The Nursing and Midwifery Council (NMC) (2018) highlighted registered nurses' responsibility to ‘recognise and respond compassionately to the needs of those who are in the last few days and hours of life’. This can be considered in accordance with the North West End of Life Care Model (NHS England, 2015), which defines end-of-life care as a process that continues beyond the death of the patient. This model supports nurse-led verification of death where possible, with nurses best placed to respond with compassion and to maintain responsibility for the patient and their family after death has occurred.
It is relevant to recognise the difference between verification and certification of death. English law states that verification of an expected death does not need to be completed by a doctor (British Medical Association, 2019). The Royal College of Nursing (RCN) (2019) expands on this definition, describing verification of death as the process of confirming that death has occurred. Hospice UK (2019) further elaborates on this, adding that a nurse verifying death would also clarify the identity of the person who has died, note any implantable devices and make relevant notifications of any infectious diseases. Hospice UK (2019) then continues to describe certification of death as the completion of a medical certificate by a registered medical practitioner, detailing the cause of death as required by the Births, Deaths and Marriages Act (1953).
Who should verify deaths?
Importantly, it should be noted that nurse-led verification of expected death is not intended to replace GP verification, but enables nurses to extend the care of those patients who are on the district nursing caseload to provide continuity of care for an individual and family at a distressing time (Hospice UK, 2019).
With compelling evidence highlighting that district nursing teams are the most appropriate, responsive service, best placed to provide verification of expected deaths, it is essential to consider how this works in practice. Myths around district nursing are slowly being dispelled, meaning that newly qualified staff nurses are more aware of community nursing as a career choice (Green, 2018). While newly qualified staff nurses bring pre-registration experience of communication, they continue to develop this skill post-qualification (Maxwell et al, 2011). A district nursing visit to complete verification does not just encompass this one clinical task. This visit includes emotional support for relatives and carers, answering any questions there may be and offering advice about onward processes after verification. Ibañez-Masero et al (2019) recognised communication as essential when providing end-of-life care, as it makes a significant difference in supporting a dignified death. Sensitive communication is also described throughout the ‘One Chance to get it Right’ report (Department of Health and Social Care (DHSC), 2015) as an essential skill to be used in the provision of end-of-life care. As a profession, nurses have one chance to support an individual to have a ‘good death’, and this includes care after death and support of the family. With this in mind, it is perhaps not appropriate for newly qualified or inexperienced staff to complete verification of death, until a period of preceptorship has been completed. The Queen's Nursing Institute (QNI) (2016) recognised that care should be given by a nurse who has the appropriate skill set for the task in hand. Geake and Ryder (2009) recommended palliative care as a key component of preceptorship for new staff. In terms of acquiring the skill set to enable verification of death, Hospice UK (2019) recommended a less prescriptive approach, placing the onus on the individual staff member to assess their own ability. The QNI and RCN (2019) recognised community nursing as potentially isolating, and, in this regard, the development and maintenance of competencies can prove challenging. However, with the support of a CSP-qualified leader, which would encourage reflection on practice and promote personal development, staff would be guided to be upskilled and adaptable to change.
Why should nurses verify expected deaths?
The district nursing team plays a central role in providing end-of-life care, with 40% of district nursing time used supporting patients who are at the end of their life, providing symptom management and emotional support for both the patient and their family (QNI, 2020). District nurses are recognised as ‘experts in end of life care’ (QNI, 2020). With district nursing teams playing such a pivotal role in the provision of end-of-life care, it is surprising that nurse-led verification of expected death remains a ‘hidden practice’ (Hospice UK, 2019). The National Institute of Health and Care Excellence (NICE) (2017) guidelines recommended that relatives and carers of the person who has died should be able to receive timely verification of death. Guidance around this has been available for some time (Box 1). Hospice UK developed the third edition of the Registered Nurse Verification of Expected Adult Death (RNVoEAD) guidance and competencies in 2019 to enable nurses to complete verification of death. The aim is to reduce the waiting times for verification of death by a GP, that families and carers experience at the time of a loved one's death (Laverty et al, 2010). This guidance recommended that an expected death at home should be verified within 4 hours. The district nursing service is well-equipped to provide this, and is able to provide a more responsive service and avoid distress for family members, which may occur due to delays in waiting for GP verification (Edwards, 2018).
Box 1.Criteria for verification of expected adult death by registered nurses
| The registered nurse is working within their care setting |
| The registered nurse is deemed competent |
| DNACPR is present and signed in line with guidance |
| Death is expected |
| There are no suspicious circumstances |
| Death occurs in private residence, hospice, residential home, prison or hospital |
Source: Hospice UK, 2019. DNACPR=do not attempt cardiopulmonary resuscitation
In terms of wider policy, the NHS Long Term Plan (NHS England, 2019) seeks to personalise end-of-life care, promoting a proactive, personalised approach to care planning. In order to do this, it is essential that thorough advance care planning is completed, as identified within the End of Life Care Strategy (DHSC, 2008). Merlane and Armstrong (2020) recognised that nurses are best placed to initiate these conversations in a proactive manner, with patient values best reflected when the patient is clinically stable (Epstein et al, 2019). The nurse–patient relationship is central to the provision of care and the development of a trusting therapeutic relationship (Griffith, 2016). The conversation regarding nurse-led verification of death should be instigated during the advanced care planning process (NHS Improving Quality, 2014).
