Chapter 11: Symptom control and care towards the end of life
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Pre‐procedural considerations
Family involvement
Some families and carers may wish to assist with personal care after death, and within certain cultures it may be unacceptable for anyone other than a family member or religious leader to wash the patient (Wilson [166]). It may also be necessary for somebody of the same sex as the patient to undertake personal care after death (Henry and Wilson [59], Martin and Bristowe [91], Rodgers et al. [127]). Families and carers should be supported and encouraged to participate if possible as this may help to facilitate the grieving process. If children are involved, nurses should be mindful of their needs and should consider the physical environment.
Families may request specific items to accompany the patient who has died to the mortuary and funeral home. These might be items of sentimental value or items of jewellery. This should be discussed with the family and next of kin, documented and witnessed in accordance with local policy.
Additional considerations
It is important to inform other patients of the death, particularly if the person has died in an area where other people are present (such as a bay or open ward) and might know the patient. Residents in communal settings, such as care homes and prisons, have often built significant relationships with other residents (Wilson [166]). It is important to consider how to address their needs within the boundaries of patient confidentiality, being careful not to provide information about the cause and reason for death (Wilson [166]).
Finally, carry out all personal care after death in accordance with safe manual handling guidance and where possible within 4 hours of death. This is because rigor mortis can occur relatively soon after death, and this time is shortened in warmer environments (Wilson [166]). It is best practice to do this with two people, to ensure privacy and dignity are maintained and manual handling guidance is followed.
Procedure guideline 11.6
Care after death
Table 11.7 Prevention and resolution (Procedure guideline 11.6)
| Problem | Cause | Prevention | Action |
|---|---|---|---|
| The family are not prepared for how the body will look and feel | Possible changes in how the patient may look following death | Prepare the family for how the person may look and feel. If the patient has died some time before the family views the body, advising them regarding how the skin may feel (cold) before they touch the patient will prepare them for this. | Meet with the family prior to reviewing the patient. Ensure the deceased has been checked before the family enter the room. |
| Relatives or next of kin not contactable by telephone or by the GP | Out‐of‐date or missing contact information | Ensure next of kin contact information is documented and up to date. | Within the UK, local police will go to the next of kin's house. Abroad, the relevant British embassy will assist. |
| Death occurs within 24 hours of an operation | Ensure the patient is cared for and monitoring in the most appropriate setting following their surgery.
If death occurs, ensure information around the circumstances of the death is documented and handed over to relevant healthcare staff (to prevent miscommunication). | All tubes and/or drains must be left in position. Spigot or cap off any cannulas or catheters. Treat stomas as open wounds. Leave any endotracheal or tracheostomy tubes in place. Machinery can be disconnected (discuss with coroner) but settings must be left untouched. Post‐mortem examination will be required to establish the cause of death. Any tubes, drains and so on may have been a major contributing factor to the death. | |
| Unexpected death | As above. | As above. Post‐mortem examination of the patient's body will be required to establish the cause of death. | |
| Unknown cause of death | As above. | As above. | |
| Patient brought into hospital who is already deceased | Not preventable but where possible ensure patients’ families are prepared for all eventualities, particularly for palliative care patients whose death is expected, and that family know who to call and what to do in the event of death. | As above, unless the patient has been seen by a medical practitioner within 14 days before their death. In this instance, the attending medical officer may complete the death certificate if they are clear as to the cause of death. | |
| Patient dies after receiving systemic radioactive iodine | There is a potential risk of exposure to radiation (IPEM [69]) | Radiation protection should be undertaken. | Ensure those in contact with the patient's body are aware. Pregnant nurses should not carry out care after death for these patients. |
| Patient dies after insertion of gold grains, colloidal radioactive solution, caesium needles, caesium applicators, iridium wires or iridium hair pins | There is a potential risk of exposure to radiation (IPEM [69]) | Radiation protection should be undertaken when removing wires. The physicist may remove radioactive wires/needles and so on themselves, depending on source. | Inform the physics department as well as the appropriate medical staff. Once a doctor has verified death, the sources should be removed and placed in a lead container. A Geiger counter should be used to check that all sources have been removed. This reduces the radiation risk when completing care after death. Record the time and date of removal of the sources. Ensure those in contact with the patient's body are aware. Pregnant nurses should not carry out care after death for these patients. |
| Patient and/or relative wishes to donate organs or tissues for transplantation | Discussion around transplantation should occur with families or next of kin wherever appropriate (as deemed by clinical team). Exceptions apply. | Contact the local transplant co‐ordinator as soon as the decision is made to donate organs or tissue and before care after death is attempted. Obtain verbal and written consent from the next of kin, as per local policy. Prepare the patient who has died as per the transplant co‐ordinator's instructions. For further guidance see www.organdonation.nhs.uk. | |
| Patient to be moved straight from ward to undertakers | Contact senior nurse for hospital. Contact local Register Office as a certificate for burial or cremation (often called the ‘green document’) needs to be obtained. Liaise with chosen funeral directors and the deceased's family. Perform care after death as per religious, cultural and family wishes. Obtain written authority from the next of kin for removal of the person by the funeral directors. Document all actions and proceedings (Travis [153]). | ||
| Relatives want to see the person who has died after removal from the ward | Inform the mortuary staff in order to allow time for them to prepare the body. Occasionally nurses might be required to undertake this preparation in institutions where there are no mortuary staff. The patient's body will normally be placed in the hospital viewing room. A nurse should accompany the family and stay in the area to support the family. | ||
| The patient has an implantable cardiac device (deactivation of implantable cardiac defibrillators needs to be considered when the patient is recognized as entering the end‐of‐life phase) | Knowledge of device being in situ prior to death. | Nurses must inform funeral directors and mortuary staff about patients with an implantable cardiac device and ensure it is clearly documented (Wilson [166], C). |
