An audit was conducted on the way last offices were performed and recommendations to improve nursing practice in after-death care
Marika Hills, MSc, RN, is assistant lead cancer nurse/cancer services project manager, Cancer Services, Southmead Hospital, North Bristol NHS Trust; John W. Albarran, DPhil, MSc, RN, is reader in critical care nursing, Faculty of Health and Life Sciences, University of the West of England.
Hills, M., Albarran, J.W. (2009)Evaluating last offices care to improve services for newly bereaved relatives.
Nursing Times; 105: 23, early online publication.
The aftercare of deceased patients and performing last offices are important aspects of nurses’ role. Regularly auditing care provision can identify whether standards are being met and highlight areas in need of development.
This article outlines the background to an audit that was prompted by concerns linked to procedures for last offices. The response to initial audit findings and consequent actions taken to raise awareness and improve services are also discussed.
Keywords: Last offices, Bereavement, End-of-life care, Bereavement care
- This article has been double-blind peer reviewed
- Many newly bereaved relatives welcome and value the opportunity to view their loved ones. Their experience is likely to be affected by whether the deceased appears in a presentable condition.
- Every effort should be made to ensure the deceased appear well groomed, tidy and presentable. In performing last offices, nurses show respect, dignity and value for each patient under their care.
- Clear and accurate documentation, managing personal property and attaching identity labels are all core activities of last offices.
- Care of the deceased and newly bereaved relatives needs to be provided within a framework where communication, whether written or oral, and the involvement of service users are central to raising standards (Haas, 2003; Li et al, 2002).
- Practice around end-of-life care needs to be based on national care standards that should be available to all healthcare professionals.
- Providing honest, compassionate, individualised information and support can positively influence the bereavement experience for relatives (Haas, 2003; Li et al, 2002).
- Similarly, adjusting the care environment, supporting and giving relatives the opportunity to spend time with and touch the deceased can be important in coming to terms with the death of a loved one (Thompson et al, 2006; Li et al, 2002).
- Whether or not the patient has suffered physical trauma, the appearance of the deceased and how personal belongings are handled can transform the experience for family/carers.
- Not all bereaved relatives will wish to see their deceased loved ones, but those who do may find the experience helpful as it enables grief adjustment and to say goodbye to a life shared (Li et al, 2002).
Providing sensitive after-death care and supporting bereaved relatives can be some of the most difficult and challenging aspects of practice for nurses, but, equally, they can also be the most rewarding.
However, while 58% of all deaths occur in NHS hospitals (Department of Health, 2008), some fail to meet recommended standards for end-of-life care. The Healthcare Commission (2007) identified that over half of the 17,000 complaints received related to end-of-life care, after-death care and care of newly bereaved people.
Performing last offices is a procedure that is intended to prepare the body for its onward journey, whether this is burial or cremation (Quested and Rudge, 2003). Arranging and laying the deceased ready for transfer to the mortuary have been activities steeped in ritual and tradition which nurses have been privileged to carry out for over a century (Dougherty and Lister, 2008; Blum, 2006).
Indeed,administering last offices has a deep and emotional meaning for many nurses, as it is the final act in which respect, dignity and sensitivity to the deceased and family are conveyed (Blum, 2006).
This article presents the findings of an after-death care audit which focused on procedures for last offices and actions taken to improve standards in one large NHS trust.
A series of health policies have emphasised a commitment to improving services for dying patients and bereaved families (Waller et al, 2008; DH, 2006; 2005; NICE, 2003). These have recommended that NHS hospitals:
- Provide access to a comfortable room, privacy and the opportunity to be with the deceased immediately after death;
- Give families an opportunity to spend time with the deceased with as few restrictions as possible (DH, 2005).
The recent end-of-life care strategy places care planning and coordinating high-quality provision for people approaching the end of life, regardless of setting, as a priority (DH, 2008; www.endoflifecare.nhs.uk).
Audit of after-death care
To support the care of patients nearing the end of life and bereaved families, the trust implemented an integrated care pathway for the last days of life.
The pathway was adapted from the Liverpool Care Pathway (Ellershaw and Wilkinson, 2003), which helps prioritise and tailor care for people in the last days of life (DH, 2008).
After the LCP was implemented,a preliminary evaluation identified that some activities in after-death care provision were suboptimal. This triggered the need for a local audit with the aim of assessing whether current provision, based on trust guidelines and in relation to last offices, was being achieved.
The content for the audit tool was based on Dougherty and Lister’s last offices guidelines (using the edition current at the time) and performance was benchmarked against observed statements.
Before the audit form was used, a panel of staff reviewed it in terms of fitness for purpose, ease of use and interpretation.
During one month, 43 deceased patients were transferred to the mortuary and for each an audit form was completed and analysed.
Baseline data highlighted that some aspects of care were not reaching the accepted minimum level (Table 1).
The findings highlighted the need to improve staff understanding of the consequences and implications of not adhering to trust procedures. These are discussed below.
