National Nurse Consultant Group (Palliative Care) Guidance for staff responsible for care after death (last offices) Developed by the National End of Life Care Programme and National Nurse Consultant Group (Palliative Care) The Royal College of Pathologists Pathology: the science behind the cure Contents 1 Foreword 2 Introduction 4 Pathways of care for the deceased person 5 Care before death 6 Care at the time of death 7 Best practice and legal issues 8 Care after death 10 Personal care after death 12 Transfer of the deceased person 13 Recording care after death 14 Glossary 14 Appendix 1: deaths requiring coronial investigations 15 Appendix 2: information required by mortuary staff and funeral directors 15 Appendix 3: key stakeholders involved in the development of this guidance To be reviewed: April 2014 Foreword Caring for a person at the end of their life, individuals – representing all organisations and after death, is enormously important and with a responsibility for caring for people a privilege. There is only one chance to get after death – have demonstrated a willingness it right and it is not at all easy to coordinate to work together and share professional everything that needs to happen. This expertise. We view these people as our guidance will help with that. partners in this work and they have shaped a cogent and cohesive pathway for delivery The DH End of Life Care Strategy (2008) for of care after death that honours the integrity England set out a pathway of care covering and wishes of the person who has died. each step in the end of life care journey. Importantly, it also puts the deceased and This document is written for all health and their carers at the focus of the care, whilst social care professionals, who care for the balancing the needs of the legal and coronial person who has died and their carers, and system and the health and safety of staff. details the key elements of care provision in the immediate period following death – the This guidance is designed to underpin training final step of the end of life care pathway. for all those involved – in the pre-registration Responsibilities for caring for the deceased curriculum, post registration training, moves between differing professions and professional training and the training of carers teams - nurses, doctors, porters, mortuary – and will helpfully affect how we can explain staff, pathologists, coroners, funeral good practice in this sensitive area of practice directors and bereavement teams – and in the future. implementation of this guidance will help prevent either duplication of roles or gaps in We recognise and acknowledge the important care provision. role that all staff play in caring for the deceased and their carers. It is a rewarding In developing this guidance there was a area of care, but the lack of clear guidance review of the evidence base and then four and training can make it challenging. This rounds of consensus building for those guidance and the associated e-learning areas of practice not yet fully researched. modules are an important step in addressing Throughout this process, over one hundred this gap. Claire Henry Jo Wilson Director Macmillan Consultant Nurse Practitioner National End of Life Care Programme National Nurse Consultant Group Palliative Care 1 Introduction The nurses’ role at the end of life extends Care after death is a key responsibility for beyond death to provide care for the registered nurses in hospitals.2 In other deceased person and support to their family settings (such as care and nursing homes, and carers. The physical care given by nurses hospices and people’s own homes) those following death in hospitals has traditionally responsible can also include carers, social care been referred to as ‘last offices’. However, in staff, GPs and funeral directors. this guidance we refer to ‘care after death’, a term more befitting of our multi-cultural The diagram on page 4 shows that care after society. death, while being the last act of nursing care, is the first stage of a pathway that involves This guidance does not use the term ‘last a range of professional groups. This process offices’ because we wish to move away from leads ultimately to cremation or burial of the the link with the military and religious origins body. of nursing and the association with ‘last rites’, a Christian sacrament and prayer administered Professionals involved in this pathway include to the dying1, and because ‘last offices’ only doctors, mortuary staff, hospital porters, applies to the physical preparation of the ambulance staff, bereavement officers, body. police, social care staff, funeral directors, pathologists, coroners and faith leaders. Co- The new terminology ‘care after death’ is ordinated working between these individuals intended to reflect the differing nursing tasks and organisations is vital if the process is to involved, including on-going support of the run smoothly. family and carers. The physical preparation of the body itself will be called ‘personal care Care after death includes: after death’. • Honouring the spiritual