VOL: 98, ISSUE: 39, PAGE NO: 36
Peter Sewell, is a nursing student, European Institute of Health and Medical Sciences, University of Surrey, and is doing clinical practice at St Richards Hospital, Chichester
The laying out of the dead can be traced back 50,000 years and is considered to be a final mark of respect (Amene and Travis, 2000). Today, the laying out of the dead is often the responsibility of the nurse and any interventions must adhere to the Code of Professional Conduct (NMC, 2002).
There is always a danger that care of the dead may be delivered without forethought or rationale, because of a lack of education or recurrent practice becoming ritualised (Walsh and Ford, 1989). It is essential that nurses have a good understanding of what is required in order to provide intelligent, professional and holistic care that focuses on the individual needs of the patient and their loved ones.
When patients are unable to express themselves nurses represent their point of view (Sutor, 1993). Therefore, advocacy must be continued after a patient’s death. The Code of Professional Conduct (NMC, 2002) states that a nurse must promote and protect the interests and dignity of patients. Death is a pertinent example of when a health professional must represent the patient’s best interests in the absence of the individual’s ability to do so for themselves.
The best advocacy is based on information already gained from the patient. However, it is rare that nurses have clear directives. So what should a nurse consider? When there are no obvious religious or cultural rituals to observe and consultation with the patient’s significant others is not possible, nurses should perform last offices as described later in this article, but should do so on an individual basis rather than follow a traditionally practised ritual.
Family and friends
A respect for the patient and an awareness of the needs of the patient’s friends and relatives can have great therapeutic value at a time of grief and later (Speck, 1992). It is essential to consult relatives and friends about procedures concerning the body and any personal effects. This ensures any nursing interventions are acceptable to the patient from a spiritual and cultural perspective, thus avoiding emotional damage and possible litigation (Clark and Jacinta, 1995).
Spiritual and cultural considerations
According to Amene and Travis (2000): ‘Few of us are whole-hearted in our acceptance of the ways of our own religious or cultural groups.’ Some ethnic and cultural groups have procedures for caring for the dead that differ considerably from the Christian-based interventions described here. Nurses need to have access to information on the beliefs and practices of all groups in multicultural Britain (Box 1). One source is the patient’s hospital admission form containing records of religious beliefs. However, this is usually not enough.
Raising the subject of what treatment a patient would like when he or she is admitted is very difficult and may be inappropriate, but the Code of Professional Conduct (NMC, 2002) states that ‘identifying their preferences with regard to care’ is part of a nurse’s duty of care.
The interventions of last offices begin soon after a doctor certifies the cause of death (Mason and McCall Smith, 1991). The practical interventions of last offices provided for the patient are categorised according to hygienic, aesthetic and legal reasons. Although correct compliance with recommended practical procedures for last offices is important, the sensitive and respectful manner of the carer was found to be as important (Green and Green, 1992).
Respect for a patient’s dignity is epitomised by closing the curtain around his or her bed immediately after death (Green and Green, 1992). Talking to other patients who may have seen the patient die will help allay their fears. No confidential information should be imparted.
Before beginning the last offices the nurse should put on plastic gloves and an apron to reduce the risks of infectious contamination to staff and cross-contamination to patients from body fluids (Amene and Travis, 2000).
The main risk of infection is via body fluids (Nearney, 1998a), so intravenous devices need to be carefully removed and disposed of. Entrance sites must be covered with a waterproof dressing. Sometimes the body can continue to excrete fluids after death, so pressure should be applied to the lower abdomen to express any residual urine. As further excretion of bodily waste is not expected, the routine packaging of orifices is unnecessary (Nearney, 1998b).
Death can alter a patient’s appearance, and friends and relatives might find this disturbing. The following course of care is suggested as a means of preparing a patient’s body for those who wish to pay their respects and to preserve dignity (Amene and Travis, 2000). This intervention can be justified on the basis that the patient would have adjusted his or her own appearance had he or she been able to.
