Bereavement Policy. and End of Life Procedure. Documentation Control. Mortuary and Bereavement service, Child undertaken

Transcription

1 and End of Life Procedure Documentation Control Reference CL/CGP/076 Approving Body Directors Group Date Approved 26 Implementation date 26 Supersedes n/a Consultation Mortuary and Bereavement service, Child undertaken Bereavement Facilitator, Resuscitation Officer End of Life Strategy Group, Department of Spiritual and Pastoral care Nursing Guidelines group, Human Tissue Management Group, Corneal Retrieval Nurses, Hospital Charities Transplant Coordinators, Patient Partnership Group Date of Completion of Equality Impact Assessment Date of Completion of We Are Here for You Assessment Date of Environmental Impact Assessment (if applicable) Target audience All nursing and medical staff All staff who have contact with deceased patients and their relatives/friends Supporting Documents and References(s) National End of Life Care Programme (2011) Guidance for staff responsible for care after death Office of National Statistics/Home Office (2008) Guidance for doctors completing medical certificates of cause of death in England and Wales When a patient dies: Advice on developing

2 bereavement services in the NHS Department of Health October 2005 NUH Property Policy NUH Consent to Post Mortem Examination Policy Breaking bad news guidelines NUH Provision of Spiritual and Pastoral Care Review Date October 2015 Lead Executive Medical Director Author/Lead Manager Bereavement Service Team Leader Bereavement Service Operational Manager Further Bereavement Service ext 61726/61113/56720/63551 Guidance/Information Page 2 of 54

3 Contents Paragraph Title Page 1. Policy Statement 4 2. Scope of the policy 4 3. Before Death 5 4. After Death 6 5. Medical Responsibilities Bereavement Service Responsibilities Other issues Equality and Diversity Equality and Environmental Impact 19 Assessments 10. Implementation and Monitoring Plans W We Are Here for You Advice Associated Documents and References 21 Appendix 1 Witnessed Resuscitation 23 Appendix 2 End of Life Procedure 24 Appendix 3 Verification of Death Procedure 40 Appendix 4 Deaths requiring a quick turnaround 43 Appendix 5 Circumstances in which a death needs to 45 be reported to the Coroner Appendix 6 Body bag notification 48 Appendix 7 Obtaining mortuary wrist bands from Notis 49 Appendix 8 Tissue Donation referrals 50 Appendix 9 Equality Impact Assessment 51 Appendix 10 Certification Of Employee Awareness 54 Page 3 of 54

4 1 Policy Statement 1.1 NUH is committed to providing a high standard of care for those whose relative or friend dies in our hospitals. The bereaved should be treated with sensitivity, kindness and understanding. Information should be given clearly, and supplemented by written documentation. Our aim is to minimise family distress when dealing with the practical aspects of a death (sudden or expected) by delivering a seamless and co-ordinated service. 1.2 NUH recognises that bereavement care starts before the patient dies and extends beyond the removal of the deceased from our premises. 1.3 This Policy is consonant with relevant Department of Health guidelines with regard to 2 Scope respect for the individual equality of provision choice communication information partnership recognising and acknowledging loss, environment and facilities staff training and development staff support health and safety audit and review 2.1 The policy applies to all adult and paediatric deaths in our hospitals. 2.2 The policy also applies where the deceased is brought in dead to the Emergency Department, or admitted to the Mortuary under the authority of HM Coroner. Page 4 of 54

5 2.3 This policy does not apply to stillbirths and pregnancy losses. Please see Cross-Town Guidelines for Pregnancy Loss in the Second and Third Trimester for Labour Ward. 3 Before Death 3.1 Breaking Bad News Staff should conform to the Guidelines for Communicating Bad News with patients and their families [NUH Intranet] when informing the patient or relatives that the patient is near to death or dying Staff should respect the wishes of the patient concerning their expected death and discuss this sensitively with them (and with relatives if appropriate) [NUH Resuscitation Policy] Family requests to be present at attempted resuscitation should be dealt with sensitively [Appendix 1] Staff should make every effort to ensure that privacy and quiet surroundings are made available for the dying patient and their family. If the family wish to stay with the patient, their wishes should be accommodated wherever possible. Staff should be sensitive to the needs of relatives with regard to refreshments in clinical areas All patients expected to die should be cared for on the Trust s Last Days of Life Pathway: umentation.aspx Staff should inform the hospital palliative care team (QMC / City 54977) when a patient is started on the pathway by contacting so additional support may be offered The Liverpool Care Pathway documentation is available from Trust s palliative care website [NUH Intranet]. Page 5 of 54

