LAST OFFICES. (Acute Operating Division)

Page 1 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 This SOP applies to all staff employed by NHS Greater Glasgow & Clyde (Acute Operating Division) and locum staff on fixed term contracts and volunteer staff. SOP Objective To provide staff with information on the precautions required when a patient with a known infection dies. KEY CHANGES FROM THE PREVIOUS VERSION OF THIS SOP Invasive Streptococcal Disease H1N1 Document Control Summary Approved by and BICC November 009 Date of Publication January 010 Developed by Infection Control Policy Sub-Group 0141 11 677 Related Documents NHSGGC Standard Precautions Policy NHSGGC Decontamination Policy NHSGGC Hand Hygiene Policy NHSGGC Transmission Based Precautions Policy Distribution/Availability NHSGGC Infection Prevention and Control Policy Manual and Implications of Race Equality and other diversity duties for this document Equality and Diversity Impact Assessment Completed Lead Responsible Director the Internet This policy must be implemented fairly and without prejudice whether on the grounds of ethnicity, gender, sexual orientation, religion, belief, disability or age. November 009 Lead Nurse Infection Control North East Board Infection Control Manager

Page of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 CONTENTS Protocol... 3 Table 1... 6 Appendix 1 - Information on religious beliefs following a death in hospital... 8 Evidence Based Requirements... 1

Page 3 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 Protocol Aim To prepare the deceased for the mortuary respecting their religious or cultural beliefs. To comply with legislation, in particular where the death of a patient requires the involvement of a Procurator Fiscal. To minimise any risk of cross-infection to relative, healthcare worker (HCW) or persons who may need to handle the deceased. To ensure the deceased is moved to the mortuary within four hours of death. Statement Before Commencing Procedure Patients may have one or more religious or cultural beliefs or personal wishes relating to death and dying; these must be respected. Infection risks do not increase after death. Death in hospital may necessitate by law the involvement of the Procurator Fiscal. It is important that HCWs comply with legislation, the wishes of patients / relatives and continue to follow Standard Precautions and where necessary Transmission Based Precautions to minimise any risk of cross-infection. VERIFICATION OF DEATH MUST BE CARRIED OUT BY A DOCTOR OR APPROVED PERSON Location at the bedside, preserving the dignity and privacy of the deceased and consider the needs of other ward patients and relatives. If death is out with the ward area, a room or screened area must be found. Check the case notes if the patient has or is suspected of having an infection, as listed in Table 1, and follow appropriate instructions. Consider if radiation precautions are still in force. Specific religious and cultural requirements advice is included at the back of the document. Consider a body bag for leakage after death. Consider any special request made before death, e.g. the keeping on of jewellery, clothes to be worn, etc. Consider if eyes are being donated for corneal grafting (if yes, the eyes should be gently taped closed).

Page 4 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 Procedure Having assessed all of the issues above: Collect and don personal protective equipment (PPE), i.e. gloves and plastic apron. If a risk of splashing, wear face protection. Remove items to be used for last offices the mortuary pack and take to the bedside. If a fiscal case, cap off, but leave all invasive devices in situ, e.g. urinary catheters, peripheral vascular catheters, e.g. venflons. If not, invasive devices should be removed. Patient should be laid flat on the bed with a pillow under the head with limbs straight. Remove all jewellery the deceased unless advised otherwise by the deceased in life or by the relatives on religious or cultural grounds. If it proves difficult for nursing staff to remove jewellery, the relatives should be advised that this could be done later. Any attached body piercing should be regarded as jewellery. Jewellery removal should be witnessed by two persons and recorded in the valuables book. Record any jewellery left on the body on the Mortuary Notification Card. Depending on the religious beliefs, carry out the remainder of the procedure if indicated in Appendix 1 Wash the deceased and close the eyes. Ensure that oral hygiene is carried out. If the deceased has dentures ensure they are in situ. Attach identification bands to a wrist and the opposite ankle of the deceased. Both identification bands should contain the following information: Deceased s Name, CHI Number, Date of Birth, Ward. If the lower jaw drops down significantly, consider putting on a chin support. Place an adult incontinence pad / diaper under the deceased. Dress the patient using a disposable gown. (If the family wish, the deceased may be dressed in their own nightwear or clothing). If the deceased is to be viewed by relatives on the ward ensure there is no blood or body fluid leakage about the face. Wrap the patient carefully in a sheet and fasten with tape. If radiation restrictions are still in force, attach a sticker RISK OF IONIZING RADIATION to the outside of the shroud (and if a body bag is to be used to the outside of the body bag).

