Last Offices Policy - Doncaster and Bassetlaw Hospitals NHS ...

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REF: PAT/T 30 v.1
Last Offices Policy
Name and title of authors: Faye Witton – Macmillan IPOC Lead
Nurse
Anne Rowe – Macmillan IPOC
Support Nurse
Date written: October 2007
Approved by (Committee/Group): Clinical Review Group
Date of approval: 7 March 2008
Date issued: April 2008
Review date: October 2009
Target audience: Trust-wide
WARNING: Always ensure that you are using the most up to date policy or
procedure document. If you are unsure, you can check that it is the most up to date
version by looking on the Trust Website: www.dbh.nhs.uk under the headings →
‘Freedom of Information’ → ‘Information Classes’ → ‘Policies and Procedures’

Last Offices Policy
Contents
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REF: PAT/T 30 v.1
Introduction 3
Legal Requirements 3
Cultural Requirements 3
Infection Control 4
Equipment 4
Page
Procedure 4-5
Rapid release of bodies 6
Duties and responsibilities of professionals performing Last
Offices
Education, training and support 6
Audit 6
Appendix 1 – Cultural and religious variations 7-8
Appendix 2 – Guidelines for handling cadavers with infectious
disease
References 11
6
9-10

Introduction:
Last Offices Policy
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REF: PAT/T 30 v.1
Last Offices is the care given to a deceased patient which demonstrates our
respect for the dead and is focused on maintaining privacy and dignity,
fulfilling religious and cultural beliefs, and upholding health and safety
requirements. This nursing procedure is also known as ‘laying out’. This
policy describes the care that is given when a patient dies to prepare the body
for transfer to the mortuary. A literature review was carried out to guide this
policy. With regards to packing, there was scant evidence within the
literature; therefore the guidance has been developed on consensus of good
practice.
Performing last offices is the final demonstration of respectful, sensitive care
that nurses offer patients and their families. It enables families to be aware
that care and respect is ongoing after death, and also allows both health care
professionals and family members the opportunity for closure in the
relationship, which can be helpful in the bereavement process. Families may
wish to spend time with their loved one on the ward after death prior to Last
Offices being performed. In this situation, the body should be repositioned
and the environment tidied, in order to allow this time to be dignified and
peaceful.
Legal requirements:
If a patient has died unexpectedly, or if the coroner is to be informed for any
reason, a post mortem examination will probably be required. Examples of
such situations include sudden death, death after invasive procedure (e.g.
surgery or endoscopies) or patient with industrial disease (e.g.
mesothelioma). If you are unsure as to whether a post mortem will be
required, consult with the medical team who can confirm whether they will
issue a death certificate or whether the case needs to be referred to the
coroner. If a post mortem is required leave all tubes/drains/lines in place and
spigot any catheters/cannulae.
Cultural/Individual requirements:
Practices relating to last offices may vary according to religious and cultural
needs. Brief information regarding these variations is included within this
policy, however further information is available from the chaplaincy
department. See appendix 1 for cultural variations.
It is good practice to sensitively discuss and document the patient’s wishes
prior to death if the opportunity presents.

Infection control:
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REF: PAT/T 30 v.1
Standard precautions should be used with all patients. Leakage of bodily
fluids creates an infection control risk; therefore steps should be taken to
avoid this. There are some situations which require extra caution when
preparing a body for the mortuary, and a body bag may need to be used.
Please see appendix 2 for guidance on which diseases require use of a body
bag.
Equipment:
• Bowl, soap, face cloths, towel, razor, comb
• Mouth care pack/toothbrush
• None absorbent cotton wool
• Shroud (or own clothes if specifically requested by family)
• Two identification bracelets
• Dressing pack/dressings/tape
• Body bag (in event of actual/potential leakage of body fluids or
infectious disease)
• Property book and property bag
• Net pants and pad
• Clean sheets
• Gloves and apron
Procedure:
1. Either medical staff or a senior nurse must verify the death, and this
should be documented in the patient’s notes. Medical staff must verify
an unexpected death.
2. Two members of staff should carry out Last Offices.
3. Offer support and information to family/carer regarding the procedure
after death.
4. Sensitively explain to other patients in the area that a patient has died,
in order to allay misconceptions and fears.
5. Ensure adequate privacy and dignity whilst performing last offices.
6. Wear gloves and apron.
7. Position the patient on his/her back leaving one pillow in place.
Support the jaw with a pillow or rolled up towel, to enable the mouth to
close. Straighten the limbs, and align in a natural position with arms at
the side.
8. Close the patient’s eyes, if possible, by applying light pressure to the
eyelids.
9. Press on the lower abdomen to empty the bladder (unless post mortem
is required, when bladder should be left full for toxicology).
10. Remove any mechanical aids such as syringe drivers.
11. Remove any sharps such as butterfly needle and dispose of carefully.
12. Remove drainage tubes and document any tubes remaining such as
Hickman lines. (If a post mortem is required leave all tubes in situ)