6 4 After Death 4.1 The medical and nursing staff have responsibility for care of patients after death, including completion of necessary documentation. The bereavement service is available to facilitate the practical arrangements with relatives of the deceased, such as handing over death certificates and property. 4.2 Verification of Death The procedure for verifying death is at Appendix If the patient has been placed on the Last Days of Life Pathway, a nurse deemed competent can verify the death, provided that none of the following exceptions apply: a. The death of a child (<18) b. Deaths which occur within 24 hours of Hospital admission or where no firm clinical diagnosis has been made c. Death in the immediate (72 hours) post operative or post invasive procedure period. d. Death following an untoward incident i.e. fall; fracture; or drug error e. Death of a patient with a notifiable disease. f. A Death in which there are any concerns about clinical practice. g. Any unclear or remotely suspicious death If death is unexpected or the patient is not on the Last Days of Life Care Pathway a doctor must verify death. 4.3 Informing and Care of Relatives The person in charge of the relevant clinical area is responsible for ensuring that the appropriate person(s) are informed of the patient s death Staff should conform to the guidance in NUH Liverpool Care Pathway when informing relatives. Page 6 of 54

7 4.3.3 If the patient died alone, guidance is available in Communication in End of Life Care [NUH Intranet] Where there are no known relatives, the nurse in charge is responsible for ensuring that reasonable enquiries are made to locate a next of kin. These could include looking through clinical notes of previous admissions, contacting a community care setting if appropriate, contacting the GP, social worker or asking other visitors to the deceased. If a next of kin cannot be found, then the nurse in charge must ensure that the steps that have been taken are documented, and inform the bereavement service. 4.4 Spiritual and Cultural Requirements The Trust has a Department of Spiritual and Pastoral Care and a Multi-faith Centre to which families and patients can be referred. Further information can be found in the Provision of Spiritual and Pastoral Care policy ref CG/CM/ The nurse in charge of the ward is responsible for ensuring that local procedures are in place to identify religious needs and to make appropriate onward referral(s) The Trust is mindful that there are some religions and cultures that have special requirements with regard to funeral arrangements (and hence death certification). For instance some cultures require the funeral to take place within 24 hours of death. Staff are expected to do what they can to facilitate such wishes but this must not be at the expense of their legal duties requirements, and must not be to the detriment of the Trust as a whole, or to other service users who are equally entitled to an efficient service. The procedure for dealing with deaths that require a quick turnaround for certification (for whatever reason) is at Appendix Written information At the time of death (or when next seen) staff should give relatives either Information for those who are Bereaved (adults) or Coping with a Death of a Child The Trust is committed to ensuring that relatives or patients whose first language is not English receive the information they need. In these circumstances the Trust interpreting service must be used. If Page 7 of 54

8 translations of documentation are required these can be made available via the Trust Communication Department. 4.6 Care of the deceased at the Time of Death All staff working in adult areas should be aware of the End of Life Care procedure [Appendix 3]. Staff working in Nottingham Children s Hospital should be aware of the Bereavement Care Guidelines following the death of a child. These guides are available in all inpatient areas The manager of each clinical area in responsible for ensuring that there is a local procedure to be followed by a designated person(s) after a death (to ensure that all the necessary procedures have been carried out). There are separate checklists for adult and child deaths, which are available to order as a stock document through procurement. 4.7 Patient s property (and mementoes ) The nurse in charge of the clinical area is responsible for the custodianship of all property held by the deceased at the time of the death When a patient dies in a clinical area it is recommended that their property is given directly to the family if they attend Personal jewellery should be left on the patient s body, secured and documented appropriately in accordance with End of Life Procedure [Appendix 3]. If a member of the family requests that jewellery be removed, the ward staff are responsible for ensuring that they are entitled to receive this, and the items should be receipted by the family member on a Trust indemnity form Property not collected at the time of death may be (1) retained securely on the ward for later collection or (2) sent to the Bereavement Centre for collection by the relatives. The nurse in charge of the patient is responsible for ensuring that property is packaged appropriately and securely, and itemised [GGFIN002 Patients Property Policy and Procedure]. The bereavement centre will not accept property that does not comply with packaging requirements or that is received after the relatives have attended the bereavement appointment. Page 8 of 54

9 4.7.5 Some areas offer mementoes to the family such as handprints of the deceased. If an area chooses to do this, then the area manager is responsible for ensuring that (1) there are appropriate resources available for this purpose, (2) appropriate consent of the next of kin is obtained before any procedures are carried out, and (3) there is a procedure which ensures that the correct mementoes are given to the correct relatives. Such mementoes should be handed over on the ward (except in a paediatric death when they may be given via the Child Bereavement Team). Such mementoes are not patient property and must not be sent to the Bereavement Centre. 4.8 Transfer of the Deceased to the Mortuary Under no circumstances must the deceased be released from a clinical or public area in the Trust All deceased patients must be transferred to the mortuary prior to release to the funeral directors or other appropriate person. The Mortuary provides a 24-hour service; out of hours an on-call service is provided (via switchboard). Arrangements can be made for relatives to accompany the deceased to the mortuary (where the relatives can wait in the Chapel of Rest or reception area while the patient is released) The deceased should be transferred to the Mortuary as soon as possible after any relatives have left the ward. Such transfer should be within 2 hours. If there is a longer interval ward staff should contact the campus silver on-call manager. 4.9 Death Certificate Issue The consultant in charge of the patients care is accountable for issuing the medical cause of death certificate. S/he may delegate the responsibility to a member of the medical team working under their direction The nurse in charge is responsible for ensuring that the appropriate Consultant (or their team) is made aware of the death so that a certificate can be issued (or Coroners referral made). Page 9 of 54