Table 1. Initial audit and post-recommendations audit data - evidence of change following trust strategy
|First audit (n=43)||Second audit (n=42)|
|Mouth not closed||30 (70%)||19 (45%)|
|Eyes not closed||18 (41%)||14 (33%)|
|Lack of oral hygiene||11 (26%)||11 (26%)|
|Dentures absent||16 (37%)||15 (36%)|
|Unshaven (men, n=?)||8 (17%)||0|
|Facial indentation||6 (14%)||2 (5%)|
|Fluid leakage from wounds, drains etc||6 (14%)||3 (7%)|
Ensuring the mouth is kept closed is important for many reasons.Following death, rigor mortis occurs within 2–4 hours, resulting in stiffness of the muscles and joints. This makes it difficult to move or close the jaw. The sight of a loved one with their mouth open may add to relatives’ distress when viewing the deceased.
Additionally, failure to restore dentures soon after death means that the patient’s jaw may have to be manipulated to enable their insertion. It may increase family distress if dentures cannot be placed as failure to do this can accentuate the cadaver-like features of a loved one.
In remaining sensitive to bereaved families’ needs, oral hygiene needs to be undertaken as part of last offices and before transferring bodies to the mortuary.
The initial audit highlighted that in 37% of cases denture sets were either misplaced or had been given to relatives. Some facial disfigurement was also caused by using tape to secure the mortuary sheet over a patient’s body.
In six cases, skin indentations, due to the tapes being too tightly applied over the face and head, were noted. Similar tissue markings from taping invasive lines such as nasogastric tubes too firmly onto the skin were also noted. Eight men arrived at the mortuary with an unshaved face. The combined effect of bruised/indented skin and untidy facial appearance can add to families’ grief.
Finally, the leakage of bodily fluids from wounds, drains and orifices was also highlighted as an area for action. The incidence of this was recorded in 14% (n=6) of cases in the audit sample. While this figure appears relatively small, over a 12-month period this number could reach 280 patients per year, based on an annual hospital death rate of around 2,000 across all trust sites. Therefore this is a serious issue that needs attention.
Documentation and property
Documentation of patient valuables and preferences about whether rings or other jewellery should remain with the deceased or be given to relatives has also been previously noted to be inadequate.
However, the audit identified only one set of documentation as inaccurate. None the less, this is an important area to address.
The audit raised several challenges for practice development. To examine this in a national context complaints similar to those described have been received, as previously stated over half of NHS acute sector complaints relate to end of life service provision and bereavement care (Health Care Commission 2007)
Meetings with senior nurses, chaplains, mortuary employees and academic staff were arranged to develop an action plan in response to audit findings.
The group identified that the delivery of after-death care was being hampered by three main barriers:
- A lack of staff knowledge and awareness of procedures for last offices;
- A lack of understanding and misconceptions around the role of mortuary staff;
- Time and resource constraints on nurses’ workload.
To address these deficits and improve standards in end-of-life care and last offices, a five-stage strategy was implemented and disseminated across the trust (Table 2).
Table 2. Recommendations for improving after-death care outcomes in light of audit findings
|Development of last offices policy with members of the multidisciplinary team|
|Senior nurses to review last offices practices in own clinical areas to identify training needs|
Senior nurse to identify:
|Implement a teaching programme and develop clinical competencies|
|Implement policy for reporting problems between mortuary and ward staff|
|Support for self-reflection for staff to identify areas for their own professional development|
Alongside the strategy, regular interdisciplinary workshops and teaching sessions were provided to address the latest policies, staff responsibilities and the new competency framework for after-death care.
To help train and educate new staff on the principles and standards for end-of-life and after-death care, two DVDs were produced and made widely available.
To further promote uniformity in care delivery, end-of-life care education was incorporated into the pre-registration core curriculum for student nurses attending the local education provider.
A repeat audit carried out 12 months after the original baseline phase, involving 42 patients, showed improvements in target areas (Table 1). However, 36% (n=15) of patients still did not have their dentures in place and no marked progress in respect of eye care and oral hygiene had been made.
However, Fig 1 reveals an increase in the number of patients having all key indicators for last offices met compared with the initial audit.
The strategy of recommendations has also led to increased staff awareness of after-death care, a positive change in nurses’ attitudes towards last offices procedures and better communication between the mortuary teams and ward personnel. Work continues to improve outcomes and to develop a culture that aims to provide coordinated high-quality care for patients at the end of life and newly bereaved relatives.
As part of this unique work, the trust has been awarded a King’s Fund grant for ‘Enhancing the healing environment for end-of-life care programme’. A nurse-led team is taking part in a training programme provided by the King’s Fund, which aims to improve the outdated mortuary viewing rooms at the trust.
Nurses’ contribution to providing high-quality, honest, sensitive and individualised care for dying patients and their grieving families remains a core activity.
For many families, spending time with the body of a loved one will be an important stage in the bereavement process. Nurses must therefore not underestimate their role in preparing the deceased so they appear clean, presentable and dignified.
Integrated policies and procedures must be developed with sensitivity. These should aim to: preserve the dying person’s dignity and relief from discomfort; promote an environment that meets the individual’s and their families’ needs; and that minimises distress to newly bereaved relatives.
The audit not only helped to improve care, but also raised the profile of this aspect of care. A yearly audit cycle will enable us to identify and address areas of continuing concern. The approach and lessons learnt are important for all those providing care for dying patients and their families.
Organisations and healthcare professionals have a duty to examine the quality of care they provide and ensure standards are maintained, while nurses have a responsibility to continually reflect on and appraise their practice, and ensure they remain competent in basic, advanced and technical end-of-life care competencies.
While the improvements achieved following these audits are modest, there has been a significant culture of change and a more positive commitment by nursing staff towards end-of-life care in the trust.
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