Pre‐procedure

ActionRationale

1. 1.Show
   Apply gloves and apron.
   To ensure staff are protected from soiled sheets/body fluids.
2. 2.Show
   If the patient has an infectious disease additional equipment such as gowns/masks/goggles may be required.
   All regular infection control principles should be applied (National Nurse Consultant Group, Palliative Care [34], C).
3. 3.Show
   If the patient is on a pressure‐relieving mattress or device, consult the manufacturer's instructions before switching off.
   If the mattress deflates too quickly, it may cause a manual handling challenge to the nurses carrying out Last Offices.

Procedure

1. 4.Show
   Lay the patient on their back with their arms lying by their side. Straighten any limbs as far as possible (adhering to your own organization's manual handling policy). This should ideally be undertaken with two nurses.
   To maintain the patient's privacy and dignity (NMC [41]) and for ongoing nursing care of the body. Stiff, flexed limbs can be difficult to fit easily into a mortuary trolley, mortuary fridge or coffin and can cause additional distress to any carers who wish to view the body. If there is a problem in being able to straighten limbs then the mortuary staff should be notified (National Nurse Consultant Group, Palliative Care [34]).
2. 5.Show
   Remove all but one pillow. Close the mouth and support the jaw by placing a pillow or rolled‐up towel on the chest or underneath the jaw. Do not bind the patient's jaw with bandages.
   To avoid leaving pressure marks on the face which can be difficult to remove (National Nurse Consultant Group, Palliative Care [34], C).
3. 6.Show
   When the death is not being referred to the coroner remove mechanical aids such as syringe drivers, apply gauze and tape to syringe pump sites and document disposal of medication.
   To try and ensure the person looks as normal as possible as the family may want to see them again.
4. 7.Show
   Do not tie the penis. Spigot any urinary catheters.
   Pads and pants can be used to absorb any leakage from the urethra, vagina or rectum (National Nurse Consultant Group, Palliative Care [34], C).
5. 8.Show
   Close the patient's eyes by applying light pressure to the eyelids for 30 seconds. (If corneal or eye donation is to take place close the eyes with gauze moistened with normal saline to prevent them drying out. If this is unsuccessful explain to the carers that the funeral director will be able to rectify this.)
   To maintain the patient's dignity (NMC [41]) and for aesthetic reasons. Closure of the eyelids will also provide tissue protection in case of corneal donation (National Nurse Consultant Group, Palliative Care [34], C).
6. 9.Show
   Contain leakages from the oral cavity or tracheostomy sites by suctioning and positioning. Suction and spigot nasogastric tubes. Cover exuding wounds or unhealed surgical incisions with a clean absorbent dressing and secure with an occlusive dressing. Leave stitches and clips intact. Cover stomas with a clean bag. Clamp drains (remove the bottles), pad around wounds and seal with an occlusive dressing. Avoid waterproof, strongly adhesive tape as this can be difficult to remove at the funeral directors and can leave a permanent mark. Cap intravenous lines and leave them in situ. If the body is leaking profusely then take time, prior to transfer to the mortuary, to address the problem.
   Leaking orifices pose a health hazard to staff coming into contact with the patient's body (National Nurse Consultant Group, Palliative Care [34]). Ensuring that the patient's body is clean will demonstrate continued respect for the patient's dignity (NMC [41], C).

