Last offices must be performed with dignity and respect. Nurses are uniquely placed to have awareness of the wishes of patients and their grieving families
Marika Hills,MSc, RN, is assistant lead cancer nurse/cancer services project manager, cancer services, Southmead Hospital, North Bristol Trust; John W Albarran,DPhil, MSc, RN, NFESC, is reader in critical care nursing, Faculty of Health and Life Sciences, University of the West of England, Bristol.
Hills M, Albarran JW (2010) After death 2: exploring the procedures for laying out and preparing the body for viewing. Nursing Times; 106: 28, early online publication.
This second in a two part unit on last offices examines the procedures to follow when preparing the body of a deceased patient for transfer to the mortuary, and issues to consider when relatives view the body. Part 1 explored relatives’ grief reactions and the importance of providing culturally sensitive care.
Keywords: Bereavement, Grief, Last offices
- This article has been double-blind peer reviewed
- Understand the importance of specific aspects relating to last offices.
- Be aware of the value of family members spending time with a relative who has recently died.
Last offices and nurses’ role
Arranging and laying the deceased out for departure to the mortuary are duties immersed in traditional practices and is a procedure that nurses are privileged to undertake (Blum, 2006; Ronaldson, 2006). The act of conducting last offices on a deceased person involves preparing the physical body for its onward journey to either burial or cremation (Quested and Rudge, 2003). In this final rite nurses need to convey dignity and respect for the deceased and their family (Blum, 2006).
Health and safety issues
Before starting last offices, it is important to establish whether there is a risk of cross infection and whether referral to the coroner is indicated. In some instances, the presence of certain infections means patients must be prepared in specific ways and, where these may be a threat to others’ health, restrictions may be imposed on viewing the deceased.
To protect co-workers and prevent further risk of infection, it is important to inform mortuary staff about patients’ infectious status. Appropriate use of biohazard labels is advocated for notifiable infections (Health Protection Agency, 2010)and similar consideration is needed if patients have been exposed to radioactive substances or radiation therapy. In the latter case, the radiation protection officer should be contacted to guide care and preparation of the deceased (Pattison, 2008).
Taking safety precautions and applying infection control procedures are equally important when dealing with both non-notifiable infections such as those found in body fluids, and notifiable infections.
Nursing practice should be informed by integrating evidence based guidelines for preventing healthcare related infections (Pratt et al, 2007) and Health and Safety Executive (2003) guidance on controlling the risks of infection for staff dealing with human remains.
Preparing the deceased for transfer to the mortuary
Unless contraindicated, last offices include washing the deceased, performing oral hygiene, brushing hair and ensuring the bedspace is neat and tidy. If there are no religious objections, patients should be placed supine with limbs straightened.
Nurses should also be mindful that due to cultural beliefs, some patients must not be washed and in these instances mortuary staff should be notified (Pattison, 2008).
If family members decide to view their relative, possibly for the last time, the deceased must be dressed in clean nightwear and covered with a white sheet and a clean counterpane leaving their hands and face exposed. Placing flowers by the bedside locker is another simple way in which nurses can express sensitivity. For male patients, a clean shaven face is important for relatives’ memories. In some instances, it is also appropriate to place personal effects with the deceased and dress them according to requirements of their faith (Pattison, 2008).
Collectively these acts show respect and concern for families’ feelings. Depending on the situation and relatives’ level of involvement in caring for the dying patient, it may be appropriate and advisable to invite them to help with preparatory aspects and rituals, which may make them feel useful and help with grief (Neuberger, 2004). Such involvement may be especially important for parents of children who have died and families of patients who have died at home.
As soon as possible, dentures should be placed in situ (except if there is a cultural preference for them to be left out). Failure to do this soon after death means the patient’s jaw may have to be manoeuvred to ease insertion (Hills and Albarran, 2009). The absence of false teeth may add to relatives’ distress as it can emphasise the cadaveric features of the deceased. It is also important, once the patient has been washed, to tape their eyes closed.
Puncture wounds as a result of venous cannulation and chest drains can result in the loss of several litres of fluid despite the use of occlusive dressings (Hills and Albarran, 2009). If it is necessary to place the deceased in a body bag, for example to reduce the spread of infections, the circulation of warm air can increase the rate of decomposition, resulting in skin deterioration. If any bodily fluids escape, the secretions remain in the sealed bag and this rapidly hastens the rate of decomposition and causes skin slippage (meaning the skin can become fragile and may slough off either through touch or movement; this can potentially alter the appearance of the deceased). Consequently, the skin, and possibly hair, may be stained and discoloured, and have an offensive smell. In addition, the potential for cross infection among healthcare staff increases. Open wounds and other incisions should therefore be securely covered and taped down with clean dressings.