10 4.9.3 The nurse in charge is responsible for ensuring that the correct Consultant is named on the death administration form, so that they can be contacted in the case of delay or any queries Death certificate books are held on most wards at QMC campus and in designated areas at City Campus. Death Certificate books in the clinical areas are in the custody of the nurse in charge It is recommended that in adult deaths the death certificate is given to the family in the Bereavement Centre. If a clinical area wishes assume the responsibility of giving the death certificate to families, they must ensure (1) that the family are given proper information about registration and (2) ensure that a letter is generated for the deceased s GP detailing the cause of death Informing the GP and NUH electronic systems Each clinical area should have a designated person responsible for informing the GP on the day of the death Each clinical area should have a designated person responsible for for updating NUH electronic systems (Notis/PAS), and for ensuring that any further appointments are cancelled Medical Records The clinical notes for adults should be forwarded to the Bereavement Centre. The notes must be filed appropriately, with all loose papers secured and placed in the correct place Death certification (and issuing) and Cremation Forms take priority over clinical coding. Page 10 of 54

11 4.12 Organ and Tissue Donation It is the policy of NUH to promote organ and tissue donation for the purposes of transplantation. NUH has an established Donation Committee, a Clinical Lead for Organ Donation, two Specialist Nurses for Organ Donation and two dedicated Corneal Specialist Nurses. Potential deceased organ donors can be referred to the Specialist Nurses for organ donation based at Queens Medical Centre or via the Midlands Organ Donation Services Team 24 hour pager The Specialist Nurse for organ donation will access the Organ Donor Register, and discuss the option of deceased donation with the next of kin. Further information for any family is available by contacting the on-call Specialist Nurse for Organ Donation (switchboard) Information about donation of tissue for transplant is available for all families Information about donation of tissue for transplant is available for up to 24 hours after a death The consultant in charge and sister/charge nurse are responsible for ensuring that families are referred to the appropriate specialist organ donation services [Appendix 10] where there is a spontaneous request for donation and/or the deceased carried a donor card or recorded their wishes to donate on the Organ Donor Register. 5 Medical Responsibilities 5.1 Issue of the Death Certificate (Medical Certificate of Cause of Death) The Consultant in charge of the care is accountable for ensuring that the death certificate is completed or the death is referred to the Coroner in the timeframe prescribed by the Trust [5.1.2] The death certificate should normally be completed by a member of the medical team within 24 hours of the death. In exceptional circumstances when this is not practical (eg death at a weekend Page 11 of 54

12 requiring a referral to the Coroner) the certificate must be completed by the close of the next working day Death certificate books are held by the Bereavement Centres at each campus, where the certificate may be completed if this is considered to be more convenient. Clinical areas can obtain certificate books from the Bereavement Centre Out-of-hours, death certificate books are available at both mortuaries, and on City campus on the Specialist Receiving Unit If the clinician is unable to certify a cause of death, or if the death requires referral to the Coroner [Appendix 5], the clinician must contact the Coroner s office before a certificate is completed. See section If the timeframe of is breached, this will be recorded as a patient safety related incident in NUH Datix system for Quality, Audit and Governance. 5.2 Deaths reported to the Coroner The Consultant in charge of the care is responsible for ensuring that, when required, deaths are reported to the Coroner via the Coroner s office. The Consultant may delegate this duty to a member of the medical team but remains accountable for the process Deaths must be reported to the Coroner s office within the same timeframe as certificates issued, within 24 hours of the death or on the next working day. There is no requirement to report a death out of normal office hours unless urgent advice is required Doctors reporting deaths to the Coroner s office must have reviewed the relevant medical history and be prepared to be questioned about elements of the medical history which may have contributed to or be associated with the death It is expected that trainee doctors reporting deaths to the Coroner will have discussed the death with a senior colleague prior to reporting The clinician referring the death must document in the notes the reason for the referral and the information supplied to the Coroners office. The Coroner has provided a comprehensive list of all Page 12 of 54

