Nursing care of the deceased.

Care of a deceased patient is a sensitive and important nursing skill that is often not discussed in open. Most of us, at some time will be involved with the immediate care of a person once they have died.

The following guide is by no means exhaustive. It is intended to provide some ideas around this process. You should always refer to your own hospitals policies and guidelines for more exact instruction.

Immediate care of the deceased and family.

At no time should the family be made to feel that they are being rushed. If possible a quiet and private area should used to allow the family and/or close friends time with the deceased.

You must prepare the family to enter the environment where the deceased is laying. If there are any tubes or wounds etc this should be explained to them in advance.

There MUST be a member of nursing staff present with the family when they first see the deceased to provide support attend to any needs at this time.

It is more common these days for family members to be present during resuscitation attempts. In this case they are already in close contact with the deceased. I like to ask the family if they would like to step out for a few minutes whist we ‘tidy up’. This gives them an opportunity to withdraw, process the situation and have a break for a few minutes.
During this time the deceased can be cleaned and prepared for viewing (see below).

If the family has been present during the resuscitation is preferable to move the body to a separate area for them (this is not always possible).

Special rituals.

Some cultural/religious observations involve special rituals such as washing and draping of the body. This is usually performed in a special area of the mortuary or other hospital area as it may take some time (up to 2 hours).

Talk to the family to find out what special arrangements may need to be made.

Valuables.

Valuables and personal effects should be documented and given to the nominated next of kin.
A word of caution here. Use your professional discretion when handing over valuables. I have made the mistake of handing over property to the person I assumed was the next of kin, only to discover poor family dynamics and significant tension between two immediate family members.
Take care if the deceased’s nominated NOK is not present or is not recorded. Thorough documentation of property and actions is important.

Valuables that are on the body may be left there. Seek guidance from the family on this. If they remain, they must be documented both in the nursing notes and on any appropriate documentation accompanying the deceased to the mortuary.

Social work.

If available a social worker should be engaged early to assist the family. The social worker is an invaluable resource in providing support and information to the families at this time.

Pastoral Care.

Check patient documentation or enquire with the family for the patients preferred religious denomination or spiritual belief. If your hospital has a Pastoral Care Service they should be involved as soon as possible.
Always ask the family what their relative would wish with respect to pastoral care.

Preparing the body for the family to view.

Preparing the body for family viewing, also known as laying out the body or last offices should be considered as a mark of respect and an honour bestowed upon you. It is a ritual that has taken place in society for at least 50,000 years.

At all times the body should be treated with dignity and respect and staff should attend to it accordingly. Studies have shown that the nursing and medical staffs behaviour and actions around this time has a huge impact on the relatives experience and subsequent bereavement process.

Standard precautions should be observed by staff involved with close contact care of the body after death.

The following guidance is intended to help you with preparing the body that is not considered to be a coroners case (this may require special procedures- see below).

Preparing the body is not a one-nurse job. You will need assistance with rolling etc and manual handling precautions should be observed:

  1. Lay the body supine and straighten their limbs (unless this is not possible).
  2. Remove any clothing from the body and pack personal possessions.
    Clothing can be packaged for return to relatives, but sensitivity should be observed when dealing with soiled or damaged belongings (consult with the family when possible).
  3. Clean the body. Pay particular attention to the face and hands.
    Depending on the situation, family members may wish to be involved with cleaning and dressing the deceased. If the body is soiled or bloody you might want to perform an initial clean of particulate matter and then allow the family to perform a second ‘washing’. Every death will be different and if you are not sure what to do the two best guides will be senior nursing staff and the patients family.
  4. Body bag (optional): During the cleaning process, I like to log roll the deceased and place an opened body bag under them. I tuck the edges under the mattress and then place a sheet over the top of that and tuck it in so it cannot be seen. Once it is time to transfer the body to the mortuary it is a simple matter to un-tuck the body bag and zip it up over the deceased.
  5. Close the eyes. Sometimes the deceased eyes may be open or partially open. This may be unsettling for the family. They can usually be closed by gently and repeatedly ‘massaging’ the eyelids downwards and outwards.
    If this is unsuccessful consider using small strips of tape.
    If corneal or eye donation is to take place close the eyes with gauze moistened with normal saline to prevent them drying out.
  6. Clean the mouth. Remove all particulate matter, suction any secretions and perform a mouth toilet. Consider applying Vaseline to the lips. Clean and replace dentures. Sometimes the mouth will ‘sag’ open, and again this can be distressing for the family. This can be addressed by rolling a small towel and placing under the chin for a while (and then removing).
  7. Try to make the patients hair tidy and in their preferred style.
  8. Dress in a clean gown. Some hospitals have designated ‘shrouds’ for this purpose. Cover the body with clean sheets (and blankets) and place a fresh pillow under their head.
  9. Position the body. I like to have at least one arm outside the blanket so the family can hold their hand. I usually position it with the hand sitting palm down on the abdomen or chest (so it is easily seen and accessed).
    I rest the other arm on top of the blanket and by their side.
    If there are many family/friends in attendance, try to have the bed away from any walls so the they can sit around the deceased rather than all crowding on one side.
  10. Prepare the environment. Remove all distractions from the immediate area where the family will view the body. Consider lowering the bed and providing adequate chairs so family members can sit and still easily touch the body.
    Lights can be slightly dimmed if this is possible but do not make it too dark (I feel this makes the atmosphere a little morbid).
    Provide boxes of tissues and access to water as required.
  11. After initially bringing the family to the deceased and spending some time settling them into this experience, it may be useful to withdraw to the background.
    Try to be attentive but not intrusive in this very personal time.
    At other times more interactive care will be required. Each situation will be unique and the family members responses and behaviours will range from quiet sobbing or silence, to anger, yelling, flailing and throwing themselves over the body (or onto the ground).
  12. Remain calm. All these responses are natural. Let them unfold and be supportive (it is extremely unlikely that any anger or violence will be directed at you).

Transport to the mortuary.

Prior to transporting the body to the mortuary it is enclosed inside the body bag. Some form of mortuary tags or ID must be attached to the body (usually 2, for example one tag around the neck and one tied to the foot.) and to the outside of the bag.
Check and cross-check that all the required information on these tags has been completed. Make sure documentation of any valuables remaining on the body is complete. Make sure time of death is correct.

Coronial Criteria.

Coroners inquest may be required to be held into the manner and cause of death in cases including:

  • A person who is killed.
  • A person who is found drowned.
  • A sudden death of unknown cause.
  • Death under suspicious circumstances.
  • Death following some accidents.
  • Death within 72hrs of an invasive medical or surgical procedure.
  • Person has not been seen by any doctor within last 3 months.
  • Dies in custody.

Again, seek guidance from your own hospital policy/procedure for information on local requirements.
Your hospital may have specific documentation or checklists that need to be completed for coroners cases.

There may be special requirements for managing a deceased patient that has been deemed a coroners case. For example, police may require the family to formally identify the deceased, and police may need to be present until the patient is released to the coroners representative.
Often the direct management of the body will need to follow set requirements in coroners cases. For example:

  • The body should not be washed.
  • The body should not be handled more than necessary.
  • Medical devices attached to the patient should not be removed, including equipment used during any resuscitation attempts. ID numbers for individual equipment (e.g. IV pumps) may need to be recorded.
  • No clothing, jewellery etc should be removed, and nothing should be placed on the body.

Special precautions (Disease).

There are several infectious diseases that may require the use of Personal Protective Equipment (PPE) by staff handling the body.
If the deceased has been exposed to the following diseases extra precautions such as double body bagging, hermetically sealing (sealing in a bag that is impermeable to air and micro-organisms), use of special labels and withholding viewing by family may be required (seek guidance from your local hospital policy/procedures):

  • Anthrax
  • Diphtheria
  • Creutzfeldt-Jakob Disease (CJD)
  • Plague
  • Small Pox
  • Yellow Fever
  • Viral Haemorrhagic Fever (including: Lassa, Marburg, Ebola, Congo Crimean Fevers)

Special Precautions (Radiation).

If death has occurred following treatment with radioactive substances expert guidance should be sought. The following principles should be observed:

  • Minimal handling of the body.
  • Viewing or handling of the body by family should be postponed until guidance is obtained.
  • Use of radioactive substances should be clearly recorded on appropriate mortuary documentation and the body-bag should have clear radiation warning labelling.

Care of yourself and your colleagues.

This is IMPORTANT: Do not underestimate the impact that the death of a patient may have on yourself and those you work with (and that includes everyone from Doctors to Cleaners).

The longer you have been caring for a patient the stronger the emotional bond between you is likely to be.

Seek support from your colleagues. This may be in the form of your informal support networks or via more structured support services.

Be aware of the responses of staff around you and provide support to them. Ask: “Are you OK?” And then listen.

The short of it is this: Being upset and ruminating on the death of one of your patients is natural, healthy, and an important part of being a nurse.

However, if the impact of this event is prolonged and intruding into your personal life, or effecting your professional performance you need to seek specialist support.

See your unit manager or senior member of staff to talk about it and arrange this support.

Sometimes a patient that has been under your care for only a very short time will ‘connect’ with you for whatever reason and you may find yourself upset at their death far more than seems appropriate. Be assured, this is not the case. Nurses working in emergency departments can sometimes find themselves deeply affected by the death of a patient that has only been in their care for minutes to hours. This is also perfectly normal.

Final words.

It is important to let the family know that they can contact the hospital to discuss their feelings or ask questions at any time.
Questions and concerns may not arise for quite some time following the death of a loved one and family need to be given the opportunity to contact staff (or a hospital representative) to discuss this.


 

References:

1. For healthcare professionals – Coroner’s Court New South Wales [Internet]. [cited 2014 Mar 19]. Available from: http://www.coroners.lawlink.nsw.gov.au/coroners/ for_health_professionals.html#When_should_you_repo
2. Guidance for staff responsible for care after death (last offices) – NHS [Internet]. [cited 2014 Mar 19]. Available from: http://www.nhsiq.nhs.uk/media/2426968/care_after_death___guidance.pdf

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