Approved By: Care Services Development Sub Committee

Verification of Expected Death Policy

Approved by: Care Services Development Sub Committee

Lead Director(s): Chair of CSD
Originator(s): Helen Hume

Date of Approval: TBC

Version: Draft 1
Review Interval: 3 years
Review due by: TBC

Appended Documents: See list of appendices
Responsibility for Dissemination and Implementation: Head of Clinical Services

Implementation date: TBC

POLICY STATEMENT

This policy and procedure sets out the process for Registered Nurses at Beaumond House Community Hospice regarding verification of the death of a patient.

Contents

1. Introduction
2. Policy and Procedure Drafting and Approval
3. Associated Policies, Procedures and Guidance
4. Aims and Objectives
5. Scope of the policy

1. Accountabilities and Responsibilities

1. Method

1. Training Needs Analysis -Staff Training requirements

1. Monitoring Compliance with the policy / procedure

1. References
2. Sign off sheet regarding dissemination of procedural documents

Appendix 1

Guidance for Registered Nurses about referrals to the Coroner

Appendix 2

Funeral Directors transfer information

Appendix 3

Appendix 4 - Persons to inform after death

Appendix 5 – RN Verification of expected adult death – knowledge and skill competencies

1.Introduction

After a loved one takes their last breath, relatives and carers and carers will look to those who have cared for them to help them through the processes that must take place. The ability of the nurse to confirm the inevitable expected death of a patient and to provide appropriate aftercare to relatives and carers, will providecontinuity at a time of stress and anxiety. This procedure and competency framework will enable Registered nurses within Beaumond House to verify expected deaths.

Verification of death should be carried out as soon as possible to avoid prolonging uncertainty for families, and the recommendations are to provide a timely verification, within one hour in an in-patient setting and within four hours in the community.

It is important that nurses help relatives to understand that there may be a difference between the time that they or carers observe the last breath and the ‘official time of death’ which is the time verification of death is complete.

At present English law does not require a doctor to verify or to review the body of a deceased person. The Law does require that the doctor who attended the deceased during their last illness issue a death certificate with details of the cause of death. Certification should occur within 24 hours or the next working day, except at weekends and bank holidays when the certificate should be produced on the next working day.

Definitions

Recognition of death -it is recognised that relatives, nursing home staff and others can recognise that death has occurred. This will be documented as the time of the last observed breath.

Expected death– is the result of an acute or gradual deterioration in a person’s health status, usually due to advanced progressive incurable disease. The death is anticipated, expected and predicted. In addition, a doctor must have seen the patient in the last 14 days.

Verification of the fact of death– documenting the fact of death in line with national guidance, and includes other responsibilities relating to identification, notification of infectious illnesses, and implantable devices.

Certification of death is the process of completing the “Medical Certificate of the Cause of Death” (MCCD) and must be completed by a medical practitioner in line with the Births and Deaths Registration Act 1953 underpinning the legal requirements for recording a person’s death.

Sudden or unexpected death – is a death that is not anticipated or related to a period of illness that has been identified as terminal. Where the death is completely unexpected there is a requirement to begin resuscitation (unless the circumstances can be justified)

Sudden or unexpected death within a terminal period – a person with a terminal diagnosis can have a sudden death e.g. an embolism. Death can be verified in these circumstances provided the DNACPR form had been completed and the Doctor has recorded in the patients notes, either paper or electronic that the RN can verify the death and the circumstances are discussed with a doctor.

If the verifying nurse has any doubt about her/his findings or about the circumstances of the patient’s death s/he must call a doctor without delay.

2.Policy and Procedure Drafting and Approval

Drafted by Head of quality and Governance

Approval by Care Service Development Committee.

3.Associated Policies, Procedures and Guidance

Care after Death: Registered Nurse Verification of Expected Adult death (RNVoEAD)

BH ‘Do not attempt resuscitation policy’

4.Aims and Objectives

To provide Registered Nurses within Beaumond House with clear, specific information so that they understand the physiological aspects of death, are aware of the legal requirements and are competent to carry out the verification of an expected death

To ensure death is dealt with in line with the law and the requirements of the coroner

To ensure the necessary processes, such as verification, are dealt with in a timely manner.