Deterioration of the body due to fluid loss can be prevented by spigoting off lines such as urinary catheters, intravenous lines and chest drains (Hills and Albarran, 2009). In addition, if fluid leakage is anticipated, it is recommended that body orifices are packed (Dougherty and Lister, 2008). While the absence of national guidelines in this area has been a source of controversy (Frost et al, 2010), a nurse consultant group is now working with the Department of Health to develop good practice guidelines for performing last offices.
Once the deceased has been washed, and viewed by family members, the body is wrapped in a shroud and covered with white sheets, and prepared according to local policies. Attaching identification labels and documentation of the death is essential. In the absence of documentary records, doctors/nurses are required to identify patients visually. In exceptional circumstances or where healthcare professionals are unavailable, relatives may be required to undertake formal identification. This could be distressing for them, but it may be necessary for medicolegal reasons.
Nursing documentation should be checked for information regarding patient valuables. Patients’ preferences might include that specific jewellery stays with them or that it is all handed to the family. Because rings can slip off during transfer, these should be secured with micropore.
Returning belongings to relatives must be conducted with empathy and respect. Returning patients’ property after death is often distressing as it can provoke painful memories for relatives; if this task is mismanaged or personal items are lost it can result in a complaint (DH, 2005). To guarantee smooth coordination of care for the deceased and newly bereaved, nurses must use good communication skills while liaising with several agencies and hospital services, and also incorporate service users’ perspectives to further improve standards of care (Becker, 2009; Hills and Albarran, 2009; Powis et al, 2004). Families should be givenclear information verbally, supported by written documentation, so they understand the tasks that need to be undertaken following death, including guidance on how, when and where to register the death.
Post mortems are usually performed to establish the cause of death, if this is not known. Other reasons include advancing understanding of disease. Aside from helping to raise clinical standards, post mortems are important to legal authorities, clinicians and families, and the latter may find comfort from knowing the cause of death. Coroners usually decide whether a post mortem is required and key reasons for referral include:
- Sudden and unexpected deaths (accidental or death due to unusual circumstances);
- Public health concerns;
- Iatrogenic causes (death as a result of medical procedures or treatments);
- The doctor certifying the death is uncertain about the cause.
Most post mortems are undertaken within three working days after death and very occasionally within 24 hours. They fall into two categories:
- Legal post mortems: these are requested by the coroner, although not all referrals result in an autopsy and these can only be challenged through a legal ruling;
- Non legal post mortems: these follow a request from the consultant in charge of the patient. This request might be to confirm the precise cause of death and next of kin consent is necessary, unless the patient’s stated preferences in relation to post mortem are known. Family members can request a post mortem but it may only be accepted if certain criteria are met (Pattison, 2008; DH, 2003). Next of kin can request a “limited” post mortem, where they can specify that certain organs remain intact.
In many religious faiths, burial must take place within 24 hours of death (Pattison, 2007). Delays resulting from post mortem investigations add to grieving relatives’ emotional burden. In particular, in the case of sudden death, family members may be in a state of shock and too overwhelmed to make informed choices or make sense of information. Nurses must make time for grieving families and provide simple and clear advice about the procedures involved in a sensitive and considered manner. Nurses can point relatives to helpful information on post mortems in DH (2003) guidance.
Organ and tissue donation
Organ donation following death can be a difficult and emotional issue for many. While it can save lives and improve others’ quality of life, currently demand is greater than the supply of organs (DH, 2008a).The Organ Donation Taskforce (DH, 2008a) produced 14 recommendations to improve the national availability of organs and tissue. Even where criteria for organ donation are not met, many other kinds of tissues such as corneas, bone and heart valves can be donated and these do not necessarily depend on age or underlying physical condition.
Having an understanding and documented evidence of patients’ wishes before death can be helpful in guiding future actions and decisions. However, when these are not known, having sensitive discussions and offering relatives the opportunity to consent after death can give them a sense of satisfaction that the death has contributed to others’ quality of life. If patients are on the organ donation register this is less problematic. Although many nurses may find raising the issue of organ or tissue donation with newly bereaved families distasteful and embarrassing, in this instance they have a moral and professional duty to respect the stated wishes of the deceased (DH, 2008a).
