CLINICAL PROCEDURE PROCEDURE FOR AN EXPECTED DEATH OF AN ADULT PATIENT FOR COMMUNITY Issue History Issue Version One Purpose of Issue/Description of Change Planned Review Date To ensure all deceased individuals, their families and carers are dealt with in a dignified and respectful manner. 2016 Named Responsible Officer:- Approved by Date Quality and Governance Service Section: - End of Life care CP: 50 Quality, Patient Experience and Risk Group Target Audience Community Nursing September 2013 UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
CONTROL RECORD Title Purpose Procedure for an expected death of an adult patient for Community Nursing To ensure all deceased individuals, their families and carers are dealt with in a dignified and respectful manner. Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Lorraine Adams Document Librarian QGS Groups consulted with:- Clinical Policies and Procedures Group Infection Control Approved Not applicable Date approved by Quality, Patient Experience and Risk Group 25 th September 2013 Method of Distribution Email Intranet:- Staff Zone Archived Date Location:- Datix Librarian Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 L Adams T Procedure updated Status New / Revised / Trust Change PROCEDURE FOR AN EXPECTED DEATH OF AN ADULT PATIENT FOR COMMUNITY 2/9
INTRODUCTION It is the policy of the trust to ensure that all deceased individuals and their families are cared for in a culturally sensitive and dignified manner. Nursing care should not cease when a person dies; caring for the deceased demonstrates respect for the individual and their families. TARGET GROUP All registered community nurses employed by the trust have a duty to follow this procedure as part of their role and job description. TRAINING All staff in the Trust are required to comply with mandatory training as specified in the Trusts Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. RELATED POLICIES Please refer to relevant Trust policies and procedures CONSENT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient s health records with a clear rationale stated at all times. Refer to Trust Patient Information and Consent Policy for further information and guidance or the Clinical Protocol for Assessing Mental Capacity and Best Interests. INDICATIONS Expected death whereby the General Practitioner/Consultant/Medical Officer concerned has diagnosed the patient as suffering from advanced progressive, incurable disease and the patient has been seen by a registered medical practitioner within the previous 14 days and is not a case reportable to the coroner(in the community the registered medical practitioner is usually the patient s own GP). Any known health and safety risk is expected to be shared by the medical officer concerned with any other medical officer or health agency who will be dealing with the individual. CONTRAINDICATIONS Sudden death, which refers to any death caused by an accident unknown or unanticipated cause, may also include those that occur in an unexplained or suspicious circumstance. PROCEDURE FOR AN EXPECTED DEATH OF AN ADULT PATIENT FOR COMMUNITY 3/9
Unexpected death, this is the term utilized when the death occurs in unexplained or suspicious circumstances that must be confirmed by a doctor and reported to her majesty s coroner. This list is not exhaustive and some of the cases of death Unknown person Child No doctor attended the deceased in their last illness Within 24hours of illness or where no firm diagnosis has been made Within 30 days of an operation or invasive procedure Linked to poison or drugs or due or due to an accident As a result of self- neglect or neglect by others, including poor care in a residential/nursing home. Due to industrial disease Due to malpractice or negligence as a result of actions of the deceased, including suspected suicide, drug or solvent abuse. NB If death is not expected or there are any mitigating circumstances e.g. a drug error then staff must follow the sudden death policy. INFORMATION TO RELATIVES/CARERS FOR THE REPORTING OF MESOTHELIOMA As part of the advanced care planning it is imperative that families are informed that a death from mesothelioma is classified as an unnatural death and is therefore a reportable condition to the coroner. This is usually reported by the General Practitioner (GP) or the Consultant; the Coroner cannot always see every family and the police will often attend on behalf of the coroner. All deceased patients are taken to the mortuary at the hospital. In these circumstances the nurse can remove syringe drivers and all other equipment. EVIDENCE TO SUPPORT PROCEDURE THE GOLD STANDARD FRAMEWORK (GSF) The Gold Standard Framework aims to improve palliative care by ensuring communication remains robust between all members of the multidisciplinary team. It enables those approaching the end of life to have care streamlined, that is their needs assessed and a timely response in relation to multi- agency involvement. The main objectives of the framework focuses on optimizing continuity of care, team work and advanced care planning (including out of hours), symptom control, patient and staff support. THE WIRRAL END OF LIFE CARE PLAN The Wirral End of Life Care Plan was developed as a tool to promote holistic assessment in the final hours/days of life. It enables community nurses to ensure patients are receiving a high quality of care that is supported by research based evidence. This includes symptom management and anticipatory prescribing. Discussions with Patients/carers must take place PROCEDURE FOR AN EXPECTED DEATH OF AN ADULT PATIENT FOR COMMUNITY 4/9
