Policy for: The Verification of Expected Death

Policy for: The Verification of Expected Death Document Reference: SCH Serco CP Version: 2 Status: For approval Type: Document applies to (area): Suffolk Community Healthcare Serco Document applies to (staff groups): All groups Required compliance: This policy must be complied with fully at all times by the appropriate staff. Where it is found that this policy cannot be complied with fully, this must be notified immediately to the owner through the waiver process Document owner: Document author: Other contact: Date this version adopted September 2011 Last review date September 2013 Next review date September 2016 Location of electronic master SCH Intranet Director of Nursing, Therapies & Governance End of Life Education Group Head of Nursing & Professional Practice AGREED POLICY/GUIDELINE REVIEW / RATIFICATION / ADOPTION PATH: Level 1: Level 2: Agreed by: End of Life Group Agreed by: Clinical Policy and Guidelines Group Date: July 2013 Date 26/7/13 Level 3: Agreed by: Clinical Quality & Safety Assurance Group Date: 27/9/13 S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc

Contents 1 Introduction... 1 2 Purpose of this Clinical Policy... 1 3 Policy Agreement Path... 1 4 Definitions... 2 5 Cross Reference to Other Related Polices... 2 6 Scope and responsibility... 2 7 Restrictions to Practice... 3 8 Practice Assessor/Supervisor (Requirements and Eligibility)... 3 9 Procedure for Verifying an Expected Death... 3 10 Documentation... 5 11 Accountability... 5 12 Training... 5 13 References... 5 Appendix 1: Verification of Expected Death Documentation... 7 S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc

STATEMENT OF OVERARCHING PRINCIPLES VERIFICATION OF EXPECTED DEATH POLICY All Policies, Procedures and Guidelines of SCH Serco are formulated to comply with the overarching requirements of legislation, policies or other standards relating to quality and diversity. 1 Introduction 1.1. Rationale for policy a) This policy has been developed to enhance patient care, reduce delays in verification of expected death and support the increased us of nurses in the management of chronic illness and end of life care. b) Before undertaking this role nurses should ensure that they have the necessary confidence, competence, knowledge and skills. Each individual is accountable and responsible for his/her own actions. c) All nurses undertaking this role must complete the training programme outlined in this policy and be deemed competent prior to commencing VOED. d) Marie Curie staff have the approval of Suffolk Community Health Care (SCH) to verify death if appropriately trained whilst undertaking work on behalf of SCH. 1.2. Background a) Verification of death is an important stage in the process for relatives and carers. Until this has been performed, no further action can be taken with regard to the deceased. b) Delays in verification of death can cause distress to family and carers and lead to difficulties when there are medical devices such as syringe drivers still running which cannot be discontinued until the verification process is complete. 1.3. Legal background The General Practitioner Committee has published guidance on Verification of death identifying there is no legal or under NHS Terms of Service, for a general practitioner to verify the fact of death. There are several legal aspects regarding the verification of death which nurses need to be fully aware of prior to undertaking the role. 2 Purpose of this Clinical Policy The purpose of this policy is: a) to enable registered nurses to verify expected adult death. b) to ensure that verification of expected adult death is carried out promptly to reduce relatives anxiety and within legislative guidelines. 3 Policy Agreement Path Refer to front sheet for policy agreement path. S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc 1

