Death should be confirmed or verified by appropriate healthcare staff. Verification of death is usually completed by a medical doctor but it can be undertaken by nurses in certain healthcare settings who have had the necessary training if death is expected and local policy permits this (Laverty et al. 2018). Certification of death occurs by the medical practitioner (National Nurse Consultant Group, Palliative Care [34]). Unexpected deaths must be confirmed by a medical doctor (and usually a senior medical doctor). Confirmation of death must be recorded in the medical and nursing notes certification process stipulates that it is mandatory for the certifying doctor to both identify the deceased and confirm the presence of any implants/devices (DH [9]).

A registered medical doctor who has attended the deceased person during their last illness is required to give a medical certificate of the cause of death (Home Office [24]). The certificate requires the doctor to state on which date they last saw the deceased alive and whether or not they have seen the body after death (this may mean that the certificate is completed by a different doctor from the one who confirmed death). Out‐of‐hours medical examiners can now certify death where there is a cultural/religious requirement to bury, cremate or repatriate patients quickly (DH [8]). Medical examiners can also certify for reportable deaths where a post mortem is not deemed necessary (DH [8]). The medical examiner (ME) is a primary care trust‐appointed but independent healthcare professional who determines the need for coroner referral. For those who need a quick burial within 24 hours, this remains at the discretion of the local births and deaths registrar in each council and depends on the individual opening hours and on‐call facilities. Local hospital policy should outline procedures for out‐of‐hours death registration and certification, and burial is usually easier to accommodate than cremation within 24 hours.

Repatriation to another country needs further documentation, alongside the death certification and registration documents, and this varies according to which country the body is being repatriated. Only a coroner or ME is authorized to permit the body to be moved out of England or Wales. A ‘Form of Notice to a Coroner of Intention to Remove a Body Out of England’ (Form 104) is required and can be obtained from coroners or registrars. This form needs to be given to the coroner along with any certificate for burial or cremation already issued. The coroner's office will acknowledge receipt of notice and inform when repatriation can occur. Coroner authorization normally takes up to 4 working days so that necessary enquiries can be made. In urgent situations, this can sometimes be expedited. The coroner's office and relevant High Commission will have further information. In terms of infection control, packing may be required by different countries and those involved with repatriation must be informed if there is a danger of infection (HSAC [22]). Funeral directors would assist with transportation issues.

If the patient's death is to be referred to a coroner or ME, this will affect how their body is prepared. The need for referral to a coroner or ME should be ascertained with the person verifying the death (DH [8]). Preparation in this situation differs according to how the patient died. Broadly, two types of death are referred to the coroner:

The Department of Health website (www.dh.gov.uk) gives more information about when to refer to the coroner or ME and when post mortems are indicated.

Post mortems can affect preparation after death, depending on whether this is a coroner's post mortem (sometimes referred to as a legal post mortem because it cannot be refused) or a post mortem requested by the consultant doctor‐in‐charge to answer a specific query on the cause of death (also referred to as a hospital or non‐legal post mortem). A coroner's post mortem might require specific preparation but the coroner or ME will advise on this and should be contacted as soon as possible after death to ascertain any specific issues. Individual hospitals, institutions and NHS trusts should provide further guidance on these issues. If the patient is to be referred to the coroner, cap off catheters and ensure there is no possibility of leakage. Do not remove any invasive devices until this has been discussed with the coroner.

If the patient is not to be referred to the coroner, invasive and non‐invasive attachments, such as central venous access catheters, peripheral venous access cannulas, Swan–Ganz catheters, tracheal tubes (tracheostomy/endotracheal) and drains, can be removed prior to Last Offices.

Consider whether the patient is a candidate for organ or tissue donation. Patients who previously expressed a wish to be a donor (or carry a donor card), or whose family has expressed such a wish, might need specific preparation (see further resources at the end of the chapter and contact local or regional transplant co‐ordinators). Patients with cancer under some circumstances can continue to donate tissue such as cornea in the event of their death but this will need to be discussed with the national transplant co‐ordinator in advance of the death.

Organ donation is an important consideration at the end of life. Current law is an opt‐in system for donation, therefore express wishes must be made by families (next of kin) or patients. Further information can be sourced from the organ donation website www.organdonation.nhs.uk.

If the patient was infectious, it needs to be established whether the infection is notifiable, for example hepatitis B, C or tuberculosis, or non‐notifiable (Healing et al. [21]). There are additional requirements for patients with bloodborne infections, so the senior nurse on duty should be consulted and local infection control policy adhered to. In the UK, notifiable infections must be reported via a local authority ‘proper officer’, which is the attending doctor's duty. Infection prevention and control contacts in local trusts or services can provide more help and guidance around notification. Placing the patient who has died in a body bag is advised for all notifiable diseases and a number of non‐notifiable infectious diseases (i.e. HIV and transmissible spongiform encephalopathies, e.g. Creutzfeldt–Jakob disease). A label identifying the infection must also be attached to the patient's body.

Certain extra precautions are required when handling a patient who has died from an infectious disease. However, the deceased will pose no greater threat of infection than when they were alive. It is assumed that staff will have practised universal precautions when caring for all patients, and this practice must be continued when caring for the deceased patient (HSAC 2003).

Porters, mortuary staff, undertakers and those involved with Last Offices must also be informed if there is a danger of infection (HSAC 2003) or radiation.

Inform and offer support to relatives and/or next of kin to ensure that the relevant individuals are aware of the patient's death and any specific care or practices can be carried out (National Nurse Consultant Group, Palliative Care [34]). The support of a hospital chaplain or other religious leader or other appropriate person should be offered. If the relative(s) or next of kin are not contactable by telephone or by the GP, it may be necessary to inform the police of the death.

Some families and carers may wish to assist with Last Offices, and within certain cultures it may be unacceptable for anyone but a family member or religious leader to wash the patient (National Nurse Consultant Group, Palliative Care [34]). It is necessary to prepare them sensitively for any changes to the body that occur after death and be aware of manual handling and infection control issues (National Nurse Consultant Group, Palliative Care [34]). It may also be required that somebody of the same sex as the patient undertakes Last Offices (Neuberger [38]).

There are occasions when it may not be possible for families to assist with last offices:

Ascertain any social, cultural, spiritual and/or religious considerations that should be observed during the procedure. Spiritual needs involved in preparation of the patient who has died can be diverse but the final sections offer current guidance; the patient's previous wishes should be established where possible and should always take precedence (Pattison [45]). If these have not been documented, try to determine the patient's previous wishes from family or carers. The patient's last will and testament might have instruction on this, or an advance directive might have information. Families, carers or members of the patient's community or faith may wish to participate in Last Offices (with consent of the next of kin or as expressed in the patient's wishes when they were alive). If this is the case, they must be adequately prepared for this with careful and sensitive explanation of the procedure to be undertaken.

Considerations before undertaking last offices:

Information required by mortuary staff and funeral directors is listed in Box 28.2.

It is important to inform other patients, 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. Senior staff should offer guidance in the event of uncertainty about how to deal with the situation.

Personal care after death needs to be carried out within 2–4 hours of the person dying to preserve their appearance, condition and dignity. The body's core temperature will take time to lower, therefore transfer to the mortuary within 4 hours of the death is optimal (National Nurse Consultant Group, Palliative Care [34]).

Families may request other items to accompany the patient who has died to the mortuary and funeral home. This might be an item of sentimental value, for instance, and in this case it should be at the discretion of those caring for the patient and the nurse‐in‐charge (local policy might also specify). It may also be possible for certain religious artefacts to remain with the patient. This should be ascertained with those closest to the patient. Further information can be found at NHS Education for Scotland ([39]).

Varying degrees of adherence and orthodoxy exist within all the world's faiths. The given religion of a patient may occasionally be offered to indicate an association with particular cultural and national roots, rather than to indicate a significant degree of adherence to the tenets of a particular faith. If in doubt, consult the family members concerned.

Regardless of the faith that the patient's record states they hold, wishes for Last Offices may differ from the conventions of their stated faith. Sensitive discussion is needed by nurses to establish what is wanted at this time. If patients hold no religious beliefs, ask the relatives to outline the patient's previously expressed wishes, if any, or establish the family's wishes. Furthermore, the patient may be non‐denominational and/or the family members may be multidenominational so all possibilities must be taken into account.