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Last offices neglected in over half of hospital deaths

  • 27 Comments

A dearth of training and guidance means nurses are failing to follow “last offices”, the simple procedures for treating dead patients with dignity and respect, a Nursing Times investigation has found.

In more than half of hospital deaths, nurses neglect to follow procedures such as straightening patients’ limbs or closing their eyes and mouth before rigour mortis sets in, according to evidence gathered by hospital trusts and shared with Nursing Times.

Such failures can mean patients have tubes and lines wrongly removed or are left with loose dressings, resulting in fluid leaks which can be distressing for relatives.

On occasions patients are not cleaned properly or are left with marks on their bodies.

Audits of how last offices are performed are rare. But Nursing Times has seen details of an audit at North Tees and Hartlepool Foundation Trust, carried out in January last year, which found problems in the way 47 out of 80 deceased patients were dealt with.

The most common error – found in 15 per cent of cases – was leakage from unsecured dressings.

The issues uncovered by North Tees and Hartlepool have been found at other trusts.

A recent audit at North Bristol Trust found problems with more than 70 per cent of the 43 deceased patients it audited. The most common being mouths left open.

Sam Goss, mortuary manager for Salisbury Foundation Trust’s hospital and community palliative care team, told Nursing Times an unpublished audit at his trust had found similar results, with the most common problems being missing identification tags and the deceased’s mouth being left open.

Karen Hill, acuity practice development matron at Southampton University Hospitals Trust, said her trust had likewise uncovered problems with the treatment of deceased patients.

Each of these trusts has made attempts to improve training and the way deceased patients are treated, but specialist nurses and mortuary technicians told Nursing Times they believe it is a problem across the country.

Mr Goss said the lack of clear guidance contributed to the problem.

“You find that in many trusts it is a case of word of mouth,” he said. “There is no national guidance. Senior nurses say ‘this is the way you should do it’ but there is never solid guidance for nurses and they can be extremely worried about what they can or cannot do.”

Ms Hill said newly qualified nurses sometimes had very little experience dealing with dead patients. She said: “If they haven’t been exposed to patients dying in their training then I think trusts should be obliged to provide that information to staff when they start in the organisation.”

Fiona Murphy, lead bereavement and donor coordinator at the Royal Bolton Hospital, agreed. She said: “Nurses require training because they are frightened of increasing a family’s grief, and they don’t want to do that.

“We have to break down the taboos around death and dying. Nearly sixty per cent of the population die in the acute hospital setting. We are duty bound to get this part of our care right. Last offices is fundamentally important.”

Failure to perform them properly was “undignified”, she said.

 “This is about giving high quality care until the end,” she said. “Death is not always a failure, people have to be allowed to die with dignity and it is our duty to get it right. We have to provide high quality bereavement care that we would expect [for] ourselves.”

A repeat of the North Tees audit this year, following a programme of nurse training, found minor problems with just five patients – indicating that although the problems cause serious distress for relatives they can be easily avoided if given sufficient attention.

North Tees mortuary manager Michelle Lancaster said the trust’s dramatic improvement had been achieved by teaching nurses what they were meant to do, encouraging them to talk about the process and having them visit the mortuary.

Southampton has also reported no mortuary complaints since the last offices policy was introduced six months ago.

What should last offices involve?

  • If the patient is not catheterised, apply gentle pressure over the bladder to allow it to drain
  • Remove and record jewellery and any personal items, unless requested or advised otherwise
  • Attend to hygiene needs, particularly hair, nail and mouth care
  • Replace dentures
  • Attempt to close the eyes, using a small piece of clinical tape if required
  • Attach identification labels
  • Dress the patient in a gown/shroud or own clothes, as required
  • Place an incontinence pad under the buttocks to contain any soiling

Poll

Does your trust have guidance on last offices?

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  • 27 Comments

Readers' comments (27)

  • rovergirl6@hotmail.com

    when i was a nurse i know here i go again. When a patient passed away ,i the nurse with one other would provide the patient with a final bed bath ,we also had the duty of packing all open areas ie the nose the anus and tie of the penis with gauze bandage ,then and only then the patient was covered with a clean sheet and the patient was taken down to the mortuary. It was not a pleasant procedure but a necessary final act as a nurse to perform or the patient in her care.

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  • rovergirl6@hotmail.com

    And one final comment we would of course provide all care listed in the above document.

