Policies, Procedures, Guidelines and Protocols Document Details Title Verification of Death Policy Trust Ref No 438-29766 Local Ref (optional) Main points the document This policy provides guidance on the process of verifying covers deaths. Who is the document Registered Nurses who undertake verification of death in the aimed at? community setting Owner Lucy Shier Community Practice Teacher Approval process Approved by Clinical Policy Group (Committee/Director) Approval Date 02 March 2016 Initial Equality Impact Yes Screening Full Equality Impact N/A Assessment Lead Director Director of Nursing and Quality Category Clinical Sub Category Review date 02 March 2019 Distribution Who the policy will be distributed to Method Document Links Required by CQC Keywords Service Leads, Clinical Leads, Palliative Care Training Forum, Community Practice Teachers, Community Service Managers, Community Hospital Leads, Palliative care & Hospice leads Interdisciplinary Team Leads. Verification, death, expected death, unexpected death, mortality, Funeral Director, DNACPR, Do Not Attempt Cardiopulmonary Resuscitation Other Amendments History No Date Amendment 1 July 2007 Policy reviewed and updated to take account of information required by undertakers in Shropshire. 2 Jan 2014 Reviewed and updated to be specific to Registered Nurses working in community settings. Associated flowcharts and forms also reviewed and updated 3 Mar 2016 Review of policy - minor change to reflect organisational changes and change to abbreviation for Do Not Attempt Cardiopulmonary Resuscitation now referred to as DNACPR 4 5
Contents 1 Introduction... 3 2 Purpose... 3 3 Definitions... 3 4 Duties... 4 4.1 Nursing and Operations Director, Deputy Director and Divisional Managers... 4 4.2 Clinical Service Managers... 4 4.3 Team Leaders... 4 4.4 Staff... 4 5 Verification of Expected Death... 4 5.1 Exceptions and Unexpected Deaths... 5 5.2 Clinical Verification of Death... 5 5.3 Actions following Verification of Expected Death... 6 6 Consultation... 6 7 Dissemination and Implementation... 7 7.1 Training... 7 8 Monitoring Compliance... 7 9 Associated Policies/Procedures... 7 10 References... 7 Appendix 1: Example of a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form... 9 Appendix 2: Verification of Death Flow Chart... 10 Appendix 3: Verification of Expected Death form... 11 Appendix 4: Funeral Directors Verification of Death Form... 12 Verification of Death Policy 2 Mar 2016
1 Introduction This policy provides guidance for Registered Nurses working in community settings to verify expected deaths and additional related information for actions to be taken in circumstances, such as unexpected deaths, where responsibilities fall outside the Registered Nurses role. Nurses working in community settings including in community hospitals and patients homes regularly provide palliative and supportive end of life care. The ability of the registered nurses to confirm the inevitable expected death of a patient will prevent delays and ensure appropriate timely aftercare to relatives and carers at a time of stress and anxiety. Respect, care, dignity and compassion for the dying, the deceased and the bereaved are fundamental in delivery of high quality care at this time. Therefore this policy has been updated in line with the Compassion in Practice Vision and Strategy for Nursing, Midwifery and Care Staff (DoH 2012). Traditionally, the task of verifying and certifying a death has been the role of medical practitioners. (Chief Nursing Officer, 2004). While someone other than a doctor cannot legally certify death, since the law requires this to be performed by registered medical practitioners, there is no requirement, either legally or under the NHS Terms of Service, for a General Practitioner (GP) to verify death (West Midlands Regional Local Medical Committee 2000) A fundamental review of death certification and investigation in England, Wales and Northern Ireland (Secretary of State for the Home Department 2003) recommends that nurses should be able to verify that a death has occurred, this is further backed by the Academy of Medical Royal Colleges Code of Conduct; (October 2008) The Nursing and Midwifery Council Code of Professional Conduct place specific responsibilities on Registered Nurses with regards to maintaining their accountability, knowledge, skills and competence for safe and effective practice (NMC 2008). The specific advice on verifying death given to nurses by the Nursing and midwifery Council (NMC, 2012) is that: In the event of death, a Registered Nurse may confirm or verify death has occurred, providing there is an explicit local protocol in place to allow such an action. Nurses undertaking this responsibility must only do so providing they have received appropriate education and training and have been assessed as competent. 2 Purpose This policy aims to ensure high quality end of life care as part of an end of life care pathway. It provides guidance to designated Registered Nurses who have received appropriate training to perform the verification of an expected death in community settings. It also provides additional guidance in circumstances, such as unexpected deaths, where responsibilities fall outside the Registered Nurses role. The ability of suitably trained Registered Nurses to verify expected deaths will make best use of resources and prevents the need to call out the general practitioner or paramedic. 3 Definitions Community Settings: This includes Community Hospitals and patient s homes and residential homes. Expected Death: this is when the patient is known to be suffering from an illness, which has been identified as terminal, and where there is no active intervention to prolong life (Chief Nursing Officer 2004). The patient has been seen by the GP within the previous 14 days and the Out of Hours service has been notified. Verification of Death Policy 3 Mar 2016