or cultural wishes of the deceased person and their family/carers The person who provides the care after while ensuring legal obligations are met death takes part in a significant process • Preparing the body for transfer to the which has sometimes been surrounded in mortuary or the funeral director’s premises ritual. Although based on comparatively • Offering family and carers present the straightforward procedures, it requires opportunity to participate in the process sensitive and skilled communication, and supporting them to do so addressing the needs of family members/ • Ensuring that the privacy and dignity of the carers and respecting the integrity of the deceased person is maintained person who has died. It is a very difficult time • Ensuring that the health and safety of for those who have been bereaved and can everyone who comes into contact with the be emotionally challenging for nurses. body is protected 1 Nursing care of dead bodies: a discursive analysis of last offices, B Quested/T Rudge, Journal of Advanced Nursing, Mar 2003 (vol 41, issue 6) pp 553-60 2 “Till death us do part?” The nurse’s role in the care of the dead: a historical perspective: 1850-2004, C Blum, Geriatric Nursing, Jan-Feb 2006 pp 58-63 2 • Honouring people’s wishes for organ and Group (Palliative Care) led the project, tissue donation working with the National End of Life Care • Returning the deceased person’s personal Programme, the Department of Health and possessions to their relatives. other partners. The nature of the death and the context The term ‘family’, rather than ‘next of kin’, in which it has occurred affects how care has been used throughout because it is more is provided, as well as the level of support representative of modern living arrangements, needed by those who have been bereaved. where people involved may not all be blood For example, some deaths are expected or relations. With respect to organ donation peaceful while others may be sudden or and postmortem, however, consent needs to traumatic. As a result, families and carers be sought from the person with the highest are likely to have a range of responses and qualifying familial relationship.6 needs and each may also have differing views about how the person should be cared for The guidance relates to other concurrent after death. They may be very protective of national work: the deceased person, feeling that their loved n NICE development of and consultation on one has ‘suffered enough’.3 Appropriate and the end of life care Quality Standard sensitive nursing care at this time is therefore n DH revision of the 2005 guidance When a vital. Patient Dies n Revision by Cruse Bereavement Care and This guidance is for nurses and those who the Bereavement Services Association of have nursing tasks delegated to them. It is the 2001 document by the London also relevant for all health and social care Bereavement Network which it called professionals who work with people at the Standards for bereavement care in the UK* end of life, having been written with the n Introduction of new regulations on death co-operation of a wide range of related certification process. professional organisations. It sets out key principles and is intended as a guide Two new e-learning modules will also support for training, as well as for informing the the implementation of this guidance. They are development of organisational protocols for being developed by End of Life Care for All this area of care. It also aims to provide a (e-ELCA), commissioned by the Department consistent view that accommodates England’s of Health and the National End of Life Care diverse religious and multi-cultural beliefs. Programme and delivered by e-learning for Healthcare (e-LfH), in partnership with the Existing work has been referenced where Association of Palliative Medicine of Great possible. Where published research was not Britain and Ireland. For more information, go available, a consensus4 approach was taken, to www.e-lfh.org.uk/projects/e-elca. based on nationally recommended guidelines 5 *The London Bereavement Network no longer exists. developed by the Royal Marsden Hospital Standards for bereavement care in the UK does not and involving key national stakeholders (see reflect the views of the Department of Health and will appendix 3). The National Nurse Consultant be renamed as part of its 2011 revision. 3 Why relatives do not donate organs for transplant: ‘sacrifice’ or ‘gift of life’?, Sque et al (2007), Journal of Advanced Nursing, Jan 2008 (vol 61, issue 2) pp 134-44 4 Consensus methods for medical and health services research, J Jones/D Hunter, British Medical Journal, 5 Aug 1995 (vol 311, issue 7001) pp 376-80 5 The Royal Marsden Hospital manual of clinical nursing procedures (seventh edition), L Dougherty/S Lister (editors), 2008 6 Code of practice 1: consent (Consent requirements part 2: tissue from the deceased), Human Tissue Authority, 3 2009 Pathways of care for the deceased person In home and care home settings the deceased person will not transfer to Discuss with coroner theatre for organ donation.