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mortuary manager for Salisbury Foundation Trust’s hospital and community palliative care team, told Nursing Times an unpublished audit at his trust had found similar results, with the most common problems being missing identification tags and the deceased’s mouth being left open.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

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Does your trust have guidance on last offices?

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  • 27 Comments

Readers' comments (27)

  • 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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