In its document “Patients and Family at the End of Life”[i], the Scottish Academy set out ethical and practical principles to guide practice to help families when a loved one is dying. The principles include kindness, respect, fairness and minimising harm as they relate to caring for the dying and their families.
Caring for people does not stop with death, rather the caring changes focus to the bereaved family. The principles remain the same. It is important that staff speaking to recently bereaved families are aware of new or changed processes after someone has died, related or not related to COVID-19, and that they communicate these clearly and effectively in the context of families’ cultural values and religious or other beliefs. To that end, this paper follows pathways taken by recently bereaved families pointing out what needs to be done and how families may choose to do these, conscious of the needs of differing faiths and cultures in Scotland.
There is guidance around caring for the deceased and about funerals. Variability in application of guidance is apparent and is potentially unhelpful, particularly for people who are recently bereaved. The purpose of this document is to raise awareness of guidance and regulation, to assist, point to useful advice and minimise upset. Helpful and accurate bereavement related resources are available from NHS Education for Scotland[ii], Scottish Government[iii] and from Scottish Care[iv] and the Inter Faith Network[v].
- Following the death of someone who has or is suspected of having COVID-19, infection control measures will be in place for staff or others carrying out last offices[vi]. This is in recognition of the need to protect people as transmission of the virus can occur in the surrounds for 48-72 hours. These acts of care should continue to be carried out in ways which maintain dignity and respect for the deceased.
- Confirmation of death will take place, followed by the timely issuing of a Medical Certificate of the Cause of Death (MCCD) which is a statutory requirement. Steps have been taken to allow remote verification of death under some circumstances in the community[vii]. The terms COVID-19 disease or Presumed COVID-19 disease will be used on the MCCD where Covid is known or suspected[viii]. The doctor completing the MCCD will provide the MCCD serial number to enable registration and will inform their local Public Health Department as COVID-19 is a notifiable disease.
- The next of kin or other delegated person must register the death with a Registrar of Births, Deaths and Marriages, usually, but not necessarily, locally. Death registration is now taking place electronically or by telephone during the COVID-19 pandemic. The certificate will be sent electronically to the Registrar, specified by the next of kin, who may, on request, see a copy[ix]. Much guidance around the electronic process is published (see www.nrscotland.gov.uk/ ). Variation on detail, availability and effectiveness is reported in practice – consultation with local Registry Offices is recommended to ensure as accurate communication with families as is possible.
- The Registrar chosen (section 3) will receive the MCCD and will explain the process for the purchase of necessary Certificates of Registration and copies[x]. How this is achieved may vary depending on location.
- The practice of MCCD review undertaken by medical examiners is currently suspended unless a family has specific reasons for a review[xi].
- There is no change in regulation about organising cremation, or cultural and religious practices, however, an additional form to enable cremation may be required; guidance on infection control should be observed (see section 12).
- Following someone dying away from home, belongings will be returned to the next of kin. Personal possessions carry at least strong sentimental value and families will wish to have them. Infection control guidance indicates the possibility of transmission from these. To prevent infection, items can be put in a bag, taken home and cleaned with household detergent and disinfected with a household bleach solution. Clothing should be washed separately using the warmest water setting in accordance with manufactures’ instructions. Families without access to a washing machine, should keep items bagged for 72 hours before taking them to a laundrette; and then dispose carefully of any container[xii] [xiii].
- If in a large hospital setting, the deceased will be taken to a mortuary. Many mortuaries are on the sites of major hospitals however they may be at some distance. In the community, the deceased’s body will be uplifted by a funeral director. This is usual practice and does not differ in COVID-related deaths.
- The risk of spread is less in death than in life although the virus may be viable for some time after an infected person has died (see section 1). In most hospital and public mortuaries, there are facilities designed specifically to allow relatives to view the deceased. The view of the Scottish Academy, in keeping with its Guidance on visiting dying patients (note i below), is that close relatives should be entitled to view the deceased unless circumstances make it unsafe or impractical to do so. Local mortuary staff will advise. Infection control measures will depend on factors including the design of buildings and their ventilation. Viewing may be offered behind glass. These procedures are as specified by regulations[xiv]. Removal of pacemakers and the like should go ahead.
- The same regulations apply to funeral homes however the physical environment there may vary as in hospitals. Viewing may be more convenient in funeral homes. Possibilities will vary with available facilities and should be discussed with the relevant funeral director.
- There is currently no need for a COVID-19 related death to be referred to the Procurator Fiscal. If there is a need for other medical or legal reasons[xv] and the Fiscal has to be informed and carry out an investigation, identification will be organised via the local investigating officer in Police Scotland. Facilities for viewing vary across Scotland – local police and funeral directors (section 10) will advise.
- Next of kin will, as is usual, make funeral arrangements in accord with their wishes, culture and faith. There is variation in the application by local authorities of the recommendations about attendance at funerals. Many crematoria are independent. The relevant Regulations[xvi] state that those who may attend funerals are (i) a member of the deceased’s household, (ii) a close family member or (iii) if no one from (i) or (ii) is attending, a friend may attend[xvii]. For cremations, funerals or burials attendees must observe the two metre social distancing (except between two members of the same household, or a carer and the person being assisted by the carer)[xviii]. Families should be advised to discuss this with their funeral director, burial ground or crematorium.
- Organ donation is going ahead as before as long as there is no risk of COVID-19 in the donor – additional tests are necessary. Tissue donations for research and, for example, corneal transplant have largely been suspended however local mortuary staