Care of thedeceased patientand their familyA Guideline for Nursing Practicein Northern Ireland

GUIDELINES ID TAGTitle:Care of the deceased patient and their family: A Guidelinefor Nursing Practice in Northern IrelandAuthor:HSC Bereavement NetworkSpeciality / Division:Bereavement CareDirectorate:Nursing and MidwiferyDate Uploaded:31 March 2017Review Date:31 March 2019Clinical Guideline ID:1

ForewordLast offices is the term traditionally used in nursing to describe the final acts ofcare for a deceased person. This guidance reflects that care but also the widerresponsibilities that nurses have; before, at the time of and immediately afterdeath.The principles contained within this document will provide guidance for nurses/midwives working in any setting and who care for dying patients and their families.Nurses/midwives lead in the coordination of this care and are uniquely placed toensure that these final acts of care for the person and their loved ones uphold standards of goodnursing practice.It is an important opportunity to provide care and attention to the bereaved family, friends andcarers ensuring that they receive sensitive and respectful information through good interaction withstaff followed up with appropriate written information to support them through that difficult time.This document provides guidance on how to achieve the delivery of effective, sensitive;person-centred nursing care to a deceased person and their families/friends/carers. The guidanceis for everyone in the nursing and midwifery family and will complement existing policies andprocedures.Charlotte McArdleChief Nursing OfficerDOHNorthern Ireland2

ContentsPage1.Introduction12.Development of the guideline23.Who will find this guideline useful?24.Aim of guideline35.Principles for care of the deceased and their family36.Preparing for death - Steps to creating a supported experience47.At the time of death - Steps to creating a supported experiencefor the family58.Governance and legal issues relevant to care after death69.Care after death910. Transfer of the deceased patient from the place of death1111. Recording care provided after death1212. Education, training and support of staff providing care after death1213. References1314. Acknowledgements15Appendix 1 HSC Services Strategy for Bereavement Care (2009) Standards16Appendix 2 Regional Body Transfer Form17Appendix 3 Principles for care of the dying person HSS (MD) 21/201418Appendix 4 Reporting Deaths to the Coroners Service of Northern Ireland19Appendix 5 Infection Control - Last offices20Appendix 6 HSC Bereavement Coordinators contact details213

1.Introduction‘Last offices’ is the term traditionally used in nursing to describe the final acts of care for adeceased person’s body.1 The term ‘personal care after death’ is now more commonly used todescribe care of the deceased patient’s body and also the wider responsibilities that nurses haveat the time of and immediately after death.2Whilst the extent of procedures performed by nurses has changed in recent years, after deathcare of the deceased patient’s body remains an opportunity for nurses to demonstrate respectand sensitivity, including due regard for any required cultural and religious considerations. At thistime nurses are in a unique position to liaise with colleagues in other professions and services tocoordinate any health and safety, legal and administrative requirements resulting from the death.Providing information and support to bereaved carers and family is also an essential element ofnursing care after death.In Northern Ireland (NI) the HSC Bereavement Network and Trust Bereavement Coordinators(TBCs) support regional implementation of the HSC Services Strategy for Bereavement Care.3The strategy outlines six standards for care that guide the quality of service and support deliveredby HSC staff before, at the time of and after death (Appendix 1).An example of an initiative introduced to meet the standards was the development of a ‘BodyTransfer Form’ for use in all NI hospitals (Appendix 2). Nurses complete this form prior to thedeceased patient being transferred from place of death. The use of the form facilitates safeand effective handling and transfer of a deceased patient’s body and communicates importantinformation to those assuming responsibility for the deceased eg. transferring and mortuary staffand family funeral directors.The introduction of the regional Body Transfer Form provided nursing staff with the opportunity toraise a number of questions in relation to care after death as they are responsible for recordinginformation about the deceased patient (Appendix 2). The TBCs noted a variation in practiceacross the region and a lack of awareness of the purpose of last offices procedures. Questionswere also raised about documenting health and safety information, such as infection controlmeasures, for the attention of staff handling and receiving the body.Other issues relevant to nursing care after death include reporting the death to medical colleaguesand being aware of the legal and professional responsibilities of doctors. These responsibilitiesinclude, verification, certification and establishing whether Coroner’s requirements will affect hownurses care for the deceased.Clear and compassionate communication when providing support and information to bereavedrelatives is a further element of nursing care after death.The Royal Marsden Manual of Clinical Nursing Procedures (2015) Care after Death (last offices) in CH 8Patient comfort and end-of-life care. 9th Ed. Accessed online 8-sec-03602Ibid. Chapter 83Department of Health, Social Services and Public Safety (2009) HSC Services Strategy for BereavementCare. Belfast. DHSSPSNI11

Nursing literature on the subject of care of the deceased patient’s body4 5 has also describedchallenges related to care after death. In 2011 the NHS National End of Life Care Programme andNational Nurse Consultant Group recognised the impact that the lack of clear guidance and trainingcan have on practice at this extremely important time. They issued ‘Guidance for Staff Responsiblefor Care after Death (last offices)’6 which has since been revised and published by Hospice UK.7It was felt that nursing staff in Northern Ireland would also benefit from similar clear, regionalguidance on care after death. This guideline has been greatly informed by that publication withadditional material that reflects professional practice, legal requirements and cultural norms inNorthern Ireland. This guideline aims to provide nursing staff with a holistic perspective on allthe processes associated with care after death and, in doing so, to facilitate the delivery of safe,effective and sensitive care for deceased patients and their bereaved families.2.Development of the guidelineAs part of the development of this guidance nurses, care assistants and midwives within the fiveHSC Trusts were consulted. The consultation process, which was undertaken between April andMay 2016 invited responses from members of Trust Bereavement Forums and the wider nursingpopulation to a draft of the document by way of a questionnaire. The results of the consultationprovided the writing group with valuable suggestions and amendments which have informed thedocuments final content.3.Who will find this guideline useful?The guideline has been written for registered nurses and health care assistants as they haveresponsibility for care and handling of a deceased patient. It complements the information andrelated theory in Chapter 8: Patient comfort and end of life care - Care after death (lastoffices) and the personal care after death procedure promoted as the gold standard for nursingpractice in the Royal Marsden Manual of Clinical Nursing Procedures.8Online access to the manual is available in all HSC Trusts. This guideline will supplement andinform policies and procedures HSC Trusts have in place for care and handling of deceasedpatients eg. those that guide the delivery of safe and sensitive care dictated by the circumstances,including last offices.It may also be informative for other healthcare professionals who provide care at the time of andfollowing a patient’s death in acute, secondary or primary care settings.Clover, B. (2010) Nurse Training ignores emotional impact of last offices. NursingTimes.netWest, D; Clover, B and Lomas, C. (2010). Last Offices neglected in over half of hospital deaths.NursingTimes.net6NHS National End of Life Care Programme (2011) Guidance for Staff Responsible for Care after Death(last offices). NEOLCP National Nurse Consultant Group. www.endoflifecareforadults.nhs.uk7Hospice UK and National Nurse Consultant Group (2015) Care after Death: Guidance for staff responsiblefor care after death. 2nd Ed. Hospice UK. www.hospiceuk.org8The Royal Marsden Manual of Clinical Nursing Procedures (2015) Care after Death (last offices) inCH 8 Patient comfort and end of life care. 9th Ed. Accessed online 03/08/15452

4.Aim of guidelineThe guideline aims to: Promote safe and sensitive care of the body at the time of and after death, taking intoconsideration the wishes of the deceased patient and their familyEnsure the deceased person is treated with dignity and respect, and that cultural andspiritual needs are metPromote effective inter-agency working by outlining the roles and responsibilities ofrelevant professionals and organisations who are involved in caring for the deceasedpatient and their relativesPromote effective communication and provide information to assist families whendealing with the practical issues that arise as a result of the death eg. registration ofdeath or a death that is referred to the CoronerInform the development of relevant policy, procedures and protocols to guide thepractice of health and social care staffProvide a resource that will be useful for pre and post registration training andeducation and contribute to the professional development of nurses in the care of thedeceased patient and their family.5.Principles for care of the deceased and their family5.1Death may be expected, sudden, peaceful or traumatic. The nature of the death and thecontext in which it has occurred will determine the level of immediate support and informationrequired by those who have been bereaved.5.2The following principles should inform nursing practice when death occurs: Acknowledgement of the grief of bereaved people and provide emotional support andinformation appropriate to the circumstancesConsideration for the religious, spiritual and cultural wishes of the deceased patient and theirfamily, whilst ensuring legal obligations are metPreparation of the deceased patient prior to family spending time with them and then fortransfer to the mortuary or the funeral director’s premisesProviding family members with the opportunity to participate in this process if they wish, andsupporting them to do soProtection of the privacy and dignity of the deceased patientProtection of the health and safety of all coming into contact with the bodyLiaison with specialist staff in organ and tissue donation processes when indicatedProvision of information on post-mortem examination if relevant (ie. Coroners, medico-legal/or hospital consented)Return of personal possessions of the deceased patient to family in a respectful manner. 3

6.Preparing for death - Steps to creating a supportedexperience6.1Where death is anticipated and predicted, care should be planned in accordance with thefive principles for care of the dying person9 and NICE guidance for care of the dying personin last days of life10 (Appendix 3). It is important that agreement is reached betweenmedical and nursing teams, patients and their families about clinical decisions and a plan ofcare that is appropriate to the needs of the dying individual.6.2Clear and unambiguous communication in advance ensures there is understanding of theprognosis and allows for appropriate preparation of the dying person and their family.Decisions documented in the patient’s care plan may include: 6.3Resuscitation status11Management of implanted cardiac devicesPreferences for place of death whenever that is possible eg. facilitating discharge to ownhome or usual residenceAny religious, spiritual, cultural or practical wishes - this is particularly important if immediaterelease for burial or cremation is a faith requirement. Advice on the requirements of a rangeof faiths and cultures around death is available in the Multicultural and Beliefs Handbookavailable in all HSC Trusts.12 Spiritual support for both the dying person and those that matterto them can be provided by their own faith representatives and hospital Chaplaincy ServicesThe individual’s wishes regarding chaplaincy support during illness and attendance afterdeath. This should be offered in a timely manner so as to allow for meaningful interaction withthe patient, their family and chaplaincy servicesContact information for those the dying person would like to have with them at the time ofdeath is discussed, recorded and should be readily accessible by all appropriate staff. It isadvisable that more than one contact telephone number is recorded in case relatives cannotbe reachedIn some cases post-mortem examination may have been discussed and documented prior todeath and in these situations the decision of the deceased should be respectedIf known, any wish on whole body donation. This can only be arranged prior to death byindividuals themselves and not by anybody else on their behalf after death.13The individual’s wishes regarding organ and tissue donation may or may not be formallyrecorded on the Organ Donor Register (ODR). Each Trust has a specialist nurse for organdonation and clinical lead that must be contacted and involved in consent discussions ifdonation is an option. They will provide appropriate information, advice and support to staffand relatives. The on call specialist nurse for organ donation can be contacted using the24 hour pager number for the NI Organ Donation Services Team 07699 748 246.Further information is available on the National Organ Donation and Transplantationwebsite.14DHSSPS (2014) HSS (MD) 21/2014 Advice to health and social care professionals for care of the dyingperson in the final days and hours of life - Principles for care of the dying person. Chief Medical Officer/ChiefNursing Officer10NICE NG 31 (2015) Care of dying adults in the last days of life., Resuscitation Council, RCN. 2016. Decisions relating to cardiopulmonary resuscitation (3rd ed-1strevision) 12HSC Multicultural and Beliefs ulturalandBeliefsHandbookMarch2012.pdf13Body Bequest information. Queens University Belfast. / Accessed 23 September 201614www.odt.nhs.uk94

6.4The environment in which a dying person and their family are cared for and supportedcan have an impact on the experience.15 Whenever possible a dying patient should be nursedin the quiet of a single room where the family have freedom to visit and stay at any timeand where significant conversations can be held in private. This is not always available andwhere a patient is being cared for in an open ward setting a private space should beidentified and used for communication with the patient and family.6.5When the dying patient is being cared for in an open ward setting, nurses should be awareof the potential impact of this situation on other patients and visiting relatives in the area.Measures should be taken to ensure the privacy and dignity of everyone affected by thesituation.6.6Normal visiting hours should be relaxed for families of dying patients and every effort shouldbe made to accommodate their wishes eg. facilitation of visits from faith representativesor other people important to the patient. Where families are having to spend extendedperiods at the bedside before death it is important that nursing staff explain whererefreshments are available and any options for reimbursement of car parking costs.6.7In sudden death situations many of the principles outlined above will be relevant. However,nursing staff should be aware of the impact of trauma on an individual’s behaviour and needfor support in the immediate aftermath of sudden and unexpected death.7.At the time of death - Steps to creating a supportedexperience for the family7.1The patient’s family should be told of the death in a clear, supportive and compassionatemanner. They should be offered the services of hospital chaplaincy and/or other personnelappropriate to provide support in the circumstances eg. social worker. The use ofcommunication strategies for breaking bad news will reduce the risk of causing further andunintentional distress.7.2If the family is not present at the time of death they should be contacted by a professionalwith appropriate communication skills. In those instances where staff are unsuccessfulin contacting the family the police service can be of assistance in locating them andbreaking significant news. When relatives arrive at the ward/department staff should meetthem and accompany them into the presence of the deceased patient.7.3Preparation of the deceased patient prior to the family spending time with them is a veryimportant aspect of nursing care. Following traumatic death they should be prepared forwhat they will see eg. the presence of lines, tubes and condition of the body that may bedistressing following trauma.7.4If the family’s first language is not English the services of an interpreter will ensure that theyreceive the information they need to make sense of what has happened, especially if thedeath was not expected.15Northern Ireland Audit: Dying, Death and Bereavement October 2010 Phase 2: The experiences of bereavedpeople and those delivering primary care services5

7.5The family will require a sensitive verbal explanation of what will happen next, which will bedependent on the circumstances of death ie. formal verification, completion of MedicalCertificate of Cause of Death or reporting the death to Coroner’s Service and transfer tomortuary. Written information that explains practical matters appropriate to the circumstancesof death as well as advice on grief and coping with bereavement should also be offered.7.6If children were close to the person who has died, adults may require help with how best totell them.16 Bereavement Information booklets are available for those supporting children.7.7Last offices procedures to prepare the deceased patient for transfer to the mortuary shouldbe carried out after death has been verified and the patient’s immediate family has had anopportunity to spend some time with them following death, should they so wish.8. Governance and legal issues relevant to care after deathIn Northern Ireland, holding a ‘wake’, where family and friends come together to view the deceasedperson in their own home or funeral home, is a common occurrence. This and the expectation thata funeral can be arranged within three to four days of death have deep religious, cultural and socialsignificance. While every effort is made by all services with a responsibility after death to facilitatethis practice as far as is possible, a number of statutory and legal processes after death have tobe fulfilled prior to a funeral and burial/cremation taking place. Nursing staff caring for deceasedpatients and their families should be familiar with such statutory and legal requirements. Knowledgeof the roles and responsibilities of other relevant healthcare professionals and agencies is essentialas they too may inform the actions nurses are required to undertake or coordinate at the time ofdeath.This section outlines the processes of which nurses need to be aware.8.1Verification of DeathAll deaths need to be formally confirmed or verified. A medical practitioner or a nurse trainedin the criteria for verifying death, in line with national guidance, is required to attend andformally verify that death has occurred17 18prior to the patient being transferred from theirplace of death.It is best practice that verification takes place as soon as possible, especially when thefamily is present, or when death occurs close to midnight as the recorded time and dateof verification informs the time and date of death that will be entered on the MedicalCertificate of Cause of Death.HSC Trusts and healthcare providers should have an appropriate policy and procedure inplace when verification of death is carried out by registered nurses.19When someone close to you dies; A guide for talking with and supporting children, HSC BereavementNetwork, ications/dhssps/hss-md-8-2008.pdf18Department of Health, Social Services and Public Safety (2008) Guidance on death, stillbirth and cremationcertification. irmation-of-death-for-registered-nurses-/166

