Last offices

An article in Nursing Times alleges nurses' neglect of Last Offices in some NHS Trust hospitals, causing added distress to bereaved families and friends. In recent years, the NT claims, nurses have not had the teaching and guidance they need to perform Last Offices, a term that describes the procedure for washing, tending and 'laying out' the body of a person who has died in hospital or nursing home, prior to (and preparatory to) their removal from the ward to the mortuary.

'Last Offices' is a fairly regular routine for nurses, and I'm a little surprised that it may have fallen by the wayside in the modern NHS, but not totally surprised. Nurses today are not what they were, which is not to say that twenty-first century nursing is necessarily inferior to earlier versions, but it is true that modern nurses do more technological high-turn-over medicine, are usually more technically proficient than their 1960s counterparts, and have a busier caseload than I ever did. It's easy to snipe from the side-lines, but I doubt I could survive a single shift in a modern hospital setting: my presence could be even be hazardous to health.

In my experience, performing Last Offices should be a leisurely, unhurried affair. I last did this about six weeks before I retired. Having nursed an elderly fellow during his last years, months, days and hours, he breathed his last one morning shortly after I had arrived on duty at 0700. His death was peaceful - "in his sleep" it might be claimed, although this expression poses a number of unanswerable questions.

I had to wait several hours after his death for his doctor to arrive to confirm his death. The doctor didn't question my 'diagnosis' of death. Although the 'certification' of death is for a doctor, most doctors will accept an experienced nurse's word on the matter, and don't attend the death as a matter of urgency.

After the doctor had left, I set about the preparations needed to minister to the old fellow's last needs, if he could be said to have any further needs at that point. I undressed the body carefuly, removing any medical equipment to which he might still be attached, removing any tubes still in body cavities, taking off dressings (replacing any that might be preventing discharge etc), and then carefully washed and tended the body as gently and carefully as if he were still living.

If necessary, a man might be shaved. Nails are carefully trimmed and cleaned, teeth or dentures cleaned, hair brushed and styled. The eyes are sometimes held closed with a small piece of adhesive tape, it used to be done with a moistened pledget of cotton wool. Jewellery may be removed and put away, suitably labelled, in safe place.

I find it a lovely thing to do Last Offices, although to some that might sound odd or macabre: it's a chance to say the final "Goodbyes", it settles the mind into a state of repose and peacefulness, it acknowledges the finality of death. If possible, I invite someone who has cared for the deceased to help with Last Offices, especially those who have not perhaps met death in this way before. On my last occasion my assistant was a relatively new care-worker, someone who had not done the Last Offices before, so it was an opportunity to show them the routine, and to explain the procedures that would be followed afterwards when the funeral director called to remove the body to his premises.

All this happened in a specialist Nursing Home rather than a busy hospital ward. In the latter setting there is enormous pressure on beds, and the body of a dead patients may be removed with 'indecent haste', without allowing the prescribed hour to elapse after death is pronounced, ostensibly to allow rigor mortis to set in, but also for the sake of decorum, and so that relatives have an opportunity to say their farewells (if they were not present at the death it is an indignity to arrive at the ward and find an empty bed).

Never an occasion goes by that I perform Last Offices without reflecting on my own death, and imagining my own corpse being tended by another. I sometimes think it would be good to be washed and tended by my kin, by my wife, or my sons, but - putting myself in their place - I think they may find this too upsetting, and I wouldn't want them to feel that they had 'let me down', so I will leave it to them to decide for themselves.

In Asian and African culture it is normal for family members to tend their dead, and to dig their own grave for the deceased, or to collect the requisites for a pyre, or whatever rite they follow: it's a do-it-yourself job, although help may be hired to provide transport, or to knock together a coffin. And a funeral is usually an occasion for a family gathering, a feast, some beer (in Africa at least), and in many cases a good deal of fractious squabbling over inheritance, the division of spoils.

Bunny Suicides

The image (centre) is of Garuda, mythical bird in Buddhist and Hindu lore, mentioned below. NOT A BUNNY.