Page 5 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 Place the deceased in a body bag if the body is likely to leak, or if the patient has an infection / alert organism and it is indicated in Table 1. Remove gloves and plastic apron and wash hands. (Use new gloves for any additional cleaning procedures to prevent direct contact with blood or body fluids or equipment contaminated with blood or body fluid). Complete the MORTUARY NOTIFICATION CARD indicating if a body bag has been used because of Leakage or Infection and secure it to the outside of the sheet or body bag and/ or the shroud. Section 1 of this card is to be completed by nurses, Section by a doctor. (Failure to complete can delay funeral arrangements). Ensure that all items being sent to the Mortuary are recorded on the Mortuary Card, e.g. pictures, religious medals, artificial limbs. Contact the porters and request they remove the deceased to the mortuary as soon as possible because decomposition is quickened in warm conditions. All patients must be removed to the mortuary prior to being moved by undertakers. Relatives viewing the deceased before moving to the mortuary if the deceased has been in the ward for four hours or approaching that time the nurse in charge of the ward MUST contact their line manager. When transferring the deceased form the bed to the trolley, follow moving and handling guidance. Ensure consideration of other patients and relatives in the ward at that time. If there is a risk of leakage or infection the porter will used gloves regardless of whether the body is in a bag. The porters will wash their hands after handling a wrapped body. Return used mortuary box to the porters who will exchange for a complete box. Complete nursing documentation. After Care Ensure all casenotes, laboratory reports and x-rays are gathered together. If the deceased is to undergo a post mortem the casenotes will accompany the patient to the mortuary. If there is contamination of the trolley transporting the deceased, follow the Spillages Section of the Decontamination Policy.

Page 6 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 Table 1 Organisms or clinical conditions which if the deceased has, or is suspected of having, necessitate precautions in addition to STANDARD PRECUATIONS. If in any doubt contact a member of the Infection Control Team. Risk Category Bagging Viewing Embalming Hygienic Preparation Acute poliomyelitis Med No Yes Yes Yes Anthrax High Yes No No No C. difficile Low No Yes Yes Yes Chickenpox / shingles Low No Yes Yes Yes Cholera Med No Yes Yes Yes CJD all transmissible spongiform High No Yes No Yes encephalopathies Cryptosporidiosis Low No Yes Yes Yes Dermatphytosis Low No Yes Yes Yes Diphtheria Med Yes Yes Yes Yes Dysentery Med Yes Yes Yes Yes E. coli 0157 Med Yes Yes Yes Yes Food poisoning Med No Yes Yes Yes Haemorrhagic Fever with Renal Med No Yes Yes Yes Syndrome Hepatitis A, E Med No Yes Yes Yes Hepatitis B, C and non-a and non-b High Yes Yes No Yes HIV, AIDS Med Yes Yes No Yes Influenza A (including H1N1) Med No Yes Yes Yes Legionellosis Low No Yes Yes Yes Leprosy Low No Yes Yes Yes Leptospirosis (Weil s disease) Med No Yes Yes Yes Lyme disease Low No Yes Yes Yes Malaria Med No Yes Yes Yes Measles Low No Yes Yes Yes Meningitis not meningococcal Low No Yes Yes Yes Meningococcal septicaemia (with or Med Yes Yes Yes Yes without meningitis) MRSA Low No Yes Yes Yes Mumps Low No Yes Yes Yes Ophthalmia neonatorum Low No Yes Yes Yes Paratyphoid fever Med Yes Yes Yes Yes