Involving the transplant or tissue transplant coordinator early can be helpful in supporting and guiding families with decision making (Sque et al, 2006). Many families fear that their relative will be surgically mutilated, so providing clear and honest explanations of what is involved and who will conduct the retrieval of organs or tissues can allay any misconceptions or fears. The newly formed NHS Blood and Transplant service aims to streamline and coordinate services for organ and tissue donation across the UK (www.uktransplant.org.uk).
Viewing the body
When a patient dies, it is a normal for relatives to find it difficult to accept. Seeing, touching and spending time with the deceased offers family members an opportunity to touch their relative and say goodbye. It is also a confirmatory process which aids acceptance. Faulkener (1995) suggested that viewing can facilitate the initial stages of grief, a process which Worden (1991) WorWdescribed as “using the body of the deceased to facilitate grief and actualisation”. However, nurses should be cautious when inviting families to view relatives if the death has been traumatic and/or involved physical mutilation or dismemberment.
While not all relatives wish to view or spend time with the body, it can be a beneficial and therapeutic experience for those who do. Current UK policy (DH, 2008b; 2005) recommends that family members who wish to view the deceased should be enabled and outlines clear directives which cover three key areas for practice:
- Respecting the privacy, dignity and security of the deceased;
- Providing appropriate privacy for the bereaved to view the body;
- Allowing time for relatives to spend with the body (this may depend on whether there are medicolegal objections or infection control risks which may restrict access).
Nurses need to give attention to the care environment, presenting the body in a dignified manner, giving support and providing opportunities for viewing the deceased. These interventions and how they are delivered can help to minimise family distress. However, it is also important to respect patients’ and families’ wishes about their after death care. The Liverpool Care Pathway (Ellershaw and Wilkinson, 2003) recommends assessing patients’ and relatives’ cultural and religious beliefs at the time of diagnosing the dying phase where this is possible. This supports care planning for the time immediately after death, although this information may not be available in cases of sudden death.
Families may express preferences about the way the body is presented or handled and these should be respected when the body is being prepared for viewing (DH, 2005); Box 1 outlines some key issues to consider.
Box 1. Preparing for viewing
Although nurses should not make assumptions about preparing the body for viewing, areas to consider should include:
Preparing the environment for viewing:
- Where possible provide a private room for viewing;
- Provide seating;
- Remove medical equipment;
- Change sheets and replace with clean bedding;
- Ensure the bedside area is tidy;
- Ensure other patients nearby receive appropriate support and communication about what is happening;
- Place photographs or similar of the deceased on the locker;
Preparing the body for viewing:
- Position the body in alignment, but consider religious beliefs;
- Patients should be washed unless forbidden due to religious beliefs;
- Consider involving relatives in washing the patient;
- Comb hair and for male patients consider shaving stubble;
- Clean the mouth and ensure dentures are placed in situ and close the mouth (note that some cultures may wish dentures to be removed);
- Close the eyes by applying light pressure for a few minutes;
- Ensure the face and hands are exposed;
Preparing the family for viewing:
- Ensure sensitive communication of what to expect and what the deceased will look like;
- Ensure that a nurse escorts the family and remains available;
- Ask relatives whether they would like a spiritual leader to be present to give blessing or perform other appropriate ceremonies;
- Ensure privacy;
- Give relatives adequate time to spend their last moments with the deceased.
Source: DH (2008b); (2005)
Providing individualised, competent, culturally sensitive, thoughtful and dignified care for dying patients and relatives throughout the dying phase, after death and into bereavement is complex and challenging. However, due to the trusting relationships that nurses develop with patients and families, they are uniquely placed to ensure quality care at the end of life.
While performing last offices can be emotionally difficult and distressing, it can also be therapeutic and rewarding.
Delivering quality, evidence-based end of life care involves gaining a wide and detailed understanding of core elements of care and engaging in supported clinical learning opportunities to develop skills in practice. Key features of quality care include a trusting relationship, providing individualised care that is sensitive to cultural and religious beliefs, involving patients and families in decisions and promoting respect and dignity throughout. For nurses to achieve these objectives, they must be skilled and effective in communication, in showing concern, empathy and compassion and have awareness of the distinct needs and wishes of their patients and grieving families.
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