regarding future needs of the patient who may require to be commenced on the Wirral End of Life Care Plan and all patients/carers must be offered a specific leaflet on end of life care. PREFERRED PRIORITIES FOR CARE (PPC) Preferred priorities for care is a patient held document, it enables patients to document their thoughts and wishes regarding future care. It enables health care professionals to know what is important to patients so that they can work together to achieve the patient s wishes, it is vital that this document is shared between health professionals and patient, if those future wishes and preferred place of care are to be met. Patients should be encouraged to identify individuals who would need to be consulted regarding patients care should the person in the future be unable to make decisions regarding their care. Patients, who have formally appointed somebody to make decisions about care, using a Lasting Power of Attorney (LPA), should be identified in the PPC document. The lasting power of attorney document should also be viewed by health professional and documented within the patient s health records along with a photo copy of the document, so that any health professional has access to this. ADVANCED CARE PLANNING Advanced Care Planning is important and should be based on the needs of the patient. It is the process for supporting people and those important to them in planning for their future as their condition progresses (Hutchinson and Foster, 2008). The potential benefits are: The individual wishes and preferences can be ascertained and documented Other services may be triggered, such as access to certain benefits Care planning and anticipatory prescribing can better reflect end of life care issues The needs of the person s carers can be reviewed and monitored The EoLC strategy clearly states that carers are entitled to an assessment and care plan in their own right. CARING FOR THE CARERS Families and carers should be made aware by the GP or community nurse that the patient s condition is deteriorating and that death is expected. Families and carers should be made aware that as a consequence of the irreversible illness /condition, cardio-pulmonary resuscitation would not be appropriate and a record of this conversation should be recorded in the health records. Families and carers should be made aware that should the patient die in the absence of a health professional not to call an ambulance but to contact GP surgery in surgery hours or GP Out of Hours at all other times. Open and sensitive communication with families and carers is required to gain an understanding of preferences and religious and cultural needs following death. PROCEDURE FOR AN EXPECTED DEATH OF AN ADULT PATIENT FOR COMMUNITY 5/9
The nurse must have sensitive discussions with the family/relatives prior to the patient s death regarding the process for removing equipment from the patient when death is suspected to maintain the patient dignity. EQUIPMENT Single use disposable apron Single use disposable non sterile gloves Doop Kit (dispose of drugs safely from syringe driver) Ampoule breaker Sharps container Cosmopore or similar dressing ACTION Introduce yourself as a staff member and any colleagues involved at the contact Wear identity badge which includes name status and designation Ensure verbal consent for the presence of any other third party is obtained Explain procedure to family/carer including risks and benefits and gain valid consent. If patient has a known or suspected infection, please follow Care of the cadaver policy Follow the Wirral End of Life Care Plan that was initiated for the individual patient. On the expected death of a patient when a nurse is present contact general practitioner (GP) /or GP out of hours. A Nurse cannot legally certify death (NMC 2010), However, if a nurse is present when death occurs or requested to visit as death is suspected the nurse can remove equipment e.g. syringe driver If a patient dies of a reportable disease e.g. Mesothelioma, providing death is expected and meets the criteria out lined in this procedure the nurse can remove equipment e.g. syringe driver RATIONALE To promote mutual respect and put family/carer at ease For family members/carers to know who they are seeing and to promote mutual respect Students for example, as the family/carer has the choice to refuse To demonstrate sensitivity and respect for the families and carers at a difficult time To reduce the risk of cross infection and to safe guard all agencies and families who come into contact with the body or bodily fluids. Key recommendation 14: NICE guidance 2004. This will enable the death to be certified This procedure allows the nurse to remove equipment following death as long as the following criteria are met: The patient was on the Wirral End of Life Care Plan, death is expected and the relatives are happy for the nurse to remove the equipment. All actions must be documented with in the patient s health records Removing such devices maintains patient s dignity and relieves stress for carers at this difficult time PROCEDURE FOR AN EXPECTED DEATH OF AN ADULT PATIENT FOR COMMUNITY 6/9
