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Nurses to lead on care after death


Exclusive: Registered nurses have been charged with responsibility for overseeing the care of patients after death, under the first national guidance on “last offices”.

The guidelines, shared exclusively with Nursing Times, outlines how bodies should be treated, how to communicate with bereaved families, and legal requirements following a patient’s death.

They have been developed by specialist nurses working with the NHS National End of Life Care Programme in response to a lack of training and guidance for the profession on the emotionally challenging work of caring for patients after death.

An investigation by Nursing Times last year suggested procedures – traditionally covered by the term “last offices” – were not carried out properly for more than half of deceased hospital patients.

The new guidelines refer to “care after death”, rather than “last offices” to move away from military and religious connotations. Although primarily aimed at nurses, they are intended to be relevant to all staff involved in the “care pathway”.

They cover a range of issues such as organ and tissue donation, coroner’s requirements, and the health and safety of staff, as well as practical guidance on how to treat a dead body such as straightening limbs and closing eye (see box, below).

The document states that in NHS hospitals and private nursing homes the personal care after death is the responsibility of a registered nurse, although it may be delegated to an “appropriately trained” healthcare assistant.

It also says staff should “convey respect” in their attitude and behaviour, highlighting that “the deceased was once a living person and therefore needs to be cared for with dignity”.

They also note that family members may wish to assist with personal care of the body due to religious or cultural requirements, and nurses must “prepare them sensitively for changes to the body after death and be aware of manual handling and infection control issues”.

For deaths being referred to the coroner, nurses are instructed to leave intravenous cannulae and lines, and endotrachael tubes in situ.

The guidelines’ lead author, Jo Wilson, a Macmillan consultant nurse practitioner and member of the National Palliative Care Nurse Consultant Group, told Nursing Times there had been a “real lack of clarity” in care after death, and this was the first time a “clear articulation of the pathway of care” had been produced.

“Nurses had seen it as their last act of care, funeral directors had seen it as the first part of their care,” she said, adding that this was the first time the deceased patient’s “journey” had been clearly set out.

Ms Wilson said the wide variety of settings in which patients died, the increased legal and health and safety requirements, and cultural differences among patients and their families, all meant there was a greater need for centralised guidance.

National End of Life Care Programme director Claire Henry said it was important that the guidelines had been driven by the nursing profession. She said: “It should help professionals and teams, but also encourage organisations to develop training and protocols in this sensitive area of care”.

Dawn Chaplin, a nurse and project director for bereavement care at University Hospitals Birmingham Foundation Trust, said because care after death was the last thing nurses could do for their patients, it was essential to get it right.

“It’s vital that the respect and dignity with which we treat patients continues after they have died,” she told Nursing Times. “This guidance provides some great overarching principles, but they can then be adapted to suit the individual patient.”

Royal Bolton Hospital Foundation Trust clinical lead for bereavement and donation, Fiona Murphy, said it was “refreshing” that guidance aimed at all staff groups who deal with patients after death was being issued.

“It’s the multi-professional team that looks after the patient after they have died, as well as the family,” she said.

Jeremy Taylor, chief executive of the patient charity umbrella organisation National Voices, said he hoped the guidance would improve communication between patients, their families, and health professionals at times of death.

“We know there is a continuing level of concern about the quality of communication between patients and health professionals, and that is always more difficult in fraught situations,” he said.

The guidance, which is endorsed by the Royal College of Nursing and the royal College of Pathologists, will be published on the end of life care programme’s website on 6 April.

It is the first in a series of forthcoming NHS publications around care after death that will include a revised version of the Department of Health’s 2005 document “When a patient dies”, which sets out recommendations for developing NHS bereavement services.


Examples from the guidance:
Personal care after death must be carried out within two to four hours of the person dying, and refrigeration of the body should occur within four hours
Jewellery should be removed in the presence of another member of staff, and staff should be aware of religious ornaments that need to stay with the body
The body should be wrapped in a sheet and lightly taped, so as not to cause disfigurement
People should never go naked to the mortuary, or be released naked to a funeral director
The dead person should be laid on their back, with arms by their sides and a pillow under their head
Eyes should be closed by applying light pressure for 30 seconds
Waterproof, strongly adhesive tape should not be used because it can be difficult to remove and leave a permanent mark on the patient’s body
If a death is being referred to the coroner, intravenous cannulae and lines should be left in situ


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Readers' comments (5)

  • Another example of traditional training lost in the move to academia.
    Wasn't this something all students were taught in nursing school ( what are those?) and had reinforced by senior staff on the wards?
    Another case of "what goes around comes around"

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  • Anonymous | 5-Apr-2011 9:24 am I'm afraid the article is a little misleading and you are a little ill informed. I am one of the Nurses who gained a degree in that 'move to academia', and during my training we were given ample training on care after death, we learned the theory of the importance of spiritual/cultural care, as well as the practical side of caring for those who have died (including last offices, etc) on placements from Nurses with experience. Nurse training has a lot of problems I agree, but I am a little tired of hearing about 'the move to academia' as if it were the end of the Nursing profession, as if it is somehow inferior to the training done in your day. Lets have a little common sense about this, shall we?

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  • I'm a 3rd year nursing student and the dignity of the patient after death was a key part of our Education from year 1, and what I've read is how I treat the deceased and it's common sence. To date I've not witness bad practice towards deceased patients, also sudden death all lines and cannulae are always left in so I don't know where all this is coming from

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  • Anonymous | 5-Apr-2011 9:01 pm
    Someone has put pen to paper, referenced it and taken the credit.

    We once had 'clinical procedures', now we have 'clinical guidelines'. Good to see from the posts that whatever or whenever nurse training was undertaken, it was of the highest quality to provide dignified and respectful patient care.

    Very fed up of this endless 'tug o' war' between degree and non-degree nurses. Just goes to show that high standards exist for both. Nurse training is only the beginning. Developing professionally is lifelong.

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  • Anonymous | 5-Apr-2011 10:23 pm, well said.

    Anonymous | 5-Apr-2011 9:01 pm, where it has come from is simply the fact that before this there was no official guidance on the procedures for last offices. Although the vast majority of us were already doing 99% of what is said in this guidance, this simply formalises those procedures to ensure that the same procedures and care are applied nationally. In that sense it is no different than any other best practice, it's just taken them until now to get it written down and formalised, and I do not think that it is a bad thing. For example, you mention that you always leave lines etc in on sudden death, which is fine, but when you explore the procedures like that, which need to be done essentially for legal reasons (coroners court, etc) then it is always helpful for us to have guidelines written down in black and white rather than falling back on 'it's always been done that way'.

    One thing I do not understand though is the move away from the term 'last offices' simply to get away from military and religious connotations. Perhaps it is my military background, but I like that term, I think sometimes the formal nature of the term can be dignified, respectful, familiar and comfortable too.

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