Carrying out Last Offices Part 1 - Preparing for the Procedure

Author
Dan Higgins, RGN, ENB100, ENB998, is senior charge nurse, critical care, University Hospital Birmingham NHS Foundation Trust.

Higgins, D. (2008) Carrying out last offices Part 1 - Preparing for the Procedure. Nursing Times; 104: 37, 20-21.

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The term last offices relates to the care given to a body after death. It is a process that demonstrates respect for the deceased and is focused on respecting their religious and cultural beliefs, as well as health and safety and legal requirements (Dougherty and Lister, 2004).

Nurses should ensure that last offices practice follows local guidelines. These are developed to ensure the body is treated with respect and practice is carried out with regard to the wishes expressed by the patient before death and the wishes of their family following death.

While these wishes will influence practice, nurses must ensure care is compliant with legal guidelines and have a high regard for health and safety issues.

Health and safety issues

The body, following death, must be prepared for transfer to the mortuary or funeral directors in a way that does not compromise health and safety. Nurses must apply universal infection control precautions as outlined by the RCN (2005) to last offices practice, as any infectious risk present before death will also be present after death.

Body fluids may leak after death and specific precautions, including the use of body bags, may be required. These may also be required for specific infectious diseases.

Good communication between nursing staff and the patient’s family will be required as some of these practices, such as the use of danger of infection labels, may cause offence or concern.

Legal issues

Nurses’ responsibility to a deceased patient continues until the body leaves the clinical environment. This requires the continuing need for excellent documentation standards until the body is removed.

Death must be verified before last offices commence. While this process has traditionally been undertaken by a medical practitioner, nurses who have undertaken training may verify death in certain cases.

There are circumstances where legal requirements, such as referral to a coroner and/or a postmortem examination, need to be fulfilled. Referral to the coroner is required when a death has occurred in or following specific circumstances. A list of these can be found in Consultation on Improving the Process of Death Certification (Department of Health, 2007). Senior nursing or medical advice should always be sought.

If referral is to be made to the coroner, all invasive lines should remain in situ. This should be done in a way that maintains the dignity of the patient and minimises distress to family members.

Involving significant others

Family members may wish to be involved in the last office procedures - this may be a religious or cultural requirement.

If this is the case, excellent communication will be required to ensure the procedure aids the grieving process and minimises the distress. This will involve explaining the rationale for certain aspects and providing support and reassurance. The procedure should not expose the family member to any risk, and guidance and advice should be offered to reduce these risks.

Fifty-four per cent of deaths in England and Wales occur in acute hospital beds, while 22% of people die at home (Office of National Statistics, 1999). Performing last offices in the home environment may present certain challenges to practice, and the ability to do so safely and within legal frameworks is a vital component of primary care services.

The procedure

The following is intended as a guide only and should be influenced by the patient’s preferences expressed in life and those of the family or significant others after death.

• Provide support to family as necessary.

• Ensure that death has been verified and discuss with senior nursing and medical staff any specific legal and health and safety issues that may influence last offices practice (Fig 1).

• Ascertain if there is any need for referral to the coroner.

• Discuss with family any preferences they may have or that the patient, in life, may have requested that will influence last offices practice (Fig 2).

• Collect all equipment necessary (Fig 3).

• Ensure the area where the procedure is to be performed is private and as free from interruptions as possible (Fig 4).

• Remove tubes, lines and access devices as agreed with senior medical staff (Fig 5).

• If lines are to remain, cut and spigot off any large-bore tubes and cover with gauze and adhesive dressing (Fig 6). Ensure that documentation alerts mortuary staff to
  their presence.

• Part 2 in this series discusses the preparation of the body.

References

Department of Health (2007) Consultation on Improving the Process of Death Certification. www.dh.gov.uk

Dougherty, L., Lister, S. (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Blackwell Publishing.

Office for National Statistics (1999) 1997 Mortality Statistics: General: England and Wales. London: The Stationery Office.

RCN (2005) Good Practice in Infection Prevention and Control: Guidance for Nursing Staff. London: RCN.

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