4 Definitions 4.1. VOED Verification of expected death is the confirmation of cessation of life by a series of checks on the patient. 4.2. Expected death When a patient is known to be suffering from a terminal illness with no active intervention to prolong life 4.3. Adults For the purposes of this policy the term adults is applicable to persons over the age of 18. 5 Cross Reference to Other Related Polices NMC Record keeping policy guide for nurses and midwifes (2009) NMC The code (2008) NMC Advice sheet Confirmation of death (2006) SCH Record Keeping policy 6 Scope and responsibility 6.1. It will be the line manager responsibility to identify who is appropriate to under go VOED training and be a verifier 6.2. A registered nurse wishing to undertake VOED must have a minimum of 6 months post registration experience. 6.3. Registered nurse(s) must obtain and complete the following: a) Line manager s written consent to undertake verification of expected death (see Role Development Portfolio). b) Successfully complete the Suffolk Verification of Expected Death Role Portfolio. c) Complete Verification of Expected Death Evidence of Completion. d) Demonstrate competence to practice annually through self-assessment of knowledge, skills (see Role Development Portfolio). e) Discuss and agree with Line Manager to continue undertaking the role. 6.4. Registered nurses who have received training and are deemed competent will be responsible for VOED 6.5. The line manager will review the VOEDs with the verifier on an annual basis to ensure documentation and legal obligations are correctly completed within PDP process 6.6. The patients expected death must be clearly documented in the patient record. Any change to the patient s condition must be reviewed by the patients GP. 6.7. The patients GP must be informed of the death by the next working day 6.8. Any requests made by the patients family to see the patients Dr at the time of death is respected with normal surgery hours or where prior agreement has been established. 6.9. The deceased body should not be left insitu longer than necessary to comply with the deceased/relatives wishes and enable Care After Death to be completed. S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc 2

7 Restrictions to Practice 7.1. All registered nurses must meet the required competencies. A registered nurse can have two attempts at VIVA. If unsuccessful at demonstrating sufficient competence and confidence at both attempts at the VIVA, the individual s manager will need to decide if further training is appropriate. 7.2. Once deemed competent the registered nurse may verify expected death independently. 7.3. Agency registered nurses may not verify death. 7.4. Registered nurses may only verify a patient s death if there is consistent and reliable evidence that death was expected. It is therefore essential that the nurse is confident that the patient is expected to die at the time they do die and that they ensure they document their reasoning for their decision making in the patient records/care plan. 7.5. Registered nurses must not verify the death of a patient who dies within 24 hours of an accident of clinical incident if the patient was not seen by a doctor. In these circumstances the nurse should discuss the patient with a doctor and consider if the accident/incident is likely to have caused the patients death. If it is felt that the accident/incident is likely to have caused the death, the coroner/procurator fiscal and/or police should be informed. 7.6. If there are any suspicions around the patients death and it is felt that the death may be due to unnatural causes such as suicide, suffocation etc the doctor and police must be informed immediately and the scene protected until the police arrive. The police will need to undertake a sudden death report for the coroner/procurator fiscal. 7.7. Certification of death: is the process of determining the cause of death. This must be carried out by a Medical Practitioner. 8 Practice Assessor/Supervisor (Requirements and Eligibility) 8.1. To be suitably qualified to assess using a VIVA the competence of a registered nurse and to confirm their fitness to undertake verification of an expected death, a practice assessor must possess relevant experience in end of life care and must therefore meet the following requirements: a) Minimum 12 months post registration experience. b) Currently working in the end of life care environment and able to demonstrate knowledge, skills and experience in palliative care/end of life care. c) Provides evidence of having completed the Suffolk VOED Portfolio to level 4 or other assessed verification of death training. d) Verifying adult deaths (this does not apply to Practice Educators). 9 Procedure for Verifying an Expected Death 1 The registered nurse should confirm the patient s identity by either: a) Checking patient identity with documentation. b) Checking with the patient, relatives or carers on arrival. 2 Check the patients notes or end of life pathway contains the relevant information regarding imminent death 3 Note the exact time of death (if witnessed) S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc 3