An expected death is also defined as a death where a patients demise is anticipated in the near future and the doctor will be able to issue a medical certificate as to the cause of death (i.e. the doctor has seen the patient within the last 14 days before the death). (Home Office 1971) Unexpected Death: An unexpected death is: Any death not due to terminal illness or, a death the family was not expecting. It will also apply to patients where the GP has not attended within the preceding 14 days. Where there is any suggestion of suspicious circumstances, trauma, neglect or evidence of industrial disease in an expected death. Patients transferred from an Acute Hospital Trust to Intermediate Care Facilities with post surgical conditions, or fractures. 4 Duties 4.1 Nursing and Operations Director, Deputy Director and Divisional Managers Directors and Divisional Managers of Services are responsible for ensuring the safe and effective delivery of services they manage; this includes securing and directing resources to support staff to deliver safe care. 4.2 Clinical Service Managers Managers will ensure that a system is in place within the services they are responsible for, for the implementation of this policy and monitoring compliance 4.3 Team Leaders Individual Team leaders will identify suitable staff to undertake verification of death within their teams and ensure that they have successfully completed appropriate verification of death training. They are responsible for informing staff of this policy and any associated policies, guidelines and documents and that the appropriate education, supervision, and mechanisms are in place to ensure safe practice. Any further training requirements must be raised and addressed via appraisal or supervision and a record of competencies kept for audit purposes. 4.4 Staff This guidance applies to all Registered Nurses employed by Shropshire Community Health NHS Trust who undertake verification of expected death. They must adhere to this policy and the associated policies, guidelines and professional codes of conduct. Registered Nurses working to this policy, have the authority to verify death only where this was an expected outcome. 5 Verification of Expected Death Where death is expected it should be recorded in the patients records the fact that the patient is suffering from an illness which has been identified as terminal and they have been identified as not for resuscitation by the patient s General Practitioner (GP). This should be recorded using a recognised Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form (see Appendix 1: Example DNACPR form). Daytime services must inform out of hours services of any such patient whose death is imminent. In considering undertaking verification of death, the practitioner must ensure that the death is expected as a result of chronic or terminal illness and is without any suspicious or unexpected circumstances (see Appendix 2: Verification of Death Flow Chart). Note: Although not legally necessary, it is good practice for a GP to attend any death of someone aged under 21 even if expected. Verification of Death Policy 4 Mar 2016
5.1 Exceptions and Unexpected Deaths Shropshire Community Health NHS Trust If the practitioner is at any time in doubt about the circumstances of the death they must inform a medical practitioner or, during out of hours, contact Shropdoc. The medical practitioner will then decide if the case needs to be referred to the coroner or the police. These include the following: Any sudden unexplained death or remotely suspicious death Deaths of people who have not been seen by GP in the last 14 days Deaths within 24 hours of discharge from hospital Deaths within 24 hours of onset of illness or where no firm diagnosis has been made Deaths following recent operative or invasive procedures Deaths that follow any accident, fall, drug error or poisoning Deaths which occur as a result of ill treatment/neglect or starvation Death of a child under 18 years of age Service disability pensioners and industrial disease Sudden Complications e.g. anaphylaxis / Haemorrhage Prisoners Cause of death unknown Deceased is to be moved out of coroner s district Actions to be taken if Unexpected Death occurs: Check clinical signs to ascertain that death has occurred using the expected death criteria Report immediately to a Medical Practitioner (e.g. GP) or, during out of hours, to Shropdoc who will then refer to the coroner or police as appropriate In Community Hospitals a Medical Practitioner must attend to verify / certify death A Datix incident report needs to be raised for all Unexpected Deaths In Community Hospitals the Clinical Services Manager must be informed so they can undertake an Unexpected Death Review. This process will include notifying the Mortality Group. 5.2 Clinical Verification of Death Parenteral drug administration equipment should not be removed prior to verification of death. If the Patient is unresponsive and there are no signs of life, e.g. movement, swallowing or coughing, they must then be checked for each of the following clinical signs and this must be repeated after a minimum of five minutes: There is no sign of spontaneous respiration (verification by use of a stethoscope) There is no palpable pulses, Carotid or Femoral The pupils are fixed and unresponsive to light (using a pen torch or ophthalmoscope) No heart sounds (verification by use of a stethoscope) The patient must show no response in all of the above tests. If there is any doubt the practitioner must not verify death but must consult an appropriate medical practitioner. Verification of Death Policy 5 Mar 2016