I can't quite work out how this fluffy bunny (see picture opposite) managed to depress the lever -from inside the toaster - after inserting himself (or herself) into the toasting slot. Can this be a case of assisted suicide or bunny euthanasia?

The technology-assisted self-destruction shown in the picture (below, at the bottom) shows a level of ingenuity, and a capacity for meticulous pre-planning, I wouldn't have associated with bunnies. But the older I get the more I realise how I may always have taken the sensibilities of animals for granted, and underestimated their intelligence.

Several years ago my daughter gave me the Book of Bunny Suicides for Christmas, and I was impressed with Andy Riley's finely-observed compilation of several dozen cartoons, each depicting the self-executed demise of a "little fluffy bunny who just doesn't want to live any more". Whatever one thinks of the incidence, causes and morbidity of depression in bunnies (and I haven't previously given it much thought at all), this book illuminates the issue vividly, and I read it at a single sitting.

To say I read it gives a false impression, as there is hardly any text at all, it's all pictures, there's a laugh on every page, and not many pages overall. On several pages I laughed out loud, and on quite a few I laughed helplessly. These cartoons are wickedly funny, consistently, inventively morbid, timeless and also de nos jours. Some bunny-suicides as illustrated take a bit of working out: for example, one bunny - presumably having tried unsuccessfully to die at his own paw using other methods - succeeds in fixing himself to the front of an Underground train (super-glue, velcro, blue-tack?) from which position - suspended above the tracks - he urinates directly and precisely onto the third 'live' rail, with the result that a violent electric charge passes up his urine-stream, with the intended result: he sizzles.

You have to see it to be swept away with admiration at his determination and his ingenuity. How did he manage to fix himself on to the front of the train without attracting the driver's attention? How much did he have to drink to be sure that he could maintain a steady urine-stream for long enough to hold the circuit and produce death? Did he have to practice this method by 'dummy runs'? All this is fascinating conjecture, without even going into what caused bunny to be depressed in the first place, even if he were depressed, which is itself debatable (there are other motives for suicide than depression).

Shortly after I got the Book of Bunny Suicides I passed it on to someone I visited in hospital, dying of an inoperable brain tumour. I did this on an impulse, and it turned out to be a helpful one. The person to whom I gave it found it a real tonic, and got many laughs out of it during his final illness. It's a book you can keep around and turn to in those moments of rather ponderous solemnity and self-concern we're all subject to now and then.

I bought a dozen of these Bunny Suicide books, one for myself, and the rest to give away when the circumstances seemed right, especially around terminal illness: I don't think offering this book as a gift to someone dying is a matter of very fine judgement, in fact I think that bringing very fine judgement to bear on dying and death can be a fearful business. Attending on the dying and death of others - and our own - calls, perhaps, for the qualities of that mythical and fearless Buddhist bird, Garuda.

Garuda is a do-anything, go-anywhere bird, and he can fly as soon as he is hatched. He crawls out of his shell on to the narrow shelf overlooking a vertiginous precipice and - finding no where to perch - falls into the void spreading his wings and flying at once, looking fearlessly for evil adversaries to slay: doubt, prevarication, hesitation, self-consciousness. It's said that Garuda sat on the Lord Buddha's throne as a protector until - during the Buddha's delivery of the Heart Sutra - a bat farted. Garuda promptly killed the bat for its insolence, whereupon he was banished for breaking the First Precept.

I do think (by the account given in the story) the Lord Buddha seemed very hard-hearted, but perhaps he didn't issue the order that banished Garuda, perhaps it was a pompous minion acting ultra vires. If the Lord Buddha lacked a sense of humour, or a sense of proportion, and had never himself farted in public (doubtful indeed), he would probably have had me banished - like that flatulent bat -for distributing Bunny Suicide books to dying friends. Which is why I've always taken stories about the life of the Buddha with a pinch of salt, or with a whiff of bat-fart.

As far as I can recollect, Garuda was eventually re-instated, and is now available to me - when the occasion presents itself - to deliver the remaining two Bunny Suicide books I've got left to give away.