8.2Completion of Medical Certificate of Cause of Death (MCCD)Registered Medical Practitioners have a legal duty to provide a certificate of cause of deathif, to the best of their knowledge, that person died of natural causes for which they hadtreated that person in the last 28 days.20 The purpose of certification is twofold; it allows thefamily of the deceased to register the death so that a permanent legal record of the fact ofdeath is recorded and it contributes to statistical information on causes of death used formonitoring the health of the population etc.It is good practice that the MCCD is issued within one working day so burial or cremationarrangements are not unduly delayed. If cultural or religious practices require completion onthe same day, this should be accommodated wherever possible.Since April 2017 all HSC Trusts have in place a new Regional Mortality and Morbidity ReviewSystem. This system will generate an MCCD following the completion of the Initial Record ofDeath (IRD) form. On completion of the IRD an email will be generated to the responsibleConsultant who will be required to review the IRD and, if applicable, the MCCD. The deathwill then be tabled for review at a monthly Mortality and Morbidity meeting where each deathwill be discussed.Nursing staff are often in a position to liaise with the doctor responsible for completing theMCCD and provide bereaved relatives with information relating to when and where it may beavailable for collection.8.3Completion of Cremation DocumentationIf the deceased or their family indicate that cremation is their preferred option there iscurrently a separate Cremation Certification Process. This involves completion of a seriesof medical forms by two independent doctors, both of whom are required to examine thebody after death.The funeral director nominated by the family will make the necessary arrangements forcompletion of cremation documentation and will liaise with medical staff and hospitalmortuary staff in the process.Sometimes bereaved relatives may ask nursing staff questions about the process forarranging cremation and nurses should reassure them that their nominated funeral directorwill assist them with arrangements.8.4Reporting Death to the CoronerWhen death resulted directly or indirectly from any cause other than natural illness or diseasefor which the deceased had been treated within 28 days prior to death, medical staff arerequired to immediately report it to the Coroner’s Service and seek advice about next steps.Medical staff should be aware of the criteria for referring a death to the Coroner’s Serviceand also the Registrar General’s Extra-statutory List of Causes of Death that should bereferred to the Coroner’s Service.21DHSSPS (2008) guidance on death, stillbirth and cremation 1Department of Health, Social Services and Public Safety, General Register Office (Northern Ireland),Coroners Service for Northern Ireland (2008) Guidance on Death, Stillbirth and Cremation Certification.DHSSPS illbirth-and-cremation-certification207