4 In order to verify expected death, the nurse must confirm the following on initial examination and after 10 minutes a) Absence of central nervous system activity. Pupils are fixed and dilated and unresponsive to light. This must be confirmed using a pen torch AND there is no response to painful stimuli. This must be confirmed by rubbing the sternum for 10 seconds. b) Absence of respiratory activity. There is absence of respiratory movement and bronchial and tracheal sounds. This must be checked for one minute by observing the chest and listening with a stethoscope. c) Absence of cardiac output. There is absence of a pulse. This must be confirmed by palpation of the carotid pulse in the neck. The nurse must feel for a pulse for a minimum of one minute AND there are no heart sounds. This must be confirmed by listening at the apex for one minute using a stethoscope. 5 Relatives should be informed sensitively that death has been verified and that the patients medical doctor/general practitioner will carry out certification and issue the death certificate 6 It is the responsibility of the nurse who verifies death to ensure that the patients general practitioner is informed 7 The patient s religious beliefs should be considered and included within the patient care plan. 8 Once the death has been verified, the parenteral drug administration equipment, catheters and syringe drivers may be removed and Care After Death performed. 9 Care of the body should be undertaken in accordance with Royal Marsden clinical nursing procedures 10 Verification of Expected Death documentation to be completed (appendices 1) and also recorded in the nursing notes. 11 It is the verifier s responsibility to inform the appropriate medical practitioner of the patient s death as soon as practicable. A notification or a copy of Verification of Expected Death documentation must be provided for/ to the patients GP on next working day. Additionally, all other agencies and health professionals must be informed of patients death 9.1. If there is any doubt over verification of death then a Senior Nurse or Doctor should be asked to carry out a separate assessment. 9.2. If an unnatural death is suspected, the death should be reported immediately to the police and the patient s general practitioner and verification must not be undertaken. In addition: a) Advise the family/carer of actions you are taking and if appropriate the reasons why. b) Preserve the scene. c) Contact the local out of hour s service and/or Doctor. d) Document your actions/events. e) Inform your line manager/on call manager and complete an Incident Reporting form (IR1). S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc 4

f) Wait until the police arrive. 10 Documentation 10.1. Nurses should follow the NMC Guidelines for records and record keeping (2009) and the following should be clearly documented in the patients notes: a) Any communication to establish that death was expected, e.g. who, job title, when and what evidence provided. b) Date, time (if witnessed) and place of death. c) Absence of CNS activity, cardiac output and respiratory activity. d) Chapel of rest, undertaken where body transferred if known. e) Name and qualifications of person verifying death. f) Requests from relatives for information/discussions. g) Persons present at time of death including contact details. h) Any known information regarding relatives wishes for the burial/cremation. 10.2. All nurses should use the Suffolk Verification of Expected Death documentation. 11 Accountability All nurses assessed to carry out Verification of Expected Death are accountable for their practice and MUST undertake annual self assessments of their skills, knowledge and competence. 12 Training 12.1. To undertake the procedure of verification of expected death, the verifier has to be able to demonstrate the following: a) Successfully complete the Suffolk Verification of Expected Death Role Portfolio. b) Complete Verification of Expected Death Evidence of Completion. c) Demonstrate competence to practice annually through self-assessment of knowledge, skills (see Role Development Portfolio). 12.2. All training documents available on Practice Development web page 13 References Death certification and investigation in England and Wales http://www.archive2.official-documents.co.uk/document/cm58/5831/5831.pdf Dimond, B. (1990) Chapter 29: Legal Aspects of Death in Legal Aspects of Nursing. Prentice Hall. London. Home Office (1971) Report of the committee on death certification for Coroners, CMND 4810. London. Her Majesty s Stationery Office (HMSO) Nursing and Midwifery Council (2006) A-Z of Advice: Confirmation of Death for Registered Nurses. NMC. London. Nursing and Midwifery Council (2002) Code of Professional Conduct. NMC. London. S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc 5

Nursing and Midwifery Council (2004) Code of Professional Conduct: standards for conduct, performance and ethics: NMC. London. Nursing and Midwifery Council (2008) Confirmation of death, Nursing and Midwifery Council. NMC. London. Nursing and Midwifery Council (2009) Guidelines for records and record keeping. NMC. London. Location of Royal Marsden Manual: http://www.rmmonline.co.uk/ S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc 6

