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mortuary manager for Salisbury Foundation Trust’s hospital and community palliative care team, told Nursing Times an unpublished audit at his trust had found similar results, with the most common problems being missing identification tags and the deceased’s mouth being left open.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