Wednesday, May 12, 2010

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.

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