Appendix 1: Verification of Expected Death Documentation Date dd/mm/yy Time Patient s Name Patient s Other names Date of birth (if known) or Approximate age Patient s home address Location of death (if different form home address) Name of patient s general practitioner (GP) Address of patient s GP Clinical findings (please observe for at least one minute) Please delete as appropriate At baseline At baseline + 10 minutes Carotid pulse Present Absent Present Absent Heart sounds Present Absent Present Absent Signs of spontaneous respiration Present Absent Present Absent Fixed dilated pupils Present Absent Present Absent Reaction to pain Present Absent Present Absent Immediate need to refer to coroner or police? Reasons for referral Yes No Who referred to When Prostheses: please specify if known (e.g. internal pacemakers, internal defibrillators, eyes etc) Verification of death Life verified extinct at: Date dd/mm/yy Hours Minutes Verified by Name Signature Witness Name Signature present? GP/ out of hours service contacted by Time Contacted Name of person informed GP/Nurse/ ECP/ paramedic Relative contacted by Name of relative Time contacted Funeral Director/ Undertaker Name To visit home by Body taken to S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc 7

This EQIA covers policies, services, protocols, procedures, guidelines and strategies, collectively known as components on the form below. EQUALITY IMPACT ASSESSMENT (EQIA) 1. Component Summary EQIA Completion Details Component Title: VOED Component Status: Proposed Associated Components (incl. ref no. and version no.): 1. 2. 3. Date: 13/08/13 2. Component Details Who is likely to be affected by the component: Staff Patients Public Names and Post Titles of staff involved in completing EQIA: Sarah Miller 3. Component Impacts Probable impact group? Race, ethnicity, nationality No Religion, belief, faith No Gender (inc. No transgender), marital status Disability No on High, medium, or low Further details Sexual orientation Age No No Other grounds: No homelessness, gypsy / travellers, refugees / asylum seekers /migrant workers 4. Differential Treatments Identified Considering the type of differential treatment identified, is this discriminatory according to legislation? Yes (Complete all Section 4) No (Go to Section 5) Which legislative Act applies? Is the discrimination identified direct or 1. Human Rights Act indirect? 2. Sex Discrimination Act Direct Indirect 3. Race Relations Act S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc 8

4. Disability Discrimination Act 5. Age Legislation (2006) 6. Equal Pay Act 7. Sexual Orientation Regulations 8. Religion or Belief Regulations 9. Health and Safety Regulations 10. Part-Time Employees Regulations Is there a genuine occupational qualification ie is the discrimination justifiable? Yes No 5. Type of Discrimination If the type of discriminatory action identified is not unlawful, does it still have an adverse effect? Yes go to section 6 No go to section 8 6. Specific Issues Identified Please list the specific issues that have been identified as being discriminatory / promoting adverse differential treatment. 1. 1. Page / paragraph / section of component that issue relates to 2. 2. 3. 3. 7. Proposals How could the identified adverse effects be minimised or eradicated? If such changes were made, would this have repercussions / negative effects on other groups as detailed in Section 3? Yes No (if No go to section 8) Please give details: Would such changes ensure that the component complies with all relevant legislation, therefore making it legal and good practice? Yes No OR: If component already complies with relevant legislation: Would such changes minimise negative differential treatment? Yes No 8. Component Implementation Upon consideration of the information gathered within the EQIA, the Chief Operating Officer agrees that the component should be adopted by SCH. Director of Nursing, Therapies & Governance Signature:. Date: 27/11/13 9. Proposed Date for Component Review Please detail the date for component review (usually in 3 years time): July 2016 S:\Provider\Quality Governance\Clinical Policies\1. UNDER REVIEW\5. APPROVED FOR PUBLISH\2. FOR PDF CONVERSION\VOED Policy 2013.doc 9