the body gave the parents the opportunity to say goodbye, to hold the deceased child, and dress and position the body, if they so desired.
Should children view the body? The decision about whether a child should view the dead body of a loved one is complex and should be informed by multiple factors such as their developmental age, which includes the child’s emotional and cognitive capacity to comprehend the experience. Parents should have the primary role in helping their child decide whether to see the body. In addition to the child’s own thoughts, feelings, and motivations, many of the same considerations apply as for adults such as the condition of the body and the viewing environment. For children who view the body, there should be a parent or another caring adult present who can calmly explain what the child should expect and support a child during a viewing. Ultimately, the decision should rest on whether viewing the body is likely to help a child understand the reality of the death and potentially be reassuring rather than overly distressing or confusing.Reference Cathcart8
Cultural and religious practices
Culture and religion affect post-mortem practices for having access to and for viewing the body. How and when bodies are viewed and cared for are factors that are strongly influenced by culture. For example, the percentage of people who died at home compared to those who died in a hospital increased from 16 to 30.5% during the period between 1989-2016.Reference Coe28 Home deaths are associated with socioeconomic status (SES) and race. A review of the research on describing the site of death found that home deaths were more likely among individuals who are white, married, and have a higher SES.Reference Gruneir, Mor and Weitzen29
In Japan, following an in-hospital death, a seeing-off ceremony may be conducted after the body has been transferred to the mortuary. Seeing-off is a ceremony derived from Buddhism and traditional Japanese culture, and is conducted by the family, nurses, and doctors. The ceremony can consist of prayer, burning incense, and expressing appreciation for the life of the deceased. This ceremony is considered the last care provided and is intended as a gesture of courtesy and respect for the life of the deceased.Reference Masaki and Asai30
In the U.S., customs derived from Spanish-speaking countries may keep the body of the deceased at home for a wake or a viewing. This ritual gives families and friends the time to gather, pray, say goodbye, reunite or strengthen bonds, and celebrate the life of the deceased. Other meaningful contacts between the body and survivors include caring for the loved one for the last time, including washing and dressing the body according to cultural traditions of the family.Reference Gonzales and Hereira31
While not a subject of this review, cultural practices vary considerably worldwide. For example, in many non-Western and low- and-middle income cultures, religious practices can affect how a body is treated after death. These practices, such as rapid interment, autopsy, embalming, caring for the body (e.g., by wrapping and washing it), and how long and where a body can remain unburied or not cremated, can also influence how and whether the survivor interacts with the body.
Aftermath of viewing
Viewing the body as a beginning of grief and mourning. There are emotional connections between the living and the deceased, and the dead can be incorporated into the lives of the living.Reference Harper32, Reference Howarth33 Viewing the body often constitutes the beginning of grieving and accepting the death. Following a death, and particularly an untimely death, survivors can create a story about the deceased, which may help them to cope with the loss. This process begins with notification, but continues through the obligations of the living to attend to the affairs of the deceased. The language used by the survivors in referring to the deceased, such as saying the name of the deceased or using a personal pronoun, can be a sign that there is still a social bond with the bereaved and that the body has a social identity. Viewing the body with loved ones helps bring people together to reunite and re-establish ties and strengthen community bonds. Other meaningful contacts between the body and survivors include caring for the loved one for the last time, including actions such as washing and dressing the body according to cultural traditions of the family. Talking to the deceased can serve as a relief for the viewer.Reference Gonzales and Hereira31 Families that mourn together in the presence of the dead value the intimacy of having time with the dead.Reference Mowll, Bindley and Lobb21
Discussion
This review describes the events and processes that typically occur following a traumatic death in the socio-cultural context of largely Western and high-income societies. These steps, in somewhat chronological order, are: death notification, identification of the body, viewing or not viewing the body, and the post-mortem period, that includes funerals and memorials and grief and mourning. Much of this review has emphasized the importance of considering the viewing of the body by survivors, usually family members. As we have described, often there is no protocol for viewing in a hospital or other setting such as a forensic facility or a morgue or mortuary. Where such a protocol for viewing does not exist, guidelines are essential for all personnel who may come in contact with survivors. Those responsible for the body may not have had training in how to discuss with family members whether and under what conditions to view the body, or how to support the family during the viewing and afterward. These activities, or the lack thereof, may have short-term consequences for families, such as their effects on grief, and those that are long-lasting in terms of mourning and memories.
While not applicable to all cases and situations, the literature reviewed here largely supports the benefits of viewing of the deceased, given that not viewing has consequences that cannot be undone. Among the main positive aspects are confirming the reality of the death and saying goodbye. Additionally, viewing also appears to further confirm how the person died, which may allow the survivors to be closer to the deceased as they think about their last moments of life. Not viewing may leave a gap in understanding the life history of the deceased and some have reported that it is difficult for them to stop looking for the dead.
Those who are present at the death, or shortly thereafter, have their own reactions to the deceased based on their personal and cultural background. As noted, the Japanese seeing-off ceremony is meant to show respect for the life of the deceased. Another culturally related practice is keeping the remains in the house where the deceased lived as a means of prolonging the goodbyes and permitting visitors the opportunity to share feelings and emotions in a special place and time.
Throughout this review, we have presented information that we hope is useful to service providers, managers, and leaders involved in the process of death notification, emphasizing the human connections between the bereaved, family members, and other loved ones, and those whose job it is to complete the necessary medical, legal, and societal obligations to care for the remains. Health care providers who have treated the deceased or attended the death have their own feelings and emotions about death notification and advising families about viewing. These are complex issues that require training and practice in considering the needs of families. Professionals must be able to provide accurate information, while considering a family’s needs for privacy, courtesy, time, support, and additional resources. An important theme that was identified by this literature review is that medical professionals should not make assumptions about how family members would best benefit regarding viewing their loved one’s remains or that viewing is always harmful to their welfare. Professionals need to be educated how their own discomfort can unduly influence their interactions with families or with other staff. It is also noted that professionals sometimes need the support of those with whom they work.
Limitations
There are many other aspects regarding the circumstances of exposures to human remains that are beyond the scope of this paper. We focused specifically on the issues and literature that are of most practical value to service providers and managers. Among the additional topics that could be explored are: ethical issues, bereavement, strategies for managers of service providers, notification and viewing of remains in non-traumatic death, and religious literature on death. Our literature search yielded mostly papers from Western countries and were published in English. Thus, we were not able to explore literature in other languages.
Research Needs
There are several topics associated with individual experiences and reactions to traumatic death. Some include: (a) Demographic and cultural characteristics of survivors, such as age, race/ethnicity, gender, and SES. (b) How cultural considerations contribute to decisions about the handling and fate of remains and the effects of such decisions on survivors’ reactions and well-being. (c) How differences in experiences and reactions to viewing of bodies differ by cause of death. (d) How exposure to bodies affects children depending on their age, maturity, and the support or lack of support from family and friends.
Research should also consider the experiences of those who are episodically exposed to traumatic death: bystanders, volunteers, emergency workers, and law enforcement personnel. For many, seeing the body is not optional as it can be an occupational responsibility. In rural areas, the distinction between personal and professional roles may blur given that it is not uncommon for rural emergency personnel to handle the remains of those whom they know and to whom they may be related, thus complicating the experience. In addition, given the increases in school shootings in the US and increasing levels of community violence, it is important to understand the needs of children in response to this type of traumatic death.
Conclusions
Complex challenges for survivors occur when a death is untimely, unexpected, premature, and due to a traumatic event. Challenges for practitioners and institutions present themselves when there is a lack of knowledge or disagreement about the practices and policies to be followed, such as when and how to conduct the death notification, and whether and how to allow families to view the body or carry out personal and religious rituals.
Given the findings of this review, we recommend the following: First, that clinicians and service providers should be trained and practiced on death notification. Death notifiers must be emotionally able to provide accurate information in a sensitive manner while interacting with survivors. They should be able to advise them of issues involved in the decision to view the body while remaining neutral about the survivor’s decision. Second, when forensic procedures are anticipated, survivors should be made aware of the reasons for the procedures, what is likely to be done, how long it may take, and what information will be shared with them. Third, when survivors elect to and are permitted to see the body, every effort should be made by those responsible for the body to assure that the survivors are: (a) prepared for what they will see and may experience; (b) given a private location and time in which to reflect on the challenges that they face; (c) provided answers to all questions by authorities who have knowledge of the circumstances of the death; (d) permitted to perform rituals according to their faith and culture, within reason and with an appreciation of the limitations of where the body is viewed and (e) given a follow-up call with a staff professional such as a nurse or social worker after they leave the facility in order to answer any remaining questions and provide support and resources, if desired.
It is important to realize that post-death events such as death notification, identification, forensic procedures, investigation information-gathering, and viewing, can be interactive and should not require excluding families from these events. When families are excluded, they can experience negative consequences. Care of survivors should be a priority throughout the process, from death notification through post-viewing and post-funeral, by continuing follow-up by authorities and personnel of helping agencies.
Competing interest
The authors declared no potential conflict of interest with respect to the research, authorship, and/or publication of this paper.
Disclaimers
The opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense.
The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, opinions, or policies of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government.
This project was conducted under the Uniformed Services University of the Health Sciences award number HU00012020073 from the Henry M. Jackson Foundation for the Advancement of Military Medicine.
