Nurse Verification of Expected Death in ICU

Nurse Verification of Expected Death in ICU

Policy Title: Nurse Verification of expected death in ICU Executive Summary: This policy provides guidance on nurse verification of expected death within the intensive care unit. Supersedes: Version 2 Description of Amendment(s): This policy will impact on: Critical care unit staff Financial Implications: Improved resource management Document Policy Area: Clinical ECT002722 Reference: Version Number: 2 Effective Date: Issued By: Sara Dean Review Date: March 2020 Author: (Full Job title ) Consultation: Intensive Care Unit Senior Sister APPROVAL RECORD Committees / Group SQS Impact Assessment Date: Date November 2013 Approved: SQS 2

SECTION CONTENTS PAGE 1.0 Policy Statement 4 2.0 Roles and Responsibilities 4 3.0 Implementation 4 4.0 The Procedure 5 5.0 Measuring Performance 7 6.0 Audit 7 7.0 Review 7 8.0 References 7 3

1.0 Policy Statement The aim of this policy is to provide a procedure for senior nurses to enable the verification of an expected death within the ICU/HDU setting, also to achieve a consistent and standardised approach to verification of death. A nurse cannot legally certify death this is required by law to be carried out by a registered medical practitioner. However in some circumstances, where a patient s death is inevitable, it may be appropriate for a registered nurse to verify that an expected death has occurred. This will enhance continuity of end of life care for individuals and their families. It is intended that the patient s death is dealt with in a timely, sensitive and caring manner, respecting the dignity, religious and cultural needs of the patient, their relatives and carers. The ability of nurses to verify death, notify relatives and arrange for the removal of the body makes best use of resources and skills. Nurse verification of expected death in ICU, will allow timely cessation of ventilation following death, therefore avoiding ongoing distress to relatives and inappropriate interventions to the deceased. 2.0 Roles and Responsibilities 2.1 Chief Executive The Chief Executive has overall responsibility for ensuring that the Trust has appropriate policies in place and that robust monitoring arrangements are in place. 2.2 Medical Responsibilities The medical team must clearly document in the medical notes that the patients death is expected and that no further medical interventions are appropriate. This decision should where possible/appropriate, be made within the multi-disciplinary setting, having consulted the patient and relatives/next of kin. 2.3 Nursing Responsibilities Verification of expected death can only be carried out by nurses who have received appropriate training, who have read and understood this policy and have been assessed as competent. All nurses must adhere to the Nursing and Midwifery Council (NMC) Code of Professional Conduct (2015) The nurse must inform the relatives / next of kin and the appropriate doctor that the death has occurred. The nurse must document all actions appropriately. 3.0 Implementation 3.1 Scope This policy only applies to registered nurses working in critical care, employed by East Cheshire NHS Trust. The nurses using this policy will be Band 6 or above. 4

Circumstances in which ICU nurses would be verifying death: Death will be expected and this must be clearly documented in the medical notes There must be a valid and current Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form in place The patient is over eighteen and is under the care of the East Cheshire NHS Trust The patient is not a potential organ donor The nurse is satisfied that nurse verification is appropriate and there are no suspicious circumstances surrounding the death, including any reason to believe that the actual cause of death is not the expected cause of death The nurse verifying the death is not the allocated nurse caring for the patient on the day the patient died 3.2 Deaths Reportable to the Coroner The coroner must be informed of sudden, unnatural or suspicious deaths. Generally nurse verification is not appropriate if the death is to be referred to the coroner, however if a patient has been admitted to ICU and has failed to respond to treatment, they may become an expected death (despite an unnatural or suspicious cause). In these circumstances the nurse may verify that the death has occurred and the responsible medical practitioner must be informed. It is then the responsibility of the medical team to refer the death to the Coroner if required. 3.3 This policy will be approved by the safety, quality and standards committee 3.4 All staff whose role it is to verify life extinct will have received training and will have been assessed as competent as part of a recognised course provided by Cheshire Hospices Education. 4.0 Procedure 4.1 The nurse verifier must ensure that the criteria in section 3.1 of this policy are met 4.2 The patient s identity must be confirmed by checking the patient identity bracelet against the medical notes. 4.3 Privacy and dignity must be maintained at all times. 4.4 Perform examination of the patient. The individual should be observed by the person responsible for verifying death for a minimum of five minutes. (Academy of Medical Royal Colleges, 2008) Verifying Death in a non-ventilated patient. Life extinct must always be verified by examining all of the following systems: Cessation of respiratory system: No respiratory effort observed No breath sounds, verified by listening with stethoscope Cessation of circulatory system: No pulses on palpation 5