    The problem continues to occur and will until we return to training our nurses rather than educating them in universities.

    Can someone please take the role of implementing the return to nurse training.
    and pay our nurses a living wage.

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  • OMG I just can't believe we have people out there who cannot do this simple but hugely important task. Don't trusts have policies and procedures that inform staff of what is expected? Don't more experienced nurses pass on their knowledge to others? What is going on with nursing? Probably chasing targets, filling in forms and trying tick all those boxes that have to be ticked..................I know we cannot live in the past, but as a student it was a task that we had all encountered before we left our first placement........

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  • I am a nurse and have been for 35 years and am still working. I used to do what Sandra says above but time has changed and procedures have changed. We now follow local policies and protocols. I still tell my young colleagues&students how we used to do it before and I still talk to my patients during the last offices and respect their privacy and dignity. This procedure takes 10 minutes , EVERY nurses should be doing it.We are all trained to do this.

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  • I cannot believe that students are not taught this most important part of our 'caring'! profession. I always looked upon it as an honour and a privilege to carry out last offices. To make sure it was done with dignity and compassion and any visiting relatives saw the patient was well cared for even after death. I am appalled it now obviously carries such little importance and not even considered part of the nurse traing programme .

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  • I am a nurse of 30 yrs, and know that many students have not encountered death in the way that many of us used to. however when my 17 yr old daughter died in Liverpool university A+E the nursing staff were fantastic, explained everything so well.

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  • as a student nurse at 48 years old and on my first placement, i dealt with my first death of a patient. I was with a young care assistant of 23 who told me what to do , she was so caring and her "teaching" of how to perfom this duty has stayed with me. After the family had seen their well cared for relative, who had been washed and clean nightie put on. She said we must wrap the body as we would "a precious item" (this way of doing things ,she said had been passed on to her from another nurse" I felt privilaged to work with this girl so young but so compassionate

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  • I worked with a male nurse who was great at performing last offices. He would wrap the body in a parcel so neat and carefully it was almost a joy to watch. I have never agreed with plugging the orifices with cotton wool, it's so undignified. We never tied a penis off either!! Whats that all about? At our hospital we have stopped using shrouds [probably to save money] but the person does look so much better in their own nightie or night gown. If a patient is discharging large amounts of fluid from the abdomen wouldn't it be better to insert a ryles tube to draw off the fluid? It dosen't take two minutes and it is so much cleaner than the fluid leaking every where.

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  • Peter Goble

    I've nursed for over fifty years so I've done last offices many times. It's a privilege, and in its own way a lovely thing to do, a last ministering to someone and an unhurried way to say "Goodbye". It should not be hurried, I reckon, as it's a way of bringing a final state of repose to what may have seemed a fraught situation for all concerned.

    Seniors can pass on a gentle and calming ambience to novices by their example, doing last offices together with them. This helps to settle the possibly anxious mind of a newcomer to death, always something of a shock or a challenge when met for the first time.

    Some of the methods mentioned above are a bit crude, tying off the penis etc. It's clearly helpful to prevent leakages during transfer to the mortuary, but less dramatic methods can be devised.

    Off-the-job training may not be the answer, and no more sniffy top-down policy injunctions please! A culture of kindness can be grown, but each of us has to start by examining at our own hearts, lovingly, patiently and methodically. In this way hearts reach out to other hearts, they coalesce, and kindness reigns, but it doesn't happen overnight.

    Nurses are used to being patient, and to growing results slowly. This is our strength, I think. Affirm it in each other constantly, and it will respond by growing, but start by affirming yourself, and believing in yourself. It might sound like sentiment to some, but there needs to be room for sentiment in nursing, without that crowding out the matter-of-fact.

    Someone will lay me out soon, I expect. It would be nice if one of my family did it, that's a nice way to arrange matters on the ward in in the home, nurse, with your help and guidance and, as no-one has mentioned it here, I thought I would, and see what reaction it got.

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  • As a nurse of only 2 years, I have read with interest all the above comments. I did not have last offices as a specific part of my training, but I did learn how to do it with dignity and respect to the patient, washing them, shaving them, talking to them, being gentle etc whilst a care assistant and a student nurse. On the elderly care ward I work on, everyone is so caring and last offices is very important to all of us. However, I have gone down the route of asking if we are allowed to ask relatives if they want a lock of hair but this was turned down which I found sad, and I read with interest including the relative in washing the patient which we do not do and I would like to put this forward to my colleagues.