13 circumstances which need to be reported (appendix 5) and all such circumstances must be included in the conversation. Details of the report made to the Coroners office must be recorded on the Coroner Report Form and retained within the medical records In complex situations where care of the patient has involved Consultants from more than one specialty the referring team must discuss the cause of death with the other specialty prior to reporting the death to the Coroner s office The doctor who reports the case to the Coroner must give contact details including a telephone number and hospital bleep number. If the doctor is not contactable, then the Coroner s office will be advised to contact the responsible Consultant named on the Death Administration Form Where a death is reported to the Coroner, the Consultant responsible for care must ensure that the reasons for the referral and process are explained to the next of kin. All such conversations should be fully recorded in the medical notes. For further advice please see CL/CGP/010 Consent to Post Mortem Examination Policy. 5.3 Cremation forms Once advised of the requirement for a Cremation Form by the Bereavement Service, it is the responsibility of the clinical team to ensure that part 4 of the Cremation Form is completed. 5.3 Consented Post Mortem examinations Nottingham University Hospital Trust is committed to ensuring that sufficient post mortem examinations are undertaken to provide teaching, and for audit purposes. Family requests for a post mortem examination should typically be accommodated (and any refusal must be agreed with the Consultant in charge). The Bereavement Service should be notified of such requests For post mortem examinations requested by clinicians please see CL/CGP/010 Consent to post mortem examination Policy. Page 13 of 54

14 5.4 Communication to the GP The Consultant with most recent responsibility for the deceased s care is responsible for sending written communication to the GP as soon as practicable. 5.5 Deaths of patients under the age of 18 years The Consultant with most recent responsibility for the deceased s care is responsible for reporting deaths of patients before their 18 th birthday to the Child Death Review Team [Ext 67444]. Bereavement Service Responsibilities 6.1 NUH Bereavement Service is managed by the Pathology Directorate (Cellular Pathology). The service consists of a mortuary, Bereavement Centre and specialist services at each campus. A member of the bereavement service can be contacted via switchboard 24 hours a day. 6.2 The Bereavement Service is responsible for care of the deceased from receipt into the mortuary to release to the funeral directors, and for providing specialist support and information to relatives, including giving the death certificate and facilitating consent for post mortem examination. 6.3 For deaths which occur in the Nottingham Children s Hospital, the Child Bereavement Team also provide support and information to relatives and staff. 6.4 Viewing in the Chapel of Rest During the first twenty-four hours after a death, relatives may view the deceased at any time by arrangement through Bereavement Services After the first twenty-four hours, viewing is restricted to the hours of 8:30 to 4:30pm, Monday to Friday, unless there are exceptional circumstances (such as relatives travelling considerable distance). The decision to allow a visit outside of these hours will rest with the on-call bereavement staff. Page 14 of 54

15 6.4.3 Permission from the next of kin is required for visitors other than immediate family All relatives visiting the Chapel of Rest should be accompanied by a member of hospital staff (or police officer when necessary) NUH reserves the right to refuse admission to the Chapel of Rest to any person who appears to be under the influence of alcohol or drugs, or who is verbally or physically aggressive to staff. 6.5 Death Certification and Cremation forms The next of kin of adult patients who die in the hospital should be asked to contact the appropriate Bereavement Centre on the working day of the death, or on the next working day It is a legal requirement on the next of kin to register a death within 5 working days. The death certificate will typically be given to the person who will register the death by the Bereavement Service, unless circumstances dictate otherwise. There is a facility for the registration of death at both campuses, and it is often easier for the certificate to be collected and the death registered at the visit In relation to death certification, the Bereavement Service is responsible for a. informing the family when the death certificate is completed b. handing over the certificate to the person registering the death c. facilitating a registration appointment for the family where posdsible In exceptional circumstances, the Bereavement Service will attempt to locate a doctor who can complete the death certificate or refer to the Coroner. However, the responsibility for ensuring that the certificate is completed remains with the Consultant in charge of the care. 6.6 Cremation forms The bereavement service is responsible for coordinating the completion of cremation forms. Page 15 of 54

16 6.6.2 The bereavement service are responsible for ascertaining whether cremation forms are required, either by asking the relatives or by receiving communication from the funeral directors The bereavement service are responsible for informing the medical team that a cremation form is required, following which it is the responsibility of the clinical staff to ensure that part 4 of the form is completed. While the bereavement officers will offer help and advice on this process, it is ultimately the doctor s responsibility to ensure that the form is completed correctly Part 5 of the cremation forms has to be completed by a suitably qualified medical practitioner who is unrelated to the care of the deceased, and has no connection with the family. Whilst this will be coordinated from the bereavement service, the medical practitioner is acting independently of the Trust and is responsible for ensuring that the whole of the form is completed correctly. 6.7 Property All property that is received into the bereavement service is dealt with in accordance with NUH Policy GGFIN002 Patients Property Policy and Procedure The bereavement service will not accept property from clinical areas that is not compliant with the Trust policy All property must be received into the bereavement service either before a bereavement appointment takes place, or within one working day of the death. Property received after this time will be returned to the Clinical area. 6.8 Patient identification Deceased patients must have identification in place in line with NUH Policy CL/CGP/037 Positive Identification of Patients Procedure. 6.9 Deaths where there are no next of kin Where there is no next of kin the bereavement office will liaise with the Nottingham City Council bereavement service who will arrange the funeral. Page 16 of 54