The role of the community specialist practitioner (CSP) is particularly significant in supporting patients who are identified as approaching the end of their life. With the recent reinvestment in the CSP qualification, it is important to acknowledge the place of this role, where those qualified have specialist knowledge and experience, enabling excellent care to be co-ordinated and delivered in patients' homes (Longstaff, 2013). The King's Fund (2016) also recognised the value of CSP-qualified nurses as experts within the field, and, as such, being best placed to support the implementation and co-ordination of verification of expected death training and competencies.
Benefits to patients and their families
Conversations regarding nurse-led verification are best started when commencing advance care planning (Merlane and Armstrong, 2020). This, in turn, enables continuity of care both for the patient and for the family. District nursing teams are well-placed to develop trusting therapeutic relationships with families due to frequency of contact, which may be low on admission to caseload and increase as patient need dictates. Families have described district nursing teams' skills in becoming a part of the family dynamic in providing care for their loved one, while maintaining professionalism at all times (QNI, 2020). This familiarity with the team would reduce distress for the family when death occurs. Communication with carers by community teams is particularly relevant in end-of-life care, enabling the team to gain invaluable insight into the patient's spiritual needs and wishes (Argyle, 2016). Hospice UK (2019) also found that bereaved families whose relative's death had been verified by a nurse provided positive feedback regarding this experience.
Nurse-led verification also provides a key opportunity to signpost bereaved relatives to the available support. Individuals who experience bereavement are more likely to experience greater morbidity and mortality, but less than half of those who are bereaved and who wish to speak with a health or social care professional about this are able to do so (National Bereavement Alliance, 2014).
Barriers
District nursing teams are increasingly stretched as they provide care for patients who have progressively complex needs (QNI, 2020). This means limited capacity to release staff to complete initial training and consequent competencies.
Hospice UK (2019) recognised that nurse-led verification may ‘ease overburdened GP caseloads, but add to overburdened nursing workloads’. It is also recognised that one of the criteria for nurse-led verification of expected death is that the patient has been reviewed by their GP within the last 14 days before death. It is questioned whether this is an appropriate use of GP time, as review may not be clinically indicated, instead being purely a ‘box-ticking’ exercise (Hospice UK, 2019). Verification of death should be recognised as an extended role of the district nursing team. As such, it is possible that not all team members will want to adopt the procedure (Byron and Hoskins, 2013). With this in mind, it is pertinent to recognise that the district nursing service is able to complement the GP service in this manner, but not take responsibility for all expected deaths on the caseload.
Cultural aspects should be addressed, and the preconception that verification of death is the responsibility of medical staff should be dispelled (Byron and Hoskins, 2013). A person-centred approach should be taken, and a shift should be made towards promoting continuity of care for the patient and their family.
Although the concept of care being delivered closer to home is not a novel idea, community services remain under-funded and increasingly stretched (The King's Fund, 2018). There has also been a significant decrease in the number of nurses who possess the CSP qualification (QNI, 2020), which is necessary for leaders to ensure an encompassing approach to caseload and team management, to overcome barriers that may be encountered in implementing this skill within a team.
What is needed to support this
Training in verification of expected adult death is available usually in conjunction with local hospice provision (St Catherine's Hospice, 2020). However, the stumbling blocks appear to be in confirming competence in the skill (Edwards, 2018).
It is essential to recognise that the district nursing service does not sit alone in the provision of end-of-life care, but is underpinned by the support of other disciplines (QNI, 2020). Gold Standards Framework meetings provide a forum in which proactive measures can be implemented for care of patients who have a palliative diagnosis. Nurse-led verification of death should be discussed within this forum to confirm GP support and authorisation (Byron and Hoskins, 2013). Multidisciplinary team working is essential to support district nursing teams initially in confirming competency following training, and then moving forward. Communication between district nursing teams, GPs and palliative care providers (hospices) is crucial to ensure that, where it is identified, nurse-led verification of expected death is possible, that this is planned and that a contingency plan is in place should the district nursing team is unable to attend due to capacity.
Conclusion
The role of the community nurse and CSP is ever evolving, requiring specialist knowledge and skill in co-ordination of complex patient care. It could be argued that taking on the task of verifying expected deaths of patients who are on the district nursing caseload is edging toward the role of a junior doctor, and that district nursing teams are ‘plugging gaps’ in GP services. However, end-of-life care encompasses a significant part of the district nursing team role, and it makes perfect sense for verification of expected death to be carried out by the team that is providing this care. This ensures continuity of care for the patient and family, as well as a more responsive service. With limited academic research in the area of implementing verification of expected death by adult nurses, this appears to be an area in which progressive developments can be made to provide good quality care for patients and their families at home.
KEY POINTS
- District nursing teams develop trusting therapeutic relationships with patients and their families at end of life, and are best placed to verify death
- District nursing teams are able to minimise distress to families, providing a more responsive service and avoiding lengthy waiting times for a GP home visit for verification
- As professionals, we have one chance to get it right in supporting patients to have a ‘good death’
- End-of-life care goes beyond the occurrence of death, and extends into the bereavement stage
CPD REFLECTIVE QUESTIONS
- What are the barriers and facilitators to registered nurses verifying expected deaths in the community?
- How has the role of district and community nurses changed in the past 5 years?
- How can end-of-life care be personalised, according to the NHS Long Term Plan?