   It is the role of the mortuary staff to pack orifices, not the nurse. If the body continues to leak, place it on absorbent pads in a body bag and advise the mortuary or funeral director (National Nurse Consultant Group, Palliative Care [34], C).
7. 10.Show
   Exuding wounds or unhealed surgical scars should be covered with a clean absorbent dressing and secured with an occlusive dressing (e.g. Tegaderm). Stitches and clips should be left intact. Consider leaving intact recent surgical dressings for wounds that could potentially leak, for example large amputation wounds. Reinforcement of the dressing should be sufficient.
   The dressing will absorb any leakage from the wound site (National Nurse Consultant Group, Palliative Care [34], C).
8. 11.Show
   Stomas should be covered with a clean bag.
   To contain any leakage from the stoma site.
9. 12.Show
   It is the responsibility of mortuary staff to discuss with the funeral director collecting the body their capacity to remove intravenous lines, drains, indwelling catheters, etc. If they are unable to remove these then the mortuary technician needs to attend to this before releasing the body. When a family member collects the deceased then mortuary staff must remove all intravenous lines, drains, indwelling catheters, etc. When release to a funeral director is prompt in order to ensure same‐day burial the funeral director needs to ensure all lines are removed in case family members wish to bathe or dress the body. This practice in some areas may be the responsibility of the nurse if the organization has no mortuary staff.
   When a death is being referred to the coroner or ME or for post mortem, all lines, devices and tubes should be left in place (National Nurse Consultant Group 2011, C).
10. 13.Show
    Wash the patient, unless requested not to do so for religious/cultural reasons or carer's preference.
    To ensure dignity and respect for the deceased (National Nurse Consultant Group Palliative Care 2011, C).
11. 14.Show
    The deceased should not be shaved when still warm; this can be undertaken by the funeral director and it may be necessary to discuss this sensitively with the family.
    Shaving when the deceased is still warm can cause bruising to the skin (National Nurse Consultant Group, Palliative Care [34], C).
12. 15.Show
    It may be important to family and carers to assist with washing, thereby continuing to provide the care given in the period before death. It is important to have a conversation with the family before undertaking this to prepare them for how the body will look and feel.
    It is an expression of respect and affection, part of the process of adjusting to loss and expressing grief (National Nurse Consultant Group, Palliative Care [34], C).
13. 16.Show
    Clean the mouth to remove debris and secretions. Clean and replace dentures as soon as possible after death. If they cannot be replaced send them with the body in a clearly identified receptacle.
    To ensure dignity and respect is demonstrated (National Nurse Consultant Group, Palliative Care [34], C).
14. 17.Show
    Tidy the hair as soon as possible after death and arrange in the preferred style (if known) to guide the funeral director for final presentation.
    This will guide the funeral director for final presentation (National Nurse Consultant Group, Palliative Care [34], C).
15. 18.Show
    Remove jewellery (apart from the wedding ring) in the presence of another member of staff, unless specifically requested by the family to do otherwise, and document this according to local policy. Be aware of religious ornaments that need to remain with the deceased. Secure any rings left on with minimal tape, documented according to local policy. Provide a signature if any jewellery is removed.
    To ensure culture and personal wishes are respected (National Nurse Consultant Group Palliative Care 2011, C). Procedures are needed to provide this information to caregivers.
16. 19.Show
    Clean and dress the deceased person appropriately (use of shrouds is common practice in many acute hospitals) before they go to the mortuary. They should never go to the mortuary naked or be released naked to a funeral director from an organization without a mortuary. Be aware that soiling can occur. The funeral director will dress them in their own clothes.
    For aesthetic reasons for family and carers viewing the patient's body or religious or cultural reasons and to meet the family's or carers’ wishes (National Nurse Consultant Group, Palliative Care, C).
17. 20.Show
    Clearly identify the deceased person with a name band on their wrist or ankle (avoid toe tags). As a minimum this needs to identify their name, date of birth, address, ward (if a hospital inpatient) and ideally their NHS number. The person responsible for identification is the person that verifies the death. Nurses should refer to local policies for the identification of deceased patients within their organization.
    To ensure correct and easy identification of the patient's body in the mortuary (National Nurse Consultant Group Palliative Care 2011, C).
18. 21.Show
    Provided no leakage is expected and there is no notifiable disease present, the body can be wrapped in a sheet and taped lightly to ensure it can be moved safely. Do not bind the sheet or tape too tightly as this can cause disfigurement. If there is significant leakage or a notifiable infection is present, put the deceased into a body bag.
    To avoid possible damage to the patient's body during transfer (National Nurse Consultant Group, Palliative Care [34], C).
19. 22.Show
    Secure the sheet with tape loosely.
    To ensure the sheet is not too tight and causes any disfigurement (National Nurse Consultant Group, Palliative Care [34], C).
20. 23.Show
    Place the patient's body in a body bag if leakage of body fluids may be anticipated or if the patient has a known infectious disease.
    To avoid actual or potential leakage of fluid, whether infection is present or not, as this poses a health hazard to all those who come into contact with the deceased patient (National Nurse Consultant Group, Palliative Care [34], C).

Post‐procedure

1. 24.Show
   Request the portering staff to remove the patient's body from the ward and transport it to the mortuary.
   This should be completed within 4 hours of death to allow refrigeration to take place (National Nurse Consultant Group, Palliative Care [34], C).
2. 25.Show
   In hospital, screen off the beds/area that will be passed as the patient's body is removed. The privacy and dignity of the deceased on transfer from the place of death is paramount Each organization involved is responsible for ensuring that the procedures adopted to transfer bodies respect the values of personal dignity and that these are incorporated in the design of the concealment trolley and the way the body is covered.
   To ensure the transfer remains as respectful as possible (Kings Fund [28]) and to avoid causing unnecessary distress to other patients, relatives and staff.
3. 26.Show
   Remove gloves and apron. Dispose of equipment according to local policy and wash hands.
   To minimize risk of cross‐infection and contamination (Fraise and Bradley [13], C).
4. 27.Show
   Record all aspects of care after death in nursing and medical documentation and identify the professionals involved. Update and organize the medical and nursing records as quickly as possible so they are available to the bereavement team and other relevant professionals, such as pathologists.
   To record the time of death, names of those present, and names of those informed (NMC [41], C).
5. 28.Show
   Transfer property and patient records to the appropriate administrative department.

   It is important to remember to give the patient's property to the family/friends in a sensitive way. If there is soiled clothing to return, try and discuss this sensitively with families/friends to ascertain if they want it returned.
   To allow the administrative formalities needed to complete the medical certification of death and to return the personal property of the patient to the nominated person.

   To avoid unnecessary further distress to families and friends (National Nurse Consultant Group, Palliative Care [34], C).