Angel Care in Practice: A Complete Guide to Postmortem Care That Begins Before Death and Extends to the Family
This article is a digest of the Angel Care Practical Training (120 minutes) that Next Co., Ltd. created for medical and care professionals. It is written for everyone involved in end-of-life care: nurses and care workers, as well as doctors, care managers and consultants, and pharmacists.
In Japan, “angel care” (enzeru kea) refers to the care given to a person’s body and to their family after death. In this training, angel care is not treated as a “procedure after death” but as a continuous process of care that runs from preparation while the person is still alive to supporting the family in their grief. How to read each chapter’s figures and the reasoning behind each type of care are explained in detail in our free eight-part series on note (in Japanese). The figures in this article come from our Japanese training materials.
In this article
1. What is angel care? Five purposes
2. Six phases that “begin before death”
3. Changes in the body after death and the reasons behind the care
4. The basic procedure in 10 steps
5. Care by condition
6. Caring for the family
7. Places of care, multi-professional teamwork and legal points
8. Case studies and a checklist
Summary: five key points of angel care
1. What is angel care? Five purposes
Angel care is the general term for care given to the deceased person’s body and to their family after a doctor has confirmed the death. In the past, “postmortem procedures” were carried out in the same way for everyone, with the aim of preventing infection and leakage of body fluids. Today, angel care is tailored to each person and includes restoring an appearance that is true to who they were and supporting the family’s grief.
Care of the body: (1) keep the body clean and prevent infection (2) tidy the person’s appearance (3) prepare for changes after death
Care as a person: (4) protect the person’s dignity (5) support the family’s grief
High-quality angel care needs both accurate procedures and warmth in how we relate to the person and family.
2. Six phases that “begin before death”
Angel care does not begin at the moment of death. In the training, we divide care into the following six phases:
Preparation before death (several months to several weeks before) / the dying phase (several days to several hours before)
Confirmation of death and farewell (from immediately after death to about one hour) / the care phase (after the farewell)
Laying out and transport (until transport and cremation) / bereavement care (from after the funeral to several months later)
The most important of these is the preparation phase before death. In everyday conversations, the team gradually confirms and shares things such as where the person wishes to spend their final days, the clothes they would like to wear, religious and local customs, whether the family wishes to take part in the care, who should be contacted, the funeral home, wishes about organ or body donation, and the plan for a sudden change in condition. For care at home, it is essential to agree with the family in advance that, when the person stops breathing, they should contact the attending physician or home-visit nursing service rather than call an ambulance.
Day-to-day care before death that eases present discomfort, such as moisturizing the skin and oral care, adds up to a peaceful appearance after death.
3. Changes in the body after death and the reasons behind the care
The figure shows how cooling of the body, livor mortis (lividity), rigor mortis, clouding of the cornea and decomposition progress over time after death. (The figures are general forensic guidelines and vary with room temperature and the person’s condition before death.) Knowing how these changes occur lets you explain the “why” behind each step.
Rigor mortis begins in the jaw at about 2 to 3 hours after death → close the eyes, carry out oral care and put dentures back in, close the mouth, and position the body before stiffening sets in
Livor mortis appears on the lower parts of the body → raise the head slightly with a pillow to keep it from appearing on the face
Decomposition starts in the intestines and tends to progress from the abdomen → cool the abdomen first, together with the chest
In Japan, cremation in principle cannot take place until 24 hours have passed since death → continue cooling throughout the expected laying-out period
After death is confirmed, first make sure the family has time to say goodbye on their own. Some care is best done before the body stiffens, but there is no need to rush it at the expense of the family’s time.
4. The basic procedure in 10 steps
The basic procedure has 10 steps: (1) explanation and preparation → (2) oral care and dentures → (3) closing the mouth and eyes → (4) removing medical devices → (5) bed bath and hair washing → (6) managing leakage of body fluids → (7) dressing → (8) skin care and angel makeup → (9) cooling and laying out → (10) recording and handover. Steps 2 and 3 are best done before rigor mortis sets in, and steps 5, 7 and 8 are ones in which the family can easily take part. The order is a guide and should be adjusted to the condition of the body and the family’s wishes.
Key points to remember in practice:
Do not tie the jaw with a bandage; support it with a pillow and a rolled towel instead (tying leaves marks)
Do not routinely pack the nose, mouth or anus. Do so only when needed according to the risk of leakage, using a small amount placed deep enough not to be visible
Skin is easily damaged after death. Pat it dry rather than rubbing, use an electric shaver for shaving, and moisturize afterward
Wrap ice packs in a towel and never place them directly on the face
Make sure the funeral home is reliably informed of any infectious disease (with the family’s consent), the risk of fluid leakage, and implanted medical devices such as pacemakers
▶ Learn more: note series, part 4 (preparation to bed bath) and part 5 (fluid leakage to recording) (Japanese)
5. Care by condition
Condition-specific care follows three steps: “the person’s condition before death → changes likely to occur after death → care before and after death.” For example, in a person with edema, the skin tears easily and fluid tends to seep out, so the skin is protected while the person is alive, and after death the puncture sites are sealed and the head is raised.