17 6.10 Notification of Death to External Agencies For all adult deaths, the Bereavement Service will complete a standard template on Medical office, which will contain details of certified cause of death and will be electronically posted to the GP. This is interim information that is intended to provide more information to the GP, and does not replace the Consultant s letter Tissue Retrieval and Post Mortem examination It is the policy of the mortuary to only carry out diagnostic or retrieval of tissue procedures with appropriate consent of the family or under the jurisdiction of the Coroner. No diagnostic or invasive procedure will be undertaken without appropriate written authority. For further information see CL/CGP/010 Consent to Post Mortem Examination Policy. 7 Other issues 7.1 Deceased brought in from the Community Only when an attempt at resuscitation is deemed appropriate should the patient be brought into the Emergency department If the patient is already deceased, but has not been verified dead, a doctor from the Emergency Department should confirm death in the ambulance and the deceased will then be conveyed to the Mortuary Where death has been verified by a competent professional in the community, an adult deceased should be taken directly to the mortuary Paediatric deaths (aged 0-17) should be brought into Area 1 of the Emergency Department, rather than going directly to the mortuary. 7.2 Deaths where there may be Interest from the Media Any enquiries received from the Media must be referred to the Communications Office. Page 17 of 54

18 7.3 Financial Donations to the Trust The bereaved may wish to make a financial donation to the Trust. Such donations must be made through the Special Trustees for Nottingham University Hospitals who are registered with the Charity Commission to receive donations from local people who want to donate money for the benefit of patients Donors can be assured that the support made available via donations is to provide additional benefits to patients, visitors and staff or to assist with research. Charitable funds are not used to subsidise those core services that are properly the responsibility of the Trust or the University Donations can be gifted to a specific clinical area or service via a designated fund, but a general donation to the hospital can also be made. Cheques should be made payable to Special Trustees for Nottingham University Hospital. Further information can be obtained from the Intranet or by contacting ext Follow up The bereaved should be advised of the services of the Bereavement Centre and Hospital Department of Spiritual and Pastoral care. The Bereavement Service has details of help services that the family may wish to use, although the Trust takes no responsibility for the service that these provide The bereaved should be made aware of the PALS service, so that they can make comments or raise questions Children s Services should advise families of the services provided by the Child Bereavement Team as appropriate After-death care is an important part of the medical care pathway, and medical staff should, wherever possible, make themselves available to discuss post mortem findings or answer questions related to care of the deceased The Trust encourages clinical areas to send a letter of condolence approximately six weeks after the death Counselling may be required by some individuals if they are struggling to cope with their bereavement. However, this is a Page 18 of 54

19 service which is usually indicated some time after the death, and is therefore, in normal circumstances, more appropriately accessed via the bereaved s GP. 7.5 Staff Support The Trust is aware that staff may find the death of a patient stressful, and provides both local and corporate staff support. All clinical areas should have processes to debrief staff after the death of a patient, and managers should facilitate necessary reflection and discussion by members of staff The Chaplains and Multi-faith Officer also provide support to staff at times of the death of a patient (and after personal bereavement). Occupational Health also offer help if the death or bereavement affecting a person s ability to work. 8. Equality and Diversity Statement 8.1 All patients, employees and members of the public should be treated fairly and with respect, regardless of age, disability, gender, marital status, membership or non-membership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social & employment status, HIV status, or gender re-assignment. 8.2 All trust polices and trust wide procedures must comply with the relevant legislation (non exhaustive list) where applicable: Equality Act (2010) Employment Relations Act (1999) Rehabilitation of Offenders Act (1974) Human Rights Act (1998) Trade Union and Labour Relations (Consolidation) Act (1999) Part Time Workers - Prevention of Less Favourable Treatment Regulations (2000) Fixed Term Employees - Prevention of Less Favourable Treatment Regulations (2001) Health & Safety at Work Act (1974) 9 Equality and Environmental Impact Assessments See Appendix 9 Page 19 of 54

20 10 Implementation and Monitoring Plans 10.1 All staff will be informed of the policy and End of Life procedure via Trust briefing The Bereavement service will have an intranet website which will include links to the relevant documentation Members of the Bereavement Team will attend senior nurse/ matrons and medical training days to describe the policy. 11 We Are Here For You standard mission statement: 11.1 This Trust is committed to providing the highest quality of care to our patients, so we can pledge to them that we are here for you. This Trust supports a patient centred culture of continuous improvement delivered by our staff. The Trust established the Values and Behaviours programme to enable Nottingham University Hospitals to continue to improve patient safety, outcomes and experiences. The set of twelve agreed values and behaviours explicitly describe to employees the required way of working and behaving, both to patients and each other, which would enable patients to have clear expectations as to their experience of our services Whatever our role we will ensure we are polite, welcoming and positive in the face of adversity, are respectful of people s individuality, privacy and dignity, take the time to listen and hear what people say and keep people informed of what s happening. We will take ownership of delivering the help that is required and will look and behave professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. We are considerate of patients pain, and compassionate, gentle and reassuring with patients and colleagues and we will answer their questions without jargon. We appreciate that other people s time is valuable, and will aim to offer a responsive service, to keep waiting to a minimum, with convenient appointments and take responsibility for our own actions and results. Every one of us is vigilant across all aspects of safety, practices hand hygiene and demonstrates attention to detail for a clean and Page 20 of 54