Page 7 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 Risk Category Bagging Viewing Embalming Hygienic Preparation Plague High Yes No No No Psittacosis Low No Yes Yes Yes Q fever Med No Yes Yes Yes Rabies High Yes No No No Relapsing fever Med Yes Yes Yes Yes Rubella Low No Yes Yes Yes SARS High Yes No No No Scarlet fever Med No Yes Yes Yes Smallpox High Yes No No No Streptococcal disease (invasive)* High Yes No No No Streptococcal disease (non-invasive) Low No Yes Yes Yes Tetanus Low No Yes Yes Yes Tuberculosis Med Yes Yes No Yes Typhoid fever Med Yes Yes Yes Yes Typhus Med Yes No No No Viral Haemorrhagic Fever High Yes No No No Whooping Cough Low No Yes Yes Yes Yellow / Orange Fever High Yes No No No Bagging: Viewing: Embalming: placing the body in a plastic body bag. allowing the bereaved to see, touch and spend time with the body before removal to the deceased mortuary or undertakers. injecting chemical preservatives into the body to slow the process of decay. Cosmetic work may be included. Hygienic preparation: cleaning and tidying the body so it presents a suitable appearance for viewing. *Invasive disease is when there is overwhelming sepsis, obvious septic foci, e.g. abscess and death occurs within 48-hours of onset of symptoms.

Page 8 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 Appendix 1 - Information on religious beliefs following a death in hospital The following is for guidance only; all deaths should be treated individually, and with equal respect. BAHA I No objection to post mortem. The body should not be cremated or embalmed. The burial should take place a distance of no more than one hour s journey the place of death. BUDDHISM No objection to post mortem. Allow privacy for quietness and meditation or chanting. The state of mind at death should be calm at time of preparation, as Buddhists believe that this will influence the character of rebirth. Do not wash the body. Wrap in a plain sheet. Advise not to remove body before Monk or Sister arrives. Cremation common. CHRISTIAN SCIENCE No special rites but Christian Science burial required unless family opt for cremation. Post mortem not advocated. Last Offices appropriate. Female staff should handle female body. CHRISTIANITY ANGLICAN / CHURCH OF ENGLAND / CHURCH OF WALES / EPISCOPAL / CHURCH OF SCOTLAND: Contact Hospital Chaplain The Hospital Chaplain or Parish Priest may be called upon to administer Holy Communion if death is imminent. If a Chaplain is not available and prayers are requested, if a nurse wishes it is advisable to say the Lord s Prayer, and make the sign of the cross on the patient s forehead. No objection to post mortem. Can be burial or cremation.

Page 9 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 CHURCH OF JESUS CHRIST OF LATTER DAY SAINTS (The Mormon Church) There is no specific ritual for the dying but spiritual contact is important, Church to be contacted. Mormons who have undergone a special Temple Ceremony may wear a sacred undergarment in death as well as in life. No religious objection to post mortem; may be a matter of family choice. Last offices are appropriate. Burial preferred. FREE CHURCH: (Methodist, Baptists, Salvation Army, Quakers) Contact Hospital Chaplain Help and comfort prayers are available for patient and relatives through their own Minister or Chaplain. The Minister is more likely to be asked to join the patient and the family in informal prayer rather than administer the Sacraments. For all Free Churches, last offices are appropriate. No particular objection to post mortem. Family may choose either burial or cremation. GREEK ORTHODOX: Contact Roman Catholic Chaplain HINDUISM Hindu patients very much wish to die at home or be alone receiving comfort readings. Hindu Priest to be contacted to perform certain rituals and blessings. Funerals if possible within 4 hours. If a delay, explanations must be given to relatives. Nursing staff should seek permission to wash the body (use disposable gloves). Wrap in plain sheet. Do not remove religious objects. Cremations usual. Rituals at death vary. Eldest son is responsible for funeral arrangements. Often post mortem is considered objectionable but accepted if all organs are returned to the body.