5.3 Actions following Verification of Expected Death Once the practitioner has verified that death has taken place they should ensure that: Any parenteral drug administration equipment such as syringe pumps and subcutaneous access devices attached to the patient should be removed The date and time of death must be recorded in the medical and nursing records using the appropriate documentation A copy of the Verification of Expected Death form (see Appendix 3) should be faxed to the GP within 24 hours If out of hours or Bank Holiday, Shropdoc should also be informed of the death The verifier should complete the Funeral Directors Verification of Death Form (see Appendix 4) and leave with deceased person for the funeral director to collect The patient s relatives and carers should be advised of the death and informed that they may contact a funeral director The body should not be removed out of the Coronial boundary / GP locality until the GP has issued a death certificate which may mean the body is temporarily held at a funeral director that may not be the first choice of the family. The exception to this is where a local undertaker agreement is in place It is the team leader s responsibility to review the cases of verification of death with the verifier. They should check the verification of expected death form has been sent to the GP and the fact that it was an expected death has been documented in the patient record, if not the GP must be contacted immediately In Community Hospitals, a Local Mortality Review should be carried out on all expected deaths and reported to the relevant Clinical Services Manager. Guidance on this can be found in the Community Hospitals Mortality Review Process 6 Consultation This policy was distributed to the following individuals & groups for consultation and comment: Deputy Director of Operations: Sally-Anne Osborne Service Delivery Managers: Karen Taylor, Andrew Matthews Community Service Managers: Hayley Butler Community Practice Teachers: Georgina English DN Clinical Lead & CPT Shrewsbury, Lucy Shier CPT (South East/West), Claire Wheeler CPT (Telford and Wrekin), Francine Nutt CPT & Rebecca Barton CPT (North) Adult Nurse Consultant: Cath Molineux Children Community Services Team Leader: Sharon Boyle Medical Director Shropdoc: Gill Clements Records Manager and Quality Facilitator: Alan Fergusson Medical Director / Mortality Group Chairman: Dr Mahadeva Ganesh Associate Medical Director General Practice: Dr Emily Peer Verification of Death Policy 6 Mar 2016
7 Dissemination and Implementation Dissemination and implementation of these guidelines will be via the following methods: Managers informed via Datix Disseminated to team leads and relevant staff. Inform article/team Brief Published on the Staff Zone of Trust website 7.1 Training All staff undertaking verification of expected death must have their Service Managers approval and have completed appropriate training to become verifiers. Training should include assessment of the individual s knowledge and ability to determine the physiological aspects of death and explore their accountability. Training should be accessed from local in house trainers who are already competent as verifiers or have undertaken training from a recognised specialist training provider (e.g. Severn Hospice) on the verification of death process. It would be the team leader s responsibility to determine the suitability of staff who may wish to become verifiers. 8 Monitoring Compliance It is the team leader s responsibility to review the cases of verification of death with the verifier. Compliance will also be monitored through the Divisional Quality and Safety Groups and the Trust s Mortality Group. In order to assist in this process the following will be monitored: Feedback from staff Review and investigation of related reported incidents Audits of the verification of expected deaths process 9 Associated Policies/Procedures Cardiopulmonary Resuscitation (CPR) and Do Not Cardio Pulmonary Resuscitation (DNACPR) Policy Clinical Record Keeping Policy Community Hospitals Mortality Review Process All Trust policies can be found on the Trust s Website: http://www.shropscommunityhealth.nhs.uk/rte.asp?id=10667 10 References A Code of Practice for the Diagnosis and Confirmation of Death Academy of Medical Royal Colleges; October 2008: http://www.aomrc.org.uk/publications/statements/doc_view/42-a-code-ofpractice-for-the-diagnosis-and-confirmation-of-death.html Chief Nursing Officer (2004) Verification of Death Cited in West Midlands Regional Local Medical Committee (2000). Recognition of Death in the Community A Regional Framework for the West Midlands Compassion in Practice Nursing, Midwifery and Care Staff Our Vision and Strategy Department of Health 2012: http://www.england.nhs.uk/wpcontent/uploads/2012/12/compassion-in-practice.pdf Death Certification and Investigation in England, Wales and Northern Ireland The Report of a Fundamental Review (2003) Secretary of State for the Home Verification of Death Policy 7 Mar 2016