21 tidy environment everywhere, working in teams to innovate and to solve patient frustrations. 12 Advice 12.1 The Trust is committed to having a well informed workforce, who have an understanding of both the practical requirements surrounding a loss, and the effects that it can have on those bereaved The bereavement service is available for advice pertaining to all aspects of after death care and arrangements. During office hours contact (QMC campus) or (City campus), out of hours contact switchboard The Chaplains and Multi faith Officer will also provide advice on religious, spiritual and cultural issues, and the effects of grief and loss contact ext The Child Bereavement Facilitator based in the Family Health Directorate on ext provides training and update sessions for staff within Children s Services and for other areas within the Trust as requested The Hospital Palliative care team organise study days for all relevant health care professionals Contact ext ges/education_program.aspx 13. Associated Documents and References Department of Work and Pensions (2009) What to do after a Death a guide to what you must do and the help you can get London: DWP Dougherty, L. Lister, S. (2008) The Royal Marsden Hospital Manual of Nursing Procedures 7 th Ed. Wiley Blackwell, Oxford General Medical Council 2010 Treatment and care towards the end of life: good practice in decision making Page 21 of 54

22 Greene, J. Greene, M. (2006) Dealing with Death: A Handbook of practices and Procedures and Law, 2 nd Edn. Jessica Kingsley publishers, London in Dougherty, L. Lister, S. (2008) The Royal Marsden Hospital Manual of Nursing procedures 7 th Ed. Wiley Blackwell, Oxford Health and Safety Commission (1974) Health and Safety at Work Act London: HMSO Health Services Advisory Committee (2003) Safe working and the prevention of infection in the mortuary and post mortem room London: HSE NMC (2008) The Code: standards of Conduct, Performance and Ethics for Nurses and Midwives. Nursing and Midwifery Council, London National End of Life Care Programme (2011) Guidance for staff responsible for care after death Page 22 of 54

23 Appendix 1 Witnessed Resuscitation There has been little research into the outcomes of relatives who witness resuscitation, however there is anecdotal evidence to suggest that some relatives wish to be present, and can find it beneficial. A request from a relative to view resuscitation should be passed to the arrest team leader. Issues to be considered when deciding whether it is appropriate for relatives to view are: The emotional state of the relatives and whether this could interfere with the procedure The effect that the presence of relatives may have on staff A member of nursing staff will need to be available to support the relatives whilst they are viewing the resuscitation and after either they have decided to leave or the resuscitation is completed. The confidentiality and dignity of the person being resuscitated. If the team leader allows the relatives to be present, ground rules need to be established. These could include that the resuscitation team may ask the relative to leave depending on the patient s condition and treatment being given, or if the relatives become so distressed that they disturb the efforts of the resuscitation team. It should be made clear that family members will not be involved in the resuscitation attempt. If the team leader decides not to allow the relatives to witness the resuscitation, the reasons for this should be sensitively explained to them and support and information both during and after the procedure provided by a nurse. Page 23 of 54

24 Appendix 2 End of Life Procedure INTRODUCTION In April 2011, the National End of Life Care programme published Guidance for staff responsible for care after death. This guidance was developed in conjunction with the Royal College of Pathologists and the Royal College of Nursing, and has been used as a basis for the procedure to be implemented at Nottingham University Hospitals. The nurses role at the end of life extends beyond death to provide care for the deceased, family and carers. The physical care given by nurses following death in hospitals has traditionally referred to as last offices. Care after death is a term that is considered to be more befitting in our multicultural society. Care after death includes: Honouring the spiritual or cultural wishes of the deceased person and their family/carers while ensuring legal obligations are met, and that other patients/ visitors are nor disadvantaged or upset. Preparing the body for transfer to the mortuary or the funeral director s premises Offering family and carers present the opportunity to participate in the process and supporting them to do so Ensuring that the privacy and dignity of the deceased person is maintained Ensuring that the health and safety of everyone who comes into contact with the body is protected Honouring people s wishes for organ and tissue donation Returning the deceased person s personal possessions to their relatives. The nature of the death and the context in which it has occurred affects how care is provided, as well as the level of support needed by those who have been bereaved. For example, some deaths are unexpected and traumatic while others may be peaceful and expected. As a result families Page 24 of 54