To respect the dignity, religious and cultural needs of the patient and family members.

To ensure timely removal of the deceased to the funeral directors or mortuary.

To ensure the health and safety of others are protected e.g. from infectious diseases, radioactive implants and implantable devices.

5.Scope of the policy

Registered nurses who are deemed competent, working within Beaumond House may verify the death of all adults (over the age of 18) providing all the following conditions apply:

Death is expected and not accompanied by any suspicious circumstances. This includes when the person has died unexpectedly from mesothelioma.

The ‘Do Not Attempt Cardio Pulmonary Resuscitation’ document is signed in line with current guidance

There is agreement for Registered Nurse Verification of Death documented clearly in the clinical notes either paper or electronic record (SystmOne).

Death occurs in a private residence or the hospice.

It includes where the patient dies under the Mental Health Act including Deprivation of Liberty

If there are any suspicious circumstances the police must be called and the body should not be moved.

6.Accountabilities and Responsibilities

Medical

1.Doctors (GP’s) will document in the patients record (paper or SystmOne) that an RN can verify the death.

2.A DNACPR decision must be documented. (See BH DNACPR policy)

3.The doctor will be available, if necessary, to speak to the families after the death of a patient, this should be arranged at a mutually agreeable time.

4.The responsible doctor (or if necessary a delegated doctor) will always explain/be able to explain the cause of death written on the death certificate.

The British Medical Association (BMA) guidance regarding actions required after death is as follows:

Does not require a doctor to confirm death has occurred or that "life is extinct".

Does not require a doctor to view the body of a deceased person.

Does not require a doctor to report the fact that death has occurred.

Does require the doctor who attended the deceased during the last illness to issue a certificate detailing the cause of death (unless the death is referred to a coroner).

So, a doctor's legal duty is to notify the cause of death, not the fact that death has taken place. Doctors, nurses or suitably trained ambulance clinicians may verify or confirm that death has taken place.

There is no legal obligation on a doctor to see or examine the deceased before signing a death certificate. This is the case across the UK.

A medical certificate of the cause of death must be provided by the appropriate doctor within 24 hours of the patient’s death, except at weekends and bank holidays when the certificate should be produced on the next working day.

Registered Nurses

All RN’s must have read and understood this guidance and received appropriate training and be deemed competent.

1.If death is expected the RN must ensure that the responsible GP is contacted (by ‘task’ on SystmOne) to confirm death is expected and an RN may verify death.

2. A valid DNACPR order must be in place in the patients record, in the patient’s home or on SystmOne.

3.The RN carrying out this procedure must inform the doctor of the patient’s death. During the day this will be by telephone. The death will also be recorded on SystmOne (both in and out of hours) and on paper checklist if required.

4.The RN carrying out the procedure must notify the funeral director/mortuary of any infections, radioactive implants, implantable devices and whether an implantable cardio-defibrillator is still active.

It is the right of the verifying nurse to refuse to verify death and to request the attendance of the responsible doctor/police if there is an unusual situation.

7.Method

Procedure for Verifying death

Equipment List

Plastic apron – for single use

Non-latex gloves (single use) well-fitting and of good quality

Stethoscope

Pen torch

Watch with second hand

Verification of death documentation

Care Required

A full explanation of the procedure should be given sensitively to the carer/family of the deceased patient. They should be offered the opportunity to stay with the patient during the process if they wish. If they do not want to stay in the room they should be shown to a private, comfortable area to wait.

Verification of expected death will require the nurse to assess the patient for a minimum of FIVE (5) minutes to establish that irreversible cardio-respiratory arrest has occurred, as well as specific additional observations.

Any spontaneous return of cardiac or respiratory activity during this period of observation should prompt a further 5 minute observation.

The nurse will verify the expected death by assessing the patient using the following criteria.

Verification of death procedure

Action / Rationale
Explain to any persons present with the patient the purpose and outline of the procedure.
Establish if they wish to remain present or would prefer to leave the room. If they choose to remain, recognise the emotional impact and ensure explanation and support is given during the procedure. / To inform and involve those who were important to the patient if that is what they wish.
Following the death of a patient the RN on duty should check the patients record to ensure the GP has recorded that nurse verification can take place / To ensure agreement of process
Confirm the identity of the patient by checking their clinical record and name band, that their name, date of birth and NHS number correlate. / To correctly identify deceased
Identify from the clinical notes(paper/electronic) if any:
Infectious disease
Implantable medical device
Radioactive implant / To ensure others involved in the care of the deceased are protected.
Instigate process for deactivation of implantable cardiac defibrillator (ICD) if not already deactivated / To ensure timely deactivation of ICD
Adopt universal control precautions – using appropriate personal protective equipment. / To ensure RN is protected.
Lay the patient flat.
Leave all tubes, lines, drains, medication patches and pumps etc. in situ, switching off flows of medicines, fluids, spigot off if necessary.
Explain to any family or others present why these are left in place. / To ensure the patient is flat ahead of rigour mortis.
To ensure all treatments are still in place prior to verifying death.
Manually check carotid pulse for at least ONE full minute / To confirm there are no signs of cardiac output
Listen to heart sound with a stethoscope for at least ONE full minute / To confirm there are no signs of cardiac output
Watch the patient’s chest and listen for breath sounds and movement for ONE full minute. / To confirm there are no respirations taking place.
Assessment of cessation of central pulse, cessation of heart sounds and cessation of respiratory effort should total FIVE minutes
Check for cessation of cerebral function by using a pen torch to confirm that both pupils are fixed, (not reacting to light or other stimulus) and dilated. / To confirm there is no cerebral activity.
Perform a trapezius squeeze and observe for any reaction. / To confirm there is no cerebral activity.
The RN verifying the death will complete the Verification of death form in the clinical notes.
Time of death will be recorded as when verification of death is completed, i.e. not when the death is first reported / To ensure legible documentation which meets legal requirements.
The RN will inform the patients GP by telephone during working hours, or if out of hours, ensure a telephone call is made.
The RN will record the verification of death on SystmOne. / To ensure timely and confidential communication takes place.
The RN will ensure that the bereaved family and others are supported and emotional and practical support and information is given.
The RN will also complete the Funeral Directors Transfer sheet. / To ensure those caring for the deceased provide appropriate care and are protected.
Provide family and others with information about the next steps and dealing with death and bereavement both verbally and offer written information.

1. Equality Impact Assessment must be carried out on Policy and considered for all other documents

Equality Impact Assessment Tool
Insert Name of Policy /
Procedure
Yes/No / Comments
1 / Does the policy / guidance affect
one group less or more
favourably than another on the
basis of:
Race / No
Ethnic Origin / No
Nationality / No
Gender / No
Culture / No
Religion or Belief / No
Sexual orientation, including lesbian,
gay or bisexual / No
Age / No
Disability - learning disabilities, physical disability, sensory impairment and mental health problems etc… / No
2 / Is there any evident that some groups
are affected differently? / No
3 / If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? / N/A
4 / Is the impact of the policy/guidance likely to be negative? / No
5 / If so, can the impact be avoided? / N/A
6 / What alternatives are there to achieving
the policy/guidance without the impact? / N/A
7 / Can we reduce the impact by taking
different action? / N/A
Name of Assessor (please print) / Signed
Helen Hume

9.Training Needs Analysis -Staff Training requirements

For an RN to verify an expected death in a safe and competent manner they must have -:

Minimum of six months post registration experience and have the confidence to undertake the procedure.

Attended resuscitation training on a yearly basis.

Received appropriate education that enables them to determine the physiological aspects of death.

Received appropriate education to enable them to be aware of the legal issues and related accountability which relates to this extended scope of professional practice.

The competency checklist Appendix 5 will be used to document training and observation of practice.

The registered nurse must understand his/her own personal accountability and be willing to undertake the procedure.

If the verifying nurse has any doubt about her/his findings or about the circumstances of the patient’s death s/he must call a doctor without delay.