Page 10 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 ISLAM Opposed to post mortem. Body to be removed hospital and buried as soon as possible, otherwise explanations must be given to family. This religion requires burial to take place at the earliest possible time following death so delays should be avoided wherever possible. Koran recited by a relative or the Imam. Family attends to duties while conforming to legal regulations. Usual for family to wash and prepare body, if not, other people must wear gloves. Modesty is crucial. JEHOVAH S WITNESSES No ceremonial rites at death. Usual last offices are appropriate. No religious objection to post mortem examination. JUDAISM If possible, open the window. Do not touch the body until minutes after death. Do not wash the body; this will be done prior to the burial. Remove false teeth where applicable. Close the eyes. Straighten the body out, lying flat with feet together, and arms by the side. Cover the body with a plain white sheet without emblems. If no family, notify the Hebrew Burial Society, or local Jewish Community. Post mortem is generally forbidden. This religion requires burial to take place at the earliest possible time following death, so delays should be avoided wherever possible.

Page 11 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 ROMAN CATHOLICISM The Sacrament of anointing the sick should be administered at the earliest opportunity to a seriously ill patient who may eventually recover to full health and also to those seriously ill who are going to die. Often a hospital Chaplain will be able to judge his regular visits if, in his opinion the patient may or will benefit receiving the Sacrament, so again it is imperative to notify the Chaplain if the patient s condition deteriorates and they are considered to be severely ill. The ward staff should note a record of the Sacrament. Routine last offices are appropriate and there is no religious objection to non-catholics handling the body. No religious reasons for objecting to post mortem. Burial was in the past the preferred option, however many Catholics choose cremation nowadays. SIKHS Sikh funerals should take place within 4 hours of death. Cremation is usual but stillborn babies and miscarriages are buried. Cremation is not possible within 4 hours in UK, but arrangements should not be unnecessarily delayed. The family may want to wash and lay out the body themselves but do not object to others touching the body. If no family, limited laying out is appropriate. If this is the case the 5K s should not be removed: 1. Kesh uncut hair. Hair or beard should not be trimmed. Hair should be kept covered.. Kangha the wooden comb which fixes uncut hair into a bun. 3. Kara an iron, steel or gold bracelet worn on the right wrist. 4. Kirpan a symbolic sword worn under clothing in a cloth sheath or as a brooch or pendant. 5. Kachhera - undergarments. The turban must remain on, even in death. Eyes should be closed, jaw supported and limbs straightened. Body covered with a white sheet. No religious objection to post mortem, but this should not delay the funeral.

Page 1 of 1 CONTROL OF INFECTION COMMITTEE Effective Nov 009 Review Nov 01 Further Information If for cultural or religious reasons the relatives wish that the deceased be moved the mortuary outwith normal working hours, please contact the duty co-ordinator. If the deceased was of a faith not listed, ask the relatives for their wishes. Evidence Based Requirements: Standard Precautions Policy. NHS Greater Glasgow & Clyde Control of Infection Committee 008. http://library.nhsggc.org.uk/mediaassets/infection%0control/microsoft%0word%0- %0Standard%0Precautions%0008.doc.pdf Transmission Based Precautions Policy. NHS Greater Glasgow & Clyde Control of Infection Committee 009. http://library.nhsggc.org.uk/mediaassets/infection%0control/tbp%0with%0a- Z%0Table.pdf Healing TD., Hoffman PN & Young SEJ. The infections human cadavers. Communicable Diseases Report 1995. 5 ISSN 1350-9349. Report of the Independent Review Group on the Retention of Organs at Post Mortem http://www.scotland.gov.uk/publications/003/11/18558/9413 Quality Improvement Scotland Standards for Management of Post-mortem Examinations http://www.nhshealthquality.org/nhsqis/files/no_post-mortem%0feb%0005.pdf The Cremation (Scotland ) Amendment Regulations 003 http://www.opsi.gov.uk/legislation/scotland/ssi003/0030301.htm NHS Education for Scotland A Multi-Faith Resource for Healthcare Staff http://www.nes.scot.nhs.uk/spiritualcare/default.asp