If a patient has an Implantable Cardioverter These devices need to be deactivated defibrillator (ICP). The undertakers must be after death and must be explanted made aware of this before a person is cremated Inform all known relevant agencies involved in delivering care of the patients death If community nurse not present at time of death family should be informed to contact general practitioner (GP) /GP out of hours and nursing team. If necessary, the GP may refer to the coroner. Follow the cultural or religious needs of the deceased as recorded in the Wirral End of Life Care plan or advanced care plan Decontaminate hands prior to procedure Apply single use disposable apron Apply single use disposable non-sterile gloves Remove all equipment/aids, prior to funeral director attendance. Dispose of medication from syringe driver into a Doop kit and sharps into a sharps container All equipment to be returned to base for decontamination Cover any open/weeping areas with dressings e.g. cosmopore On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of Personal Protective Equipment Clean equipment in line with Trust policy and manufacturer s instructions. Dispose of any additional medication appropriately or advise carers how to dispose of medication-to comply with the safe storage and To avoid unnecessary future contacts with the family that may cause distress In order for community nurses to arrange a return visit to support family members and remove equipment To comply with current legislation Respect and dignity for all deceased patients To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of micro-organisms To protect hands from contamination with organic matter and transfer of micro-organisms To maintain dignity and respect following death. To ensure medication/sharps are disposed of safely and equipment is returned and decontaminated as per trust policy To contain any leakage of bodily fluids To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE Decontamination of medical equipment is essential for the effective delivery of patient care. Comply with Trust policies and procedures, if disposing of controlled drugs in the patients home complete PROCEDURE FOR AN EXPECTED DEATH OF AN ADULT PATIENT FOR COMMUNITY 7/9
administration of medicines policy Trust disposal of controlled drugs form. Give family leaflet What to do after Death in England and Wales. Document all relevant information within the patient s health records and remove from patients property and take to base for filing Advise Family to contact Community Equipment service to arrange collection of any equipment if necessary. Community nurse to contact Community Equipment Service if needed Plan appropriate and timely bereavement visit within 14 days following the death To inform families and carers of current legislation, all team leaders must ensure that there is a supply of these booklets available in all bases. Follow Trust record keeping policy and ensure personally identifiable information of patients is stored in boot of car for transportation from patient s home directly to the base. To comply with the trusts policies and procedures To meet the psychological and spiritual needs of families and carers. WHERE TO GET ADVICE FROM Team leader/line Manager/General Practitioner (GP) / GPOOH INCDENT REPORTING Clinical incidents or near misses must be reported via the Trust s Datix incident reporting system. This is vital if changes within practice are to occur to improve the patient s journey and safeguard staff, ensuring quality of care is at the forefront of the trusts objectives. Here are some examples of situations that need incident reporting. Unsafe discharge Delay in palliative care medication e.g. anticipatory prescribing Any medication errors Any delay in the availability of equipment DOCUMENTATION All registered nurses in the community must use the Wirral End of Life Care plan. Copies are available on the trusts internet. SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. REFERRALS PROCEDURE FOR AN EXPECTED DEATH OF AN ADULT PATIENT FOR COMMUNITY 8/9
Any referrals to health professionals, therapists or other specialist services must be followed up and all professional advice or guidance documented in the patients health records. EQUALITY ASSESSMENT During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place. REFERENCES Department of Health (2008) The National End of Life Care Programme www.dh.gov.uk Department for Work and Pensions (2009) What to do after a death in England and Wales. http://www.dwp.gov.uk/docsdwp1027.pdf. Dougherty, L. & Lister, S. (2011).The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 8 th Edition, John Wiley & Sons Ltd Publication, Chichester, West Sussex Gold Standard Framework.www.goldstandardsframework.nhs.uk Home Office (1971) report of the Committee on death certification and Coroners. Home Office, London. Hutchinson, C. & Foster, J.(2008) Best Interests of End of Life: Practical Guidance for Best Interest Decisions Making and Care Planning at End of Life http://www.endoflifecare.nhs.uk/eolc/files/nhs-elpct Best Interests at EoL Booklet May2008.pdf National Institute for Clinical Excellence (2004) Improving Supportive and Palliative care for Adults with Cancer. Executive Summary. www.nmc-uk.org Nursing and Midwifery Council (MNC) (2008) the code: Standards of Conduct,Performance and Ethics for Nurses and Midwives.www.nmc-uk.org Nursing and Midwifery Council (NMC)(2010)Advice sheet: Confirmation of death-for registered nurses.www.nmc-uk.org/aarticle.aspx?article.id=4002 Preferred Priorities for Care (2007) led by National PPC Review team. Further Information. www.endoflifecare.nhs.uk PROCEDURE FOR AN EXPECTED DEATH OF AN ADULT PATIENT FOR COMMUNITY 9/9