Clinical supervision will be available to all RN’s to support practice thus enabling the maintenance and improvement of standards of care.

10.Monitoring Compliance with the policy / procedure

Compliance with this policy will be monitored by the Head of Clinical Services through reviewing documentation and in clinical supervision.

11. References

➢Home Office (1971) Report of the Committee of Death Certification and Coroners Cmnd 4810 London: HMSO

➢Nursing and Midwifery Council (2015) The Code

➢‘Care after death:guidance for staff responsible for care after death (Second edition) Available at

➢Memorandum of Understanding (2006) Department of Health, HSE, Chief of Police Officers

➢Gold Standard Framework for Palliative Care (2016) available at

➢NICE Quality Standard End of Life Care for Adults QS13 2011 available at

➢NICE Guidelines Care of Dying Adults in the Last Days of Life 2015 available at

➢BMA Confirmation and Certification of Death 2016 available at

➢Care after Death: Registered Nurse Verification of Expected Adult death (RNVoEAD) Available at https:

➢RCN Confirmation or verification of death by registered nurses available at

1. Policy Review
   Every 3 years or earlier if any new information or evidence emerges.

13.Sign off sheet regarding dissemination of procedural documents

To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.

Title of document: / Complete and sign
Lead Director: / Chair of Care Services Development
Sub Committee: / Care Services Development (CSD)
Date Approved:
Ratified by Board: / Delegated to Sub Committee
Dissemination Lead: / Head of Clinical Services
All relevant staff informed of changes, training plan in place to allow for full implantation.
Date placed in policy files:
Review Date:

Appendix 1

Guidance for Registered Nurses about referrals to the Coroner

General notes

When a patient dies it is the statutory duty of the doctor who has attended in the last illness to issue the Medical Certificate of Cause of Death (MCCD).

The doctor may certify the death where he or she has:

Attended the deceased in life AND seen after death OR

Attended to the deceased within 14 days of death, when it is not necessary to view the deceased after death.

The doctor should be familiar with the patient’s medical history, investigations and treatments.

To help doctors fulfil their requirements and to ensure unnecessary distress to families RN’s should ensure that patients believed to be nearing the end of life are seen and reviewed by a doctor. RN’s must also ensure that doctors have all the necessary information about the patient, in particular any criteria that would trigger a referral to the coroner.

Deaths that should be referred to the coroner

1. Cause of death not known
2. Cause of death may be due to trauma or unnatural cause e.g. road traffic collision, possible suicide, poisoning, self-harm, fracture.
3. Cause of death may be related to an industrial disease e.g. pneumoconiosis, (deceased was a miner), mesothelioma, farmer’s lung
4. Patient had been in hospital for less than 24 hours
5. Cause of death is due to a fall or there has been a fall in the 3 days prior to death
6. At death, grade 3 or 4 pressure sore present, or more than one grade 2 pressure sore.
7. Surgery or invasive procedure involving general or local anaesthetic performed within the preceding 12 months (including endoscopies)
8. A medical procedure or treatment which may have caused of contributed to the death, includes, chemotherapy, radiotherapy, biological/hormonal therapies, stem cell and bone marrow transplants.
9. Patient is a prisoner or is otherwise legally detained, including detention pursuant to Mental Health or other legislation. This includes all patients who are subject to Deprivation of Liberty Orders after such orders have been approved by the court, where the death occurred prior to 3 April 2017.
10. Alcohol or any prescribed or non-prescribed drug is mentioned as contributing to the cause of death in part 1 of the certificate.
11. Death during pregnancy or within a year of giving birth.
12. All deaths of minors under 18.
13. Death is associated with or occurs after a clinical incident.
14. Where allegations of negligence have been made against the hospital or others involved in the nursing or medical care of the deceased, regardless of whether it is considered such allegations have merit.
15. Death may be due to the neglect of others.
16. Any other unusual circumstances.

Pressure damage - RN’s are responsible for ensuring the GP is aware of pressure damage. Stage 3 and 4 sores are to be reported and more than one stage 2 sore.