25 and carers are likely to have a range of responses and needs and each may also have differing views about death. 1. Care before Death a. Where dying is anticipated and predictable it is important that agreement is reached between nursing and medical teams, patients and where appropriate their families about clinical decisions. These include whether to attempt cardio-pulmonary resuscitation, whether to use the End of Life Pathway or whether treatment ceilings are required. If possible, preferred place of death should be discussed with the patient or their families. If an implanted cardiac device is in situ it is important to assess whether it should be left in place, as it may affect the dying phase. Pacing therapy is not normally discontinued but the deactivation of implantable cardiac defibrillators needs to be considered. b. Unambiguous communication on all of the above decisions ensures that there is clarity about whether a death is expected or not and allows appropriate preparation of the dying person and their family/carers. c. Wherever possible, assess the dying person s wishes regarding organ, tissue and body donation and possible post mortem examination and document in the notes. d. Whole body donation can only be agreed by individuals themselves and not by anybody else on their behalf after death. For information contact University of Nottingham School of Anatomy or the pathology specialist nursing and midwifery team. e. Identify and document in advance any spiritual, cultural or practical wishes the dying person and their family/carers may have at the time of death or afterwards, particularly regarding family/carers. Detailed information about different cultural and religious practices and beliefs about death is available in Multifaith a-z (Nottingham University Hospital Trust 2009). A copy of this handbook should be available on all wards, and is available from the Department of Spiritual and Pastoral Care. However it must be stressed that whilst this information is useful as a guide, it is not a substitute for discussion with the patient and their Page 25 of 54

26 family/carers to establish their individual wishes. Appendix 4 contains a procedure to follow if a quick turnaround of death certification or release of the deceased is required. 2. Care at the time of death a. If present at the time of death, the registered nurse or doctor needs to record the time, who was present (including addresses and telephone numbers if possible), the nature of the death and details of any relevant devices (such as implanted cardiac urgent release for burial or cremation. This can be done as part of the advance planning process or it can be completed nearer to the point of death. b. Ask the person (if this is possible and/or appropriate) who they wish to be present at the time of their death. If this is not possible, try to find out from the family/carers as well as details of how and when they wish the news of the death to be communicated if they are not present. Relevant contact details will need to be recorded in the nursing documentation. c. Deliver care that is sensitive to the cultural and religious needs and personal preferences of the dying person and their defibrillators) as well as their own name and contact details in the End of Life Pathway documentation if used, or using Death Administration Form (Appendix 8). If relatives have any concerns about the death these should also be documented. d. When death occurs, the medical practitioner primarily responsible for that person s care must be notified as soon as possible, as they then become responsible for ensuring that either a Medical Certificate of Cause of Death form is issued or the death is referred to the Coroner. e. The medical staff must verify an unexpected death. If the patient is on the Last Days of Life pathway, death can be verified by a registered nurse who has been assessed as competent. Please see appendix 3. f. The verification of death must be recorded in the notes, preferably by using the death administration form which is included in the Liverpool Care Pathway or can be used alone. Page 26 of 54

27 g. When a patient dies, if the relatives or significant others are not present they should be told as soon as possible, or as agreed with relatives beforehand. Care must be taken to ensure that the correct persons are contacted and that they are informed as sensitively and compassionately as possible. Where there are no relatives or significant others but there is a known patient representative (e.g. solicitor), this person should be informed at an appropriate time. h. When the death is unexpected, the family should be informed face to face if possible. Interpreting services are available via the emergency contact line which is available on the intranet, under language and interpreting services. i. Consideration should be given to the needs of any children present. Information packs for the families of bereaved children are available from the Child Bereavement Facilitator and the bereavement centre and on some wards. j. The immediate care of the deceased following the death is documented in the chart below. If possible this should be carried out before the deceased is viewed by the relatives. Personal care prior to viewing on the ward (This can be combined with care prior to transfer to mortuary if no relatives are attending) ACTION RATIONALE 1. Screen the bed area completely. To maintain privacy. 2 Complete Notice of Death form using block capitals (NB this may be able to be printed from Notis) To provide required information to the Mortuary and bereavement service Page 27 of 54

28 3. Assess the need for Personal Protective Equipment (PPE) and put on as appropriate to attending to deceased. To prevent the risk of cross infection NUH Infection prevention and control policy 2011 NUH Pulmonary Tuberculosis Policy 2009 NUH Viral Haemorrhagic Fever Policy Ascertain whether any attending family members wish to assist with final care if appropriate. 5 Lay the patient flat on their back with arms by their side and legs straight. Leave one pillow under the head as it supports alignment and helps the mouth to stay closed. Cultural and religious factors may denote when family members wish to assist (Green & Green 2006), as well as infection control measures. An appropriate position prior to rigor mortis, which occurs 2-4 hours after death. The portering staff can remove the patient on the bed and the patient can be stored respectfully in the mortuary. 6 If the death is or may be reported to HM Coroner, all tubes and lines must be left in situ but occluded by a bung or spigot. If a death is not being reported, then all external tubing and lines can be removed (cover with a clean dressing). Non-removable should be occluded. To present as normal appearance as possible whilst preserving material which may need to be examined if a post mortem examination takes place, To present as normal an appearance as possible Page 28 of 54