No heart sounds, verified by listening with stethoscope This can be supplemented by asystole on a continuous ECG display and/or absence of arterial trace. Cessation of cerebral function: Pupils dilated and not reacting to light No reaction to painful stimuli Any spontaneous return of cardiac or respiratory activity during this period of observation should prompt a further five minutes observation from the next point of cardio respiratory arrest. The time of death must be recorded as the time at which the patient fulfils these criteria. Verifying Death in a ventilated patient Cessation of Ventilation In ICU expected deaths often occur following withdrawal of treatment. Treatment aimed at sustaining life has been withdrawn because it has been decided to be of no further benefit to the patient and not in his/her best interests to continue and/or is in respect of the patient s wishes via an advance decision to refuse treatment. (Academy of Medical Royal Colleges, 2008) In some circumstances ventilation may be continued whilst other treatments are withdrawn. In these situations the verification should occur as follows. Once the patient is confirmed dead the ventilator is switched off. When the patient is on mandatory ventilation it is not appropriate to assess respiratory function at the time of death, as the ventilator will continue to deliver breaths until it is turned off. In these circumstances death must be verified based upon cessation of circulatory and cerebral function. The individual should be observed by the person responsible for verifying death for a minimum of five minutes. (Academy of Medical Royal Colleges, 2008) Cessation of circulatory system: No pulses on palpation No heart sounds, verified by listening with stethoscope This can be supplemented by asystole on a continuous ECG display and/or absence of arterial trace. Cessation of cerebral function: Pupils dilated and not reacting to light No reaction to painful stimuli Any spontaneous return of cardiac activity during this period of observation should prompt a further five minutes observation from the next point of cardio respiratory arrest. The time of death must be recorded as the time at which the patient fulfils these criteria. At this point if the patient is ventilated, the ventilator can be switched off. 4.5 The nurse must document the verification of death in the medical notes, using the following format; Breath sounds absent (if not ventilated) Heart sounds absent 6

Pupils fixed and dilated Death confirmed; (date and time using 24hr clock) Signature Print name ID badge number Designation 4.6 The nurses must inform the relatives/next of kin, where possible/appropriate, that death has occurred. 4.7 The nurse must inform the appropriate doctor that the death has occurred, the doctor s name and the date and time of this communication must be documented in the notes. 5.0 Measuring Performance 5.1 Clinical team leaders will be expected to assess individuals practice as part of the appraisal process. 5.2 Nurse verifiers will be expected to update their competency in verifying expected death every two years. 6.0 Audit Where internal audit are carrying out an audit that includes trust policies they will audit against the contents of this policy. 7.0. Review This policy will be reviewed on an annual basis. 8.0 References Academy of Royal Medical Colleges (2008) A Code of Practice for the Diagnosis and Confirmation of Death. Unknown place of publication. [online] [accessed on 9 th September 2013] Available from: lhttp://www.aomrc.org.uk/publications/statements/doc_view/42-a-code-of-practicefor-the-diagnosis-and-confirmation-of-death.html Nursing and Midwifery Council (2012) Confirmation of death for registered nurses. [online] [accessed on 8 th October 2013] Available from: http://www.nmc-uk.org/nurses-and-midwives/regulation-in-practice/regulation-in- Practice-Topics/Confirmation-of-death-for-registered-nurses-/ Nursing and Midwifery Council (2008) The code: standards of conduct, performance and ethics for nurses and midwives. [online] [accessed on 2 nd September 2013] Available from: http://www.nmc-uk.org/publications/standards/thecode 7

Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Nurse Verification of Expected Death in ICU Details of person responsible for completing the assessment: Name: Justine Somerville Position: Senior Sister Team/service: ICU State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) To enable senior ICU nurses to verify expected death. 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document The population of Cheshire as at the 2005 mid year figures (Cohesia Report 2008) is 684,400. Age: 17.8% (30,500) of the population in Cheshire East is over 65 compared with 15.9% nationally. This results in a high old age dependency ratio, i.e. low numbers of working-age people supporting a high non-working dependant older population. The percentage of older or frail old is also considerably higher, with 2.3% (8,200) persons 85 and over compared to 2.1% nationally. Cheshire East has the fastest growing older population in the North West. By 2016, the population aged 65+ will increase by 29.0% (8,845) and the population aged 85+ by 41.5% (3,403). This will have an impact on the number of patients being managed by ECT and the complexity of the health and social care issues that the older person is experiencing. In addition the staffing profile of ECT will change to include an increasing number of staff over 65 in the workforce. 8

Race: The 2005 mid year estimate (Cohesia Report 2008) show that the majority of the population in Cheshire (94.6%) is White British, with 5.4% non White British. The Cheshire 2007-10 Local Area Agreement identified that minority ethnic communities account for around 3% of the population. Issues for BME communities include lack of knowledge of services, access to services, access to translation/interpretation, cultural differences, family values. Many people from BME communities experience poverty, poor housing and unemployment which make it difficult for them to lead healthier lives. 4180 migrant workers registered in Cheshire in 2006/07 and comparison to the mid- year population estimates for Cheshire in 2005 strongly suggests that Cheshire s migrant worker population is larger than every individual BME group other than the White-Other White group. Gypsies and travellers at the last count (July 2006) the highest number was recorded in the Borough of Congleton (125). 42% of gypsies and travellers report limiting long term illness compared to 18% of the settled population, with an average life expectancy 10-12 years less than settled population. 18% of gypsy and traveller mothers have experienced the death of a child compared to 1% in the settled population. Disability: There are over 10 million disabled people in Britain, of whom 5 million are over state pension age. Nearly 1 in 5 people of working age (7 million, or 18.6%) in Great Britain have a disability. Hearing loss: 1 in 4 has a hearing problem. Sight problems: There are 2 million people with sight problems in the UK. Learning disabilities: There is quite a high proportion of people with learning disabilities in the local area due to there being a number of residential homes/institutions in the area. Problems encountered can be lack of staff awareness, communication issues, information requirements. Dementia Approximately six in 100 people aged over 65 develop dementia and this rises to around 20 in 100 people aged 85 or over. Dementia affects 750,000 people in the UK. Carers Around 6 million people (11 per cent of the population aged 5+) provided unpaid care in the UK in April 2001. While 45% of carers were aged between 45 and 64, a number of the very young and very old also provided care. By 2037, it is anticipated that the number of carers will increase to 9 million. Gender On average in Cheshire, 49% of the population are male and 51% are female Transgender: No local data available, national trends show: 1/12,000 males, transgender from male to female 1/33,000 females, transgender from female to male Specific issues around access to services, specific services for men or women, and single sex facilities. In terms of the transgender population, GIRES (Gender Identity Research and Education Society ) gives an estimate of 600 per 100,000. If these 9