The eyes should be closed with downward pressure and the jaw closed and supported by a bandage tied around the head. Amene and Travis (2000) suggest that a pillow may be used instead of a bandage. This seems a more appropriate and dignified intervention and has less potential to cause harm or leave pressure marks on the patient’s face or neck (Green and Green, 1992). The patient’s dentures should then be removed and cleaned, the inside of the mouth cleaned and the dentures replaced. This ensures that any unpleasant odours are eradicated (Green and Green, 1992).
After undressing, the patient should be washed and dressed in a shroud according to hospital policy. Bed linen should be removed and replaced with clean sheets, and the bedside area tidied.
Dressing the patient in a shroud can make him or her look inappropriate and unnatural. There is no obvious reason that patients should not be dressed in their own, or even in hospital clothes, other than it is not always hospital policy. Next the patient’s head should be placed on a pillow and the arms and legs straightened. It has been suggested that laying the arms by the side of the body may cause the hands to blacken, and this would be a concern if relatives wished to hold the deceased’s hand later. The suggested remedy is to place the hands on the chest, but I have been unable to find any evidence to support this.
Before removal of the body to the mortuary, it should be wrapped tightly in a sheet, to avoid damage during transfer. It is fortunate that other patients do not have to suffer this dehumanising intervention when being transferred by trolley around the hospital; a set of bedrails and a careful porter would seem to suffice. The body is then taken away in a special hospital trolley designed to secrete the body, a protective gesture, but one that some might argue only furthers the perception of death as a subject to be avoided.
The final intervention involves providing a means to easily identify the patient’s body and taking an accurate record of all the personal belongings. Attaching hospital identity bands to a patient’s wrist and ankle aids identification. A notification of death certificate can also be attached to the sheet in which the patient is wrapped. The certificate should be attached with tape, rather than with a pin, as this may present a hazard to staff handling the body (Amene and Travis, 2000).
All personal items should be documented in the patient’s property book in the presence of another staff member. Care should be taken that the descriptions of items are accurate: for example, a gold ring should be described as a gold-coloured metal ring to avoid any confusion when the property is returned to the patient’s family (Dimond, 2001). The property should be placed in the patient’s own bag, documented, and returned to the next of kin or the executor of the will.
Other patients and confidentiality
Amene and Travis (2000) suggest that patients on the same ward should be spoken to after someone has died. The lack of communication and the protective act of closing the curtains does little to allay patients’ fears and may arouse suspicion and anxieties (Nearny, 1998a).
However, although it is important to discuss a patient’s death, it is essential not to disclose confidential information (Sommerville, 1993). Randall and Downie (1999) describe confidential material as that relating to the patient’s personal identity, medical information such as diagnosis, and sociological and psychological status.
They also warn that if health professionals go on to divulge this information, intentionally or accidentally, then confidentiality has been broken. The Guidelines for Professional Practice (UKCC, 1996) state: ‘The death of a patient does not give you the right to break confidentiality.’
The only exceptions are where the patient’s prior consent was gained or if divulging information is in the interests of the patient, court orders, statutory duty, public interest or the police (Mason and McCall Smith, 1991). Information may also be given to persons under jurisdiction of the Access to Medical Reports Act 1988, for example, insurance claims. According to Mason and McCall Smith (1991), preserving confidentially is not simply a legal requirement but a moral obligation. Maintaining confidentiality is the basis of trust in the nurse-patient relationship and any misuse of personal or private information could jeopardise this (Randall and Downie, 1999).
Many patients fear that their rights and standards of care will be compromised in the palliative stages of illness and after death (Sommerville, 1993). As a consequence it is important that patients and their relatives should trust nurses to protect their privacy.
Caring for the dead illustrates why nurses need to possess not only practical skills but a knowledge of the professional, ethical and legal factors that are intrinsic to holistic care. The safe, accountable and sensitive delivery of care is the only means to assure patients and relatives that nurses’ responsibilities are not forsaken after a patient has died.
Caring for the dead is a unique aspect of nursing because the deceased will never be aware of it. Although the necessity of providing a high standard of care on the basis of ‘upholding and enhancing the good reputation of the professions’ (NMC, 2002) is reason enough to provide excellent care, it is respect for the dignity and individuality of all patients that will ultimately ensure that high standards of care are provided whether a patient is alive or dead.