Department: http://www.kcl.ac.uk/depsta/law/research/coroners/review_june03.pdf NMC 2008, The Code: Standards of conduct, performance and ethics for nurses and midwifes: http://www.nmcuk.org/documents/standards/nmcthecodestandardsofconductperformance AndEthicsForNursesAndMidwives_LargePrintVersion.PDF NMC 2012, NMC Advice, Confirmation of death for Registered Nurses. http://www.nmc-uk.org/nurses-and-midwives/regulation-in practice/regulation-in-practice-topics/confirmation-of-death-for-registerednurses-/ Guidance for doctors completing Medical Certificates of Cause of Death in England and Wales http://www.gro.gov.uk/images/medcert_july_2010.pdf Verification of Death Policy 8 Mar 2016
Appendix 1: Example of a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form Verification of Death Policy 9 Mar 2016
Appendix 2: Verification of Death Flow Chart Yes Was the Death Expected? No Expected Death This is when the patient is known to be suffering from an illness, which has been identified as terminal, and where there is no active intervention to prolong life. The patient has been seen by the GP within the previous 14 days and the Out of Hours service has been notified. Registered Nurse Follows Steps to Verify Death Unexpected Death Any death not due to terminal illness or, a death the family was not expecting. It will also apply to patients where the GP has not attended within the preceding 14 days. Where there is any suggestion of suspicious circumstances, trauma, neglect or evidence of industrial disease in an expected death. Patients transferred from an Acute Hospital Trust to Intermediate Care Facilities with post surgical conditions, or fractures Registered Nurse Not to Verify Death Check Clinical signs to ascertain that death has occurred If the Patient is unresponsive and there are no signs of life, e.g. movement, swallowing or coughing, they must then be checked for each of the following clinical signs and this must be repeated after a minimum of five minutes: There is no sign of spontaneous respiration (verification by use of a stethoscope). There is no palpable pulses, Carotid or Femoral The pupils are fixed and unresponsive to light (using a pen torch or ophthalmoscope) No heart sounds (verification by use of a stethoscope). The patient must show no response in all of the above tests. If there is any doubt the practitioner must not verify death but must consult an appropriate medical practitioner Nurse records the date and time of death nursing notes and completes the Verification of Expected Death form Fax a copy to the patient s GP If OOH inform Shropdoc Funeral directors confirmation of death form to be completed and left with the body Inform patient s relatives and carers and provide them with and advise them they may contact a funeral director In Community Hospitals, carry out a Local Mortality Review If a death is unexpected it MUST be reported to the GP or during OOHs to Shropdoc who will then refer to the coroner or police as appropriate A Datix incident report needs to be raised for all Unexpected Deaths In Community Hospitals, a Medical Practitioner must attend to verify / certify death In Community Hospitals, the Clinical Services Manager must be informed so they can undertake an Unexpected Death Review Note: Although not legally necessary, it is good practice for a GP to attend any death of someone aged under 21 even if expected. Arrangements made for removed of body to local Undertaker of family s choice or temporary removal to the mortuary until death certificate issued. Note: Body must not be removed out of county until GP issues death certificate. The exception to this is where a local agreement is in place. GP issues death certificate within 24 hours or next working day (taking into account weekends and bank holidays) Verification of Death Policy 10 Mar 2016
Appendix 3: Verification of Expected Death form Shropshire Community Health NHS Trust Patient Addressogram Verification of Expected Death Patient s Details: Date of Birth: Home Address: First Name: Last Name: NHS Number: _ / _ / Patient s GP and Surgery Address: History: There have been no vital signs of life for a period in excess of.. minutes 1. There are no signs of spontaneous respiration 2. There are no palpable pulses, Carotid or Femoral 3. The pupils are fixed and unresponsive to light 4. No heart sounds Tick Box : Comments: Life extinct verified by (Please Print Clearly): Signature: Designation: GP/ Registered Nurse Verification of Death: Date: Time: Persons present at time of death: Information leaflets given to relatives? Yes* No *If Yes please give details of relative(s) and information leaflets given: Relatives informed if not present at time of death? Name of person informed: Is the coroner likely to be involved? Please fax this form to the patient s General Practitioner within 24hrs Note: If out of hours or Bank Holiday ensure Shropdoc are informed. Date and Time Faxed: Yes No Yes No Verification of Death Policy 11 Mar 2016
Appendix 4: Funeral Directors Verification of Death Form Shropshire Community Health NHS Trust Funeral Directors Verification of Death Form Verifier to complete and leave with deceased person for the funeral director to collect Full Name of Deceased: Address: Date of Birth: Date of Death: Place of Death: Usual GP and Practice: Deceased Next of Kin: Contact Details: Verification of Death: Date: Time: I confirm that this is an expected death and all appropriate life extinct assessment procedures have been carried out. I confirm I am a qualified verifier and have received the appropriate training. Verifier Details Name (please print): Signature: Designation: Contact Details (Base and Telephone number): Additional Information (e.g. implantable devices, notifiable infections, any jewellery or religious mementoes left on deceased): Verification of Death Policy 12 Mar 2016