figures were applied to the Cheshire East community based on the 2005 mid year estimates, there may be around 2,100 trans people in the area. Religion/Belief In the Cheshire East area: Christian - 80% Sikh - 0.05% Buddhists - 0.16% Other religion - 0.15% Hindu - 0.15% No religion - 11.84% Jewish - 0.12% Not stated - 6.67% Muslim - 0.36% The Muslim population has the highest levels of ill health amongst faith groups this includes higher smoking rates amongst men and higher rates of coronary heart disease and diabetes. Sexual Orientation Lesbians, gay men and bi sexual people (LGB) make up to 5-7% of the UK population (Dept of Trade and Industry, 2003). 13% of Gay men and 31% Lesbian women are parents (Morgan and Bell, First Out: Report of the findings of Beyond the Barriers national survey of LGB people) The experience and health needs of gay men and women will differ. However, both groups are likely to experience discrimination, higher levels of mental ill health and barriers to accessing health care National Health Inequalities data shows that lesbian, gay, bisexual and transgender (LGBT) people are e 2001 census showed: significantly more likely to smoke, to have higher levels of alcohol use and to have used a range of recreational drugs than heterosexual people. They are also at greater risk of deliberate self-harm. Although most LGBT people do not experience poor mental health, research suggests that some are at higher risk of mental health disorder, suicidal behaviour and substance misuse no 2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or concerns raised either from patients or staff (grievance) relating to the policy, procedure, proposal, strategy or service or its effects on different groups?) 2.3 Does the information gathered from 2.1 2.3 indicate any negative impact as a result of this document? no 3. Assessment of Impact Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy or service (part 1) and looked at the data and research you have (part 2), this section asks you to assess the impact of the policy, procedure, proposal, strategy or service on each of the strands listed below. RACE: service affect, or have the potential to affect, racial groups differently? Yes No x Explain your response: Staff involved will need to talk to the patient s relatives/carer/partner. If their first language is not English, staff will follow the Trust s interpretation and translation policy. Staff have access to the Opening the spiritual gate website. 10

GENDER (INCLUDING TRANSGENDER): service affect, or have the potential to affect, different gender groups differently? Yes No x Explain your response: No differential impacts identified. DISABILITY service affect, or have the potential to affect, disabled people differently? Yes No x Explain your response: If the relatives/carer/partner has a sensory disability then information will be communicated in the most appropriate format to enable them to understand. Pre planning will have taken place to assess people s needs. AGE: service, affect, or have the potential to affect, age groups differently? Yes No x Explain your response: Applies to adults only. LESBIAN, GAY, BISEXUAL(LGB): service affect, or have the potential to affect, lesbian, gay or bisexual groups differently? Yes No x Explain your response: There should be no adverse impacts, staff have access to equality and diversity training and specialised LGB training. If it is a same sex couple, then the partner should be informed and involved in the sane way as a heterosexual couple.- RELIGION/BELIEF service affect, or have the potential to affect, religious belief groups differently? Yes No x Explain your response: Written in the policy is the need to observe people s religious and cultural beliefs. Staff have access to a range of information including the Opening the spiritual gate website. CARERS: service affect, or have the potential to affect, carers differently? Yes No x Explain your response: See all sections above. OTHER: EG Pregnant women, people in civil partnerships, human rights issues. service affect, or have the potential to affect any other groups differently? Yes No x Explain your response: No other impacts identified. 4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children? Yes No x 11

b. If yes please describe the nature and level of the impact (consideration to be given to all children; children in a specific group or area, or individual children. As well as consideration of impact now or in the future; competing / conflicting impact between different groups of children and young people: c. If no please describe why there is considered to be no impact / significant impact on children: Children not impacted as ICU is an adult only area at MDGH. 5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and that the made sure that the policy, procedure, proposal, strategy or service will affect them in the way that you intend? Have you spoken to staff groups, charities, national organisations etc? Senior critical care staff SQS 6. Date completed: 3.3.17 Review Date: 3.3.20 7. Any actions identified: Have you identified any work which you will need to do in the future to ensure that the document has no adverse impact? Action Lead Date to be Achieved 8. Approval At this point, you should forward the template to the Trust Equality and Diversity Lead lynbailey@nhs.net Approved by Trust Equality and Diversity Lead: Date: 3.3.17 12