Following report of a death the Coroner in NI will direct one of three courses:1.2.3.Advise doctor to complete MCCDAllow death to be processed under Pro forma SystemDirect a post-mortem examination.If the Coroner directs to use the Pro forma System, the family are not given an MCCD. TheCoroner will ask the doctor to complete a special Pro forma Form or accompanying letter thatbriefly sets out the background and circumstances to the death and send it to the Coronerwith an unsigned MCCD.For deaths in hospital, the new Regional Mortality and Morbidity Review System will generatea Clinical Summary in place of the Pro forma for issue to the Coroner on completion of theIRD.The Coroner will send this information to the Registrar of Deaths who will in turn providethe family with the certificate of death. If a death is being processed using the Pro formaSystem this will need to be explained to the family.In order to establish the cause of death the Coroner may direct that a post-mortemexamination takes place.22 Brief details of the circumstances of death reportable to theCoroner can be found in Appendix 4.At this particularly distressing time, bereaved relatives should be given information and helpto understand the Coroner’s process and what will happen next eg. that they may be spokento by police officers acting as the Coroner’s agents to gather information on the deceased’slast minutes/hours and details about where and when the post mortem examination will takeplace.Regardless of the Coroner’s decision to proceed with a post-mortem any contact with theCoroner’s Office should be shared with the family as part of an HSC Trusts obligation ofduty of candour.Nursing staff can support medical colleagues in providing support and information to thefamily in these situations. They also need to be made aware that, as part of the Coroner’sprocess, they may be required to provide information on the circumstances of death andshould follow their organisations policy and guidance for assisting the Coroner’sinvestigations.Requests for formal statements or medical records are usually requested through RiskManagement/Litigation Departments who will follow agreed protocols and assist staff toprovide information to the Coroner’s Service.A key consideration for nurses when the Coroner directs a forensic post-mortem examinationis the restrictions that will apply to handling of the body. If a forensic autopsy is ordered itis essential that the body is seen by the pathologist exactly as the deceased was at the timeof oners/Pages/default.aspxWorking with the Coroners Service of Northern /Working%20with%20the%20Coroners%20Service%20 for%20Northern%20Ireland%20%28PDF%29.pdfAccessed 3rd October 2016 at 11.17am8

8.5Implications for care of the body when the Coroner orders a post-mortem examinationLiaise with medical colleagues for confirmation of the Coroner’s directions and seek advicefrom the Mortuary Team as necessary.Where the Coroner requires a post-mortem examination the following measures are advisedin relation to caring for the body: Do not wash the body. Fluids or discharge should be managed by using absorbentdressings or padsLeave all intravenous cannulae and lines in situ and intravenous infusions clampedbut intactLeave endotracheal (ET) tubes in situLeave any catheter in situ with the bag and contentsContinue using universal infection measures to protect people and the scene fromcontaminationFollow the HSC’s Trust policy and procedures for preserving evidence in suspiciouscircumstances and transfer of the body to the mortuary pending examination.Sensitively inform the family of the reasons why devices are left in situ and that afterexamination they will be removed and they will then be able to spend time with the deceasedif they wish.8.6Serious Adverse IncidentsOn occasion a death may be reported as a Serious Adverse Incident (SAI) to the Health andSocial Care Board to help identify learning even when it is not initially clear if something hasgone wrong. The purpose of an SAI is to find out what happened, why it happened and whatcan be done to try to prevent it from happening again and to explain this to those involved.Relatives of the deceased will be informed and invited to be involved in this process.9. Care after deathThe body of the deceased person needs to be cared for with dignity. It is helpful if the surroundingenvironment conveys this respect. This includes the attitudes and behaviour of staff, particularly asbereaved relatives can experience high levels of anxiety and/or distress.Evidence suggests that the entire end of life care environment - including the journey to the mortuaryand how the deceased’s possessions are handled has not only an immediate impact on relatives butalso affects their subsequent bereavement and grieving.9.124The care and handling of the deceased patient’s body is the responsibility of two people,one of whom will be a registered nurse or suitably trained person.24 The registered nurse isresponsible for correctly identifying the deceased person whilst carrying out last officesand communicating accurately with the mortuary or funeral director in line with local policyand protocols.Care after Death (2015) Hospice UK and National Nurse Consultant Group9

9.2Personal care after death will be carried out within two to four hours of the person dying, topreserve their appearance, condition an

1 ‘Last offices’ is the term traditionally used in nursing to describe the final acts of care for a deceased person’s body.1 The term ‘personal care after death’ is now more commonly used to describe care of the deceased patient’s