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Care of the bereaved when postmortems are required

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Bereavement is always distressing to family members. When the death is unexpected or its cause is uncertain a postmortem examination may be considered.


VOL: 100, ISSUE: 36, PAGE NO: 32

Kevin Teasdale, PhD, MA, RMN, CertEd, is training manager, United Lincolnshire Hospitals NHS Trust.

Bereavement is always distressing to family members. When the death is unexpected or its cause is uncertain a postmortem examination may be considered.



The inquiry into events at Alder Hey Hospital (House of Commons, 2001) showed that procedures for explaining postmortems and seeking consent were paternalistic and unsound. This led to a national review and the publication of guidelines on good practice related to postmortem (Department of Health, 2003a).



Types of postmortem
Coroners’ postmortems are carried out to determine the cause of death, and the family’s consent is not required for the examination, although it is required to retain organs/tissues for educational or research purposes. While their consent is not required, family members do need to understand what will happen in the postmortem and how it, or an inquest, may affect funeral arrangements.



Hospital postmortems are carried out to gain a fuller understanding of the illness or cause of death and to enhance future medical care. The valid consent of the family or those close to the deceased person is a legal requirement, even if the deceased has already given consent. Positive consent should be obtained from the mother for the use of her foetus or foetal tissue. Written consent must also be obtained if any tissue/organs are to be preserved from any postmortem for diagnosis, therapeutic purposes, medical education or research.



Although it is good practice to gain the patient’s consent to a postmortem this is a sensitive matter and staff should use their judgement in each case. Even then, the patient’s consent may not be binding if close family members do not also give their consent after the person has died. One of the main learning points from Alder Hey (House of Commons, 2001) is that those close to the deceased must be enabled to understand the reasons for postmortems, the processes involved and their rights.



The family must understand that consent for postmortem and consent for tissue or organ retention are separate decisions, so they may give consent for one but withhold it for the other. The discussion must also make clear the meaning of the term ‘human tissue’ (Box 1), the various purposes for its retention, and options to give or refuse consent for the retention of any particular organ or tissue and for any particular use.



It is important to recognise the complexities of modern family relationships, which include cohabitation and same-sex partnerships. When asking patients to nominate their next of kin, nurses should make it clear that this is more than a contact number and may be needed in consent issues. It should also be made clear that the nominated next of kin does not have to be a blood relative or spouse and may be a same-sex partner or even a close friend. All reasonable steps should be taken to contact the nominated next of kin or, failing that, a member of the family to seek consent. There may be more than one next of kin, but it is not necessary to trace them all if this is not practical. If no relatives can be traced and there is no evidence of an objection on the part of the deceased person, a hospital postmortem may legally be carried out, but the decision should be made by the chief executive or designated senior manager or clinician.



Discussions about postmortems (Box 2) should take place in an area with suitable privacy and comfort, and the family should not feel rushed, even if an early postmortem will be beneficial. It may be helpful for a nurse to be present who has known the deceased and family beforehand, to act as an advocate (Teasdale, 1998).



Children, babies and foetuses
Postmortem consent must be sought with great sensitivity from those with parental responsibility. If the child was in care, the local authority may have had parental responsibility, but the natural parents may still reasonably expect to be consulted. When possible, discussion should be with both parents and if either objects a hospital postmortem should not go ahead. Before the Alder Hey Inquiry (House of Commons, 2001) consent was not generally obtained for babies born dead before the age of viability (24 weeks). However, this is no longer acceptable. Written consent from the mother must be obtained regardless of gestational age. Guidance is available for health professionals on managing pregnancy loss and the death of a baby (Kohner, 1995).



Funerals and disposal of retained tissue
The deceased’s executor (or next of kin if there is no executor) has responsibility for disposal of the body. The usual options are burial or cremation, accompanied by a religious or non-religious ceremony. The same options apply after pregnancy loss, stillbirth or neonatal death. Arrangements may be made by the family or with help from the hospital, which must offer to make suitable arrangements after a stillbirth. Cremation authorities have discretion to permit cremation of pre-viable foetuses.



Although there is no legal duty to bury or cremate babies born dead before 24 weeks’ gestation, there is nothing to prevent it. Some parents who suffer an early pregnancy loss may wish to bury their baby themselves, and staff can support them, while others may not wish to be involved in arrangements for their baby and their wishes must be respected and documented.



Where family members have given consent for the retention of tissue or organs, they should be offered the option of allowing the hospital to dispose of the residual material. If this is to be incinerated, care should be taken that the method is appropriate. Some hospitals arrange for foetal material to be incinerated on its own, following weekly cleaning of the incinerator, with a short ceremony taken by the hospital chaplain. Alternatively families may want the hospital to arrange for tissue or organs to be collected at a specified time after the postmortem, so they can arrange cremation or burial. Release should preferably be to funeral directors acting for those who have legitimate responsibility for disposal of the body, including consultation with any executor.



Cultural and religious issues
Where there are language difficulties interpreters may be used, but it is important that children of the family should not be used as interpreters in relation to formal postmortems. Also, information does not have to be presented in writing - video or audiotapes can be used. Consent forms should be available in all the main local community languages.



Every effort should be made to carry out a postmortem within 24 hours of death for people of Jewish, Hindu and Muslim faiths. If this is not practical, or organs cannot be returned within that period, this should be explained. The family will need help to get certification completed before the funeral. Although they cannot refuse a coroner’s postmortem, relatives may want to discuss the practical or spiritual implications of any delay.



Bereaved people need support, and nurses may be well placed to offer immediate help. Giving clear and accurate information about the circumstances surrounding the death and any postmortem request or requirement may help relatives accept the reality of the loss. Lack of clarity about these issues is harmful, as shown by the vehement public reaction to the lack of clarity about retention of tissues and organs documented in the Alder Hey Inquiry (House of Commons, 2001). It should be noted that a postmortem that clarifies the cause of death may help people come to terms with the loss.



Hospital staff may be affected emotionally by a patient’s death, and confidential counselling, clinical supervision and debriefing should be available.



This article has been double-blind peer-reviewed.



CRUSE Bereavement Care:



SANDS (Stillbirth and Neonatal Death Society):

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