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  • I have read through your "practical procedures" on last offices and it doesn't mention tubes or closing the mouth or straightening the limbs. It seems there are different policies everywhere

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  • my 1st experience of death and last offices was 30 years ago when i was just 18 and working in a care home as a domestic and what i observed has stayed with me when i started at other care homes followed by nursing in hospitals as a hca and now finally as a qualified nurse.i have done many last offices with HCAs and students since then, treating all my patients with dignity and respect, talking to them whilst i clean them and place their own night attire on, cleaning their mouths and placing their dentures inside.this has been one of my favourite parts of nursing and one that i have never and will never hurry.

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  • I have beenn a mental health nurse for 18 yrs and have performed last offices on several occassions.On the last occassion on a dementia care ward, the daughterof the patient was with him when he died.This was 3 weeks after my own father had died.I asked the daughter if she wanted to help me,which she did.I told her I was performing the last offices in the same wat I would have if I had been able to do it for my father.She washed his face and hands,shaved him,combed his hair and helped me dress him.She wrote to me afterwards thanking me for this and said she would always remember the care that I gave her father after he died

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  • i have been nursing for nearly 30 years and have seen changes in the way last offices are carried out.i try always to think of the cultural differences people would want .sometimes though it is hard to put the dentures in after death
    i hate the term last offices why not something like last respects ?

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  • I am currently a student nurse, due to qualify in September. I can only speak for myself, but I was given a 4 hour session (theory and practical session) on the theory behind and the correct ways to perform last offices. I found it very useful as I myself had never seen or dealt with a dead person before as I went straight into nursing after college.
    I just assumed that ALL universities would include this into their curriculum; clearly i assumed wrong.
    But I believe it should be taught to students and all care staff within hospitals, not only so they are competent and confident to carry out this honourable task for the patient, but also to ensure that the patient recieves the dignity they deserve!. :)
    Amy

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  • I work for a cancer charity and do night shifts. My first experience of death was on my very first shift working alone. Although i knew this was the nature of my job, i was very unprepared as i remember not being given clear training as what was expected of me when preforming the last offices on a patient that dies in our care. Now eight years later i find it an honour to be present and give care in the last moments before and after death. By following a protocol of what we are expected to do makes it a more dignified death for the patient as well as relatives/carers being present by ether explaining what you are going to do or by even asking if they wish to take part in the one last act of care they can give to a loved one. I have found that given the chance they are happy to participate.

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  • When I perform last offices I treat my patients exactly the same as I did when they were alive-talk to them and handle them gently ect, but the article states it is not acceptable for the mouth to be left open, in my experience the mouth rarely stays shut. Surely they are not suggesting we tied a bandage under the chin and round the head like older colleagues have told me they used to do-this seems more undignified to me than the mouth being open

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  • As a Healthcare assistant I can honestly say that I have not seen a trained nurse do last offices in the last five years!!! (and I do work full time) teaching of last offices to students and new HCA's also comes down to the HCA.

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  • Agree with above - thank goodness for our wonderful HCAs. The ward I work on often operates with only 2 members of staff - it is an acute surgical ward so if we have a death we are torn between "laying the patient out with dignity and respect" which I believe should not be rushed, whilst tending to the acute post op needs of the other patients. It is an impossible situation. Please, somebody up there with a blue dress and a clipboard, let us have more staff on the shop floor so we can deliver.

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  • rovergirl6@hotmail.com

    when my mother in -law died my sister in Law and myself did last offices ,both being nurses ,it was an honour and a privilege.

    As a trainee nurse in the seventies we did tie of the penis as i said in my last comment ,it was how they did it the. That was what we were taught to do. I seem to remember that i also had to attend a post mortem.

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  • within the trust where I work we still tie the penis and bung the nose,throat,vagina and rectum with cotton wool! even if there is no leakage of body fluid,and place a chest pad under the chin and bandage the head,How can this be treating the deceased with respect and dignity??

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  • laura collins

    It is sad to hear that their are incident like this. As a nurse we should still give that proper care until the last breathe of an individual. We must not disregard all the things that should be done and unfortunately those basic things are commonly neglected.

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  • Maybe the importance of the task is reflected in the name. Within our hospital great importance is placed on this aspect of patient care. The term "last offices" is never used. For our patients we provide the "Final Act of Care". Even as a nurse working in an Emergency Department within the hospital, where we may never have actually cared for the patient when they have been alive, the importance of the nurses advocacy for that patient is paramount.