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REF: PAT/T 30 v.1
13. Leave any cannulae in situ, cover and tape. This will prevent
unnecessary leakage of bodily fluids.
14. Wash the patient in accordance with religious/cultural needs. Shave
male patients if necessary. Family/carers may wish to assist in this as
a final act to demonstrate their love and care for the patient.
15. Clean the patient’s mouth and teeth. If possible put patient’s dentures
in, if not send the dentures to the mortuary with the body and document
this.
16. Remove the patient’s jewellery and document in valuables book. If
family request that certain jewellery (e.g. wedding ring) be left on body,
this should be documented on the notification of death form. A second
member of staff should witness this. Rings should be taped for
protection.
17. Pack throat with none absorbent cotton wool. This will prevent the
body from vomiting after death, and therefore leakage of bodily fluids.
Do not pack throat if it is anticipated that a post mortem may be
required. Apply pad and pants to lower body to absorb any leakage of
bodily fluids. Cover any wounds with an absorbent dressing and
secure with an occlusive dressing. (If a post mortem is required leave
existing dressings in situ and cover)
18. If patient’s belongings are soiled, sensitively ask for family’s permission
to destroy. Otherwise, send clearly labelled to hospital laundry for
cleaning.
19. Dress the patient in a shroud, unless patient/family specifically request
own clothes. It is usually more appropriate for funeral directors to
dress bodies in own clothes.
20. Complete notification of death form and two identification labels.
Attach one label to wrist and one label to opposing ankle. Each label
should detail patient’s name, hospital number, ward, date of birth and
date of death. If the body is unidentified, label as ‘unidentified
male/female’.
21. Wrap the body securely in a sheet ensuring that limbs are held in
position and tape securely using a minimal amount of tape, to avoid
possible damage to the body during transfer.
22. If a body bag is required, the body does not need to be wrapped in a
sheet as above. Document on the notification of death form the reason
for using body bag, e.g. leakage or infection. Appendix 2 details
situations in which a body bag should be used.
23. Attach one copy of notification of death form to body.
24. Record all care after death within the relevant documentation.
25. Inform shift leader that body is ready for transfer to mortuary.
26. To maintain patient’s dignity, screen off area when porters arrive to
collect body.
27. Prepare notes and property for bereavement office/general office.

Rapid release of bodies:
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REF: PAT/T 30 v.1
On occasion, family members may request that a body be released from the
hospital more quickly than usual, for religious or cultural reasons. This can
usually be arranged, if the medical team are able to issue a cause of death
certificate. In the event of this circumstance, please seek advice from the
chaplaincy department, or the hospital bleep holder.
Duties and responsibilities of professionals performing Last Offices:
Health care professionals have a legal duty to prepare a body in accordance
with Coroner requirements if a post mortem examination is required.
Health care professionals are responsible for ensuring that a body is prepared
for mortuary in accordance with the principles of infection control and health
and safety.
The NMC (2004) Code of Professional Conduct: Standards for Conduct,
Performance and Ethics states that nurses are personally accountable for
ensuring that the interests and dignity of patients are promoted and protected,
irrespective of gender, age, race, ability, sexuality, economic status, lifestyle,
culture, religious or political beliefs.
The NMC (2004) Code of Professional Conduct: Standards for Conduct,
Performance and Ethics states that if care delivery is delegated to others who
are not registered nurses, nurses remain accountable for the appropriateness
of the delegation, and ensuring that adequate support or supervision is
provided.
Health care professionals are responsible for ensuring that patient’s valuables
and belongings are packed carefully and documented in accordance with
Trust policy.
Education, training and support:
Last Offices training sessions are available for all staff to attend. To book
training sessions please contact Gill Hinton, Clinical Skills Co-ordinator on
extension 2884 at Bassetlaw hospital or Pamela Whitehurst on extension
2914 at Bassetlaw hospital.
If you are unsure regarding any aspect of performing Last Offices, please
contact the palliative care team on extension 3142 at Doncaster Royal
Infirmary or 2981 at Bassetlaw hospital, or the mortuary technicians on
extension 3526.
Audit:
An audit of staff awareness and compliance with the policy will be undertaken
a year after implementation of the policy, and annually thereafter.