29 7 Clean the patient s mouth if needed. Clean and replace dentures if worn. If the dentures cannot be replaced, place them in a clearly labelled denture pot to be sent to the mortuary with the patient. To remove debris and secretions. To present patient in a natural and dignified repose 8 Close the eyes with gauze moistened with normal saline to prevent them drying out. Apply light pressure to the eyes for 30 seconds, in order that the patient s eyes remain closed (Dougherty & Lister 2008) Ensures that the patient s dignity is maintained (NMC 2008), as both mouth and eyes remain closed, giving as peaceful and as normal an appearance as possible. To keep the orbit moist delay globe collapse. To prevent environmental contamination, particularly if there is a delay in transfer to mortuary 10 Cover the deceased with a sheet, leaving the head and face exposed for viewing. To show respect. 3. Viewing the Deceased a. Relatives should be offered the opportunity to view the deceased in order to facilitate acceptance of the death and to say goodbye. Relatives should be offered the choice of viewing the deceased either on the ward where the patient has been nursed or in the Chapel of Rest, which can be arranged in consultation with the bereavement centre, mortuary or the on call technician out of office hours. Some relatives may wish to wait and view the deceased at the funeral directors premises. PPE may be required to be worn by relatives viewing patients that have been infected with a category 3 if Page 29 of 54

30 not previously been exposed to the pathogen. Please note that category 4 infectious patients cannot be viewed by relatives. b. If viewing on the ward the nurse should offer to stay with the relative(s) or be available nearby. As much time as is needed should be allowed. c. If relatives prefer to view the deceased in the Chapel(s) of Rest, this can be arranged by the ward staff, the Bereavement Service or relatives may contact the Chapel of Rest directly. All relatives should be escorted to the Chapel of Rest and supported if needed. 4. Property a. Property should be dealt with in accordance with the Trust Policy GG/FIN/002 Patients Property Policy and Procedure, available on the intranet under Governance, Finance policies. It is preferable that property is returned to the relatives whilst on the ward, but relatives should be given the option of collecting from the bereavement centre if they prefer. b. The ward safe and General office should be checked to ensure that there are no valuables stored. When valuables are returned it is important to ensure that they are given to the correct person, that is the next of kin or executor of the will. c. Property that is stored within General Office can be accessed out of hours if necessary at QMC campus via the Duty Nurse Manager. 5. Specific Information for relatives a. The Information for those who are Bereaved booklet should be given to all relatives attending the ward. If possible, relatives / next of kin should be offered the opportunity to speak, in a private environment, to a doctor or healthcare professional who has been involved in the care of the deceased (NUH 2005). Any verbal advice and communication should be recorded in the patient notes. b. The relatives should be advised to contact the bereavement centre (QMC campus ; City Campus ) on the next working day to make the arrangements to collect the necessary paperwork and to register the death, if applicable. Where a death occurs in normal working hours the bereavement centre should be Page 30 of 54

31 informed immediately and the relatives advised that they can contact the bereavement centre that day if they wish. c. If the death is to be referred to the Coroner, the medical staff should advise the relatives of the reason for this, and advised of the likely outcome. They should be advised to contact the bereavement centre unless they hear from the Coroner first. d. If, for any reason, the family wish to obtain the death certificate or remove the deceased out of hours, then arrangements can be made to facilitate this. The death certificate can be issued at any time, and if a Coroners referral is required this can be done out of hours. Please see Appendix Organ and Tissue Donation a. There may be occasions whereby the deceased carried a donor card or a family member will spontaneously request donation of tissues for transplant. Referral of these requests can be made to the Corneal Retrieval Nurses on Extension (in working hours) or directly to the national Blood Service on Tel No: At the specific request of the deceased relatives, the eye retrieval staff or the National Blood Service Coordination Centre at Liverpool will, after their donor assessment and consent telephone interview with the family, liaise with the hospital mortuaries to arrange retrieval. b. Critical Care and Emergency Department areas also have in place their own guidelines with regards to solid organ donation. Please contact the on call Donor Coordinator with any queries regarding eligibility on (24 hrs). c. If families wish to donate tissues for teaching or research purposes only, this can be arranged through the Pathology Specialist Nurses who can also be contacted via the bereavement service. This service is only available in office hours so there may be a delay involved. However, this delay will not jeopardise the donation. If the family are anxious to discuss donations out of hours, then advice can be obtained by contacting the on-call mortuary technician via switchboard. d. It is important to transfer patients to the mortuary as soon after death as possible, that is, within two hours of the relatives Page 31 of 54