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  • It would seem that there are many issues surrounding Last offices. Simply not having the skills taught in the first place is a lame excuse in my humble opinion. If you nurse the living with the ethos of respect and the aim to maintain their dignity and self respect then surely it isn't rocket science to continue to respect and maintain the dignity of those who pass away! This is somewhat of an issue for me at the moment, and do forgive my rant. My father passed away in hospital 3 weeks ago. I went to the hospital promptly after receiving the dreaded call to find my Dad looking like he had been dragged through a hedge backwards with his mouth open wide. All his belongings where stuffed into bags with no care at all. Now I know you may say there are many factors that could have contributed to this i.e no staff, busy etc BUT it takes but a second to make somebody look tidy and even less to close their mouth. That image created by a careless moment could have a lasting psychological effect on a more sensitive individual. I am a midwife and sadly we have to perform last offices too, however I am pleased to say I treat the babies with the uttermost respect. This is a very important time for the loved one's family and their transition to the grieving process, maybe this is overlooked when it clearly shouldn't be?

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  • I find it unbelievable that there are some nurses who reach the end of their training without seeing a dead or dying patient. This just sums up for me the appalling lack of experience this generation of nurses are receiving. Having qualified they are then thrown in at the deep end and expected to know how to do things properly having received a theoretical training at Uni! I trained 40years ago and when I qualified felt confident to do most things as I had seen and done it all the way through my training. How lucky we were. Regarding the problem of closing the mouth, we used to bandage the head to keep the mouth closed but that was stopped in the 80's. I always felt it was a shame as sometimes it is very difficult to close the mouth if the patient had ill fitting dentures. Another way was to place a pillow under the chin until rigor mortis set in. I always talked to my patients whilst carrying out this final duty to them and encouraged my students and HCA's to do the same.

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  • I have read the comments above with interest on this topic. I have to agree I am appalled that nurses now are not taught how to do this properly and that some patients are being treated in this way after death.

    I trained in the early 1980s and I was fortunate enough to be one of the last group of nurses to be trained in what had been the 'traditional way' - working on the wards and having placements in schools in between ward specialities. We spent an average of 11 weeks on most wards and during that time learnt all the basic procedures, and other more specialised procedures as they arose or we were in a position to take advantage of the training available. We were taught by staff who had the knowledge and experience to teach us well, (mostly - some treated us as 'pairs of hands' but this was rare).

    When I qualified in 1988 I spent some time on a general ward and moved to Intensive Care when I intended to specialise. But everywhere I worked this basic fundamental of nursing, caring for the patient who had died, call it last offices (we did) or any other name, was of paramount importance and regarded as some have observed above - the last final act of help and assistance one was giving to a patient.

    It was considered imperative to take time over performing all the procedures properly and in a dignified manner. We always spoke to the deceased while doing these things and acted with compassion and care towards them, as we would have done if they had been alive.

    On ITU I had the privilege, and it was considered so, to perform these tasks for many patients. I also had the opportunity to include patients relatives in the care if they wished to do so, and many did, and thanked me for asking them as they too felt it was an honour for them to help their relative with the last care they could give to them.

    On many occasions relatives thanked me for taking the time to wash, shave, change nightwear and comb the hair of their deceased relative, and stated it was the image they would take away with them. (And we used to place a small pillow under the chin of the deceased if their mouth refused to close properly, discreetly hidden if possible under the top sheet).

    I was always taught that the final picture of the deceased that a relative takes away when they leave the unit or ward will live with them for a long time. If the patient is unkempt, dirty, unshaven, in nightwear with blood or secretions all over it, and a dirty mouth or teeth - that is the image they will remember, and for a long time afterwards!!

    It is common sense really. What image would you want to take away with you of your father/mother/brother/sister etc?

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  • I found some of the above comments quite touching. It has never occurred to me to ask family if they would like to participate in the act of performing last offices, but I think I will broach the subject now where I feel it is appropriate, although I'm sure some of my colleagues may not agree.

    To some it may sound strange people referring to this act as an honour and a privilege, but it is true as is caring for people in the end stage of life. The final offices is a form of the physical body passing out from this life. If we think the person is born, goes through their childhood and lives their life, now this is the final concluding act. To be a part of it, is an honour. Yet another taboo to be confronted

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