Appendix 1
Cultural/religious variations:
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REF: PAT/T 30 v.1
Please use this section for guidance only; individuals may have different
preferences regardless of religion/culture. For further advice, please contact
a member of the chaplaincy team via switchboard. Please follow the Human
Tissues Act guidance for organ/tissue donation.
Baha’i faith: Cremation not permitted, burial should take place as near as
possible to place of death. Baha’i relatives will wish to say prayers for dead.
Routine last offices are acceptable.
Buddhism: Consider dying is a very important part of life and that it should
be approached positively and in as clear and conscious state of mind as
possible. Routine last offices are acceptable; however, the body should not
be moved for at least one hour if prayers are to be said. Cremation preferred.
Chinese: Customs vary very widely in the Chinese tradition; therefore, it is
difficult to speak for all Chinese. Mostly for adults, the body is bathed, and
sometimes the body is dressed in white or old- fashioned clothing.
Christianity: Offer support of appropriate chaplain.
Roman Catholic patients should be offered visit by priest to give Sacrament of
Sick when dying, and may wish to have a rosary or crucifix in their hand.
Church of England patients may require prayers to be said at bedside of the
dying.
Christian Scientists: Worship is kept free from ritual. Routine last offices
are appropriate. Female staff should handle a female body. Cremation
preferred, prefer to not have post mortem unless required by law.
Hinduism: Post mortems disliked unless required by law. Consult the family
by asking whether they wish to perform last offices, as distress could be
caused if non-Hindus touch the body. If family are not available, wear
disposable gloves, close the eyes and straighten the limbs. Do not remove
jewellery, religious objects or sacred threads. Do not wash the body, as this
is part of funeral rites and will usually be carried out by relatives using Ganges
water. Wrap the body in a clean sheet. Body is cremated.
Jainism: Prefer no post mortem unless required by law. Prayers are offered
for soul of dying patient. Presence of a Jain Spiritual Caregiver is preferred.
Family may wish to assist with Last Offices. Body is cremated.
Jehovah’s Witnesses: No objection to post mortem. No special practices
for the dying, but will appreciate a pastoral visit from one of their elders.
Routine Last Offices are appropriate. May be buried or cremated.

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REF: PAT/T 30 v.1
Judaism: Prefer no post mortem unless required by law. Cremation is
forbidden. Dying person should not be left alone, may wish to hear special
psalms and prayers, can be said by a relative or Rabbi. Patients must not be
washed and should remain in the clothes in which they died. The body will be
washed in a ritual purification. It is important that the body is released to
family as soon as possible.
Mormon: Do not object to post mortem. No rituals for dying, however
spiritual contact is important. Routine last offices appropriate, if wearing a
sacred undergarment must be replaced on body following last offices. Burial
is preferred.
Muslim: Prefer no post mortem unless required by law. Patients may wish to
face Mecca (South East). Family/friends may sit with patient reading the Holy
Quran and making supplication. At death do not wash the body. Where no
relatives are available, staff should wear gloves to avoid direct contact with
the body. The body should face Mecca and the head should be turned
towards the right shoulder before rigor mortis begins. The body can be made
respectable by combing hair and straightening limbs, however the family will
ritually wash the body before burial. The body of a female should be prepared
by a female member of staff and vice versa for a male body. It is important to
bury a body as quickly as possible.
Plymouth Brethren: As death approaches family may wish to keep a 24
hour vigil. After death the family may wish to attend to Last Offices
themselves. Prefer no post mortem unless required by law.
Quakers: Do not object to post mortem. No special rules or practices for the
dying, will appreciate a visit from an Elder or other Quakers who may sit in
silent worship.
Rastafarianism: Post mortem is extremely distasteful to most Rastafarians,
unless required by law. Routine last offices appropriate. Burial preferred.
Romany origin: Many people of Romany origin are Christians. If a traveller
is dying, family/friends from around the country will wish to visit before death,
meaning that there will often be many visitors. After death, the family will
request that the person be laid out in clothing of their choice.
Sikhism: No objection to post mortem, however prefer not to if possible.
Sikh men wear the five K’s: kesh (long hair kept under a turban), kangha (a
small comb worn in the hair), kara (steel bracelet or ring worn on right wrist),
kachha (special type of underwear) and kirpaan (sword worn symbolically by
baptised Sikhs. After death routine last offices may be performed, but the 5
K’s should not be removed. Body is cremated.
Zoroastrian/Parsis: No religious objection to post mortem. Routine last
offices are appropriate. Believe it necessary to commence prayers as soon
as possible after death. No preference for burial or cremation.

Appendix 2
Degree
of risk
LOW
MEDIUM
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REF: PAT/T 30 v.1
GUIDELINES FOR HANDLING CADAVERS WITH INFECTIONS
NOTIFIABLE IN ENGLAND AND WALES
Infection Bagging Viewing Embalming Hygienic
preparation
Acute
encephalitis
No Yes Yes Yes
Leprosy No Yes Yes Yes
Measles No Yes Yes Yes
Meningitis
(except
meningococcal)
No Yes Yes Yes
Methicillinresistant
staphylococcus
aureus (MRSA)
No Yes Yes Yes
Mumps No Yes Yes Yes
Ophthalmia
neonatorum
No Yes Yes Yes
Rubella No Yes Yes Yes
Tetanus No Yes Yes Yes
Whooping
cough
No Yes Yes Yes
Relapsing fever Adv Yes Yes Yes
Food poisoning No/Adv Yes Yes Yes
Hepatitis A No Yes Yes Yes
Acute
poliomyelitis
No Yes Yes* Yes
Diphtheria Adv Yes Yes Yes
Dysentery Adv Yes Yes Yes
Leptospriosos
(Weil’s disease)
No Yes Yes Yes
Malaria No Yes Yes* Yes
Meningococcal
septicaemia
(with or without
meningitis)
Adv Yes Yes Yes
Paratyphoid
fever
Adv Yes Yes Yes
Cholera No Yes Yes* Yes
Scarlet fever Adv Yes Yes Yes
Tuberculosis Adv Yes Yes Yes
Typhoid fever Adv Yes Yes Yes
Typhus Adv No No No

Degree
of risk
HIGH
(rare)
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REF: PAT/T 30 v.1
GUIDELINES FOR HANDLING CADAVERS WITH INFECTIONS
NOTIFIABLE IN ENGLAND AND WALES
Infection Bagging Viewing Embalming Hygienic
preparation
Hepatitis B, C
and non-A non-
B
Yes Yes No No
Anthrax Adv No No No
Plague Yes No No No
Rabies Yes No No No
Smallpox Yes No No No
Viral
haemorrhagic
fever
Yes No No No
Yellow fever Yes No No No
HIV Yes Yes No No
vCJD Yes Yes No No
SARS (Severe
Acute
Respiratory
Syndrome)
Yes No No No
Adv = Advisable and may be required by local health regulations
* Requires particular care during embalming
Definitions:
Bagging: placing the body in a plastic body bag.
Viewing: allowing the bereaved to see, touch and spend time with the body
before disposal.
Embalming: 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 that it presents a
suitable appearance for viewing (an alternative to embalming).
Other situations in which a body bag should be used:
• Known intravenous drug user
• Severe secondary infection
• Gangrenous limbs/infected amputation sites
• Large pressure sores (e.g. grade 4)
• Clostridium difficile if leakage present
Always consider the people who will be handling the body after it leaves
the ward. Document any infectious disease on the notification of death
form to allow mortuary staff to communicate this to funeral directors.

Reference list
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REF: PAT/T 30 v.1
• Docherty B (2000) Care of the dying patient. Professional Nurse 15
(12) 752.
• Dougherty L & Lister S (eds.) (2004) The Royal Marsden Hospital
Manual of Clinical Nursing Procedures. 6 th edn. Oxford: Blackwell
Publishing.
• Green J & Green M (2006) Dealing with Death – A handbook of
practices, procedures and law. London: Jessica Kingsley
Publishers.
• Healing T D, Hoffman P N & Young S E (1995) The Infection
Hazards of Human Cadavers. Communicable Disease Report CDR
Review 5 (5): R61-68.
• Nearney L (1998) Last Offices – Part 1. Nursing Times 94 (27)
Insert 1-2.
• Nearney L (1998) Last Offices – Part 2. Nursing Times 94 (28)
Insert 1-2.
• Nearney L (1998) Last Offices – Part 3. Nursing Times 94 (29)
Insert 1-2.
• Nursing & Midwifery Council (2004) The NMC code of professional
conduct: standards for conduct, performance and ethics. London,
NMC.
• St Christopher’s Hospice Clinical Guidelines (2007) Last Offices.
End of Life Care 1 (3): 41-45.