Edema and fragile skin: “Don’t rub, don’t pull, don’t shift, and keep tape to a minimum”
Jaundice: soften the color with a base in the complementary color (for a yellowish tinge, blue or purple tones; for a greenish tinge, pink tones), and explain to the family in advance that the color may change
Risk of bleeding: keeping dark-colored towels ready helps soften the impact of blood on the family if bleeding does occur
Implanted medical devices: these can burst during cremation, so make sure the funeral home and crematorium are always informed
Medical narcotics: do not dispose of leftover medicine at your own discretion; return or dispose of it following the set procedure (at home, the family can return it to a pharmacy, for example)
Infections: apply standard precautions to every deceased person, and do not restrict farewells more than necessary
This quick-reference table summarizes the “likely conditions” and “key points of care” for common diseases. In reality, conditions often overlap, so judge by observing each person’s condition.
▶ Learn more: note series, part 6: “Care by Condition” (Japanese)
6. Caring for the family
Right after a loss, family members show a wide range of reactions: sadness, anger, guilt, and sometimes relief after a long period of caregiving. All of these are natural. Listening and accepting what they feel matters more than finding the right words. The careful way you handle the person’s body is itself a message to the family.
Offer the family levels of participation to choose from: “watching nearby,” “speaking to the person or holding their hand,” “wiping the face and hands or combing the hair,” and “dressing or applying makeup together.” Choosing not to take part is also an important choice. Farewell customs vary with local traditions, religion and values, so if you are unsure, ask, “Could you tell us how your family would like to do this?”
▶ Learn more: note series, part 7: “Caring for the Family and Multi-Professional Teamwork” (Japanese)
7. Places of care, multi-professional teamwork and legal points
Hospitals, care facilities and homes differ in who confirms the death, who provides the care, how medical narcotics are handled and where the body is laid out. In care facilities and at home in particular, it is important to agree in advance on whom to contact at night and in what order. Angel care is not the responsibility of nurses alone: doctors, care workers, care managers and consultants, pharmacists and funeral homes each have a role to play.
Death is diagnosed by a doctor, and angel care is carried out afterward
It is a misconception that the police must be notified if more than 24 hours have passed since the last medical examination. If the doctor can determine that the person died of an illness under treatment, a death certificate can be issued after examining the body
If the death cannot be judged to be from illness, the doctor reports it to the police. Until the police inspection is complete, do not touch the body and leave any medical devices in place
The figure shows what to do after noticing that breathing and heartbeat have stopped. When in doubt, don’t decide on your own; contact a doctor first.
▶ Learn more: note series, part 7: “Caring for the Family and Multi-Professional Teamwork” (Japanese)
8. Case studies and a checklist
At the end of the training, participants practice planning care by considering both the predicted changes in the body and the family’s feelings, using three cases: a person with cancer cared for at home, a person who died of frailty of old age in a care facility, and a person who died of liver failure in a hospital. The training also covers accepting the distress felt by caregivers as natural, and the importance of reflecting together as a team (a “death conference”).
The content of the training is summarized in a checklist with three stages: before, during and after care. Adapt the items to your facility’s procedure manual and use the checklist for reviews right after care and for training new staff.
Summary: five key points of angel care
Start before death: confirming wishes and providing daily care lead to a peaceful appearance
Be mindful of time: do the care that shapes the person’s appearance before rigor mortis sets in
Base care on evidence: understand bodily changes and conditions, and tailor care to each person
Work with the family: let them choose how to take part, and stay close to them in their grief
Connect as a team: pass care on to the next caregivers through records and handovers
Learn more in our free series on note (8 parts, Japanese)
All 59 figures from the training, with explanations of how to read them and the reasoning behind each type of care, are covered in our free series on note (in Japanese). You can read the whole series in the magazine “Angel Care Practical Training (8 parts).”
Related training textbooks (Japanese, sold on note)
Training Textbook for Care Facility Placement Consultants, Volume 3 (Advanced): basics of the body and medical procedures, major illnesses, hospitals and discharge support, end-of-life and palliative care
Senior End-of-Life Planning Business: Comprehensive Training Textbook, Vol. 9: basics of long-term care insurance, senior facilities and medical care (including end-of-life care)
Senior End-of-Life Planning Business: Comprehensive Training Textbook, Vol. 6: basics of funerals, graves, Buddhist altars and farewell gatherings
For English readers, our Senior End-of-Life Planning Textbook (English edition) covers Japan’s senior care and end-of-life market as a whole. See our Publications page for all textbooks.
Training requests
We offer the Angel Care Practical Training (conducted in Japanese) as staff training for hospitals, care facilities, home-visit nursing agencies and other organizations. Please feel free to contact us about the content and length.
This article summarizes general principles based on Next Co., Ltd.’s training materials “Angel Care Practical Training.” In practice, follow the doctor’s instructions, your facility’s procedure manual, and the latest laws and government guidelines in Japan.
This is an English translation of an article originally published in Japanese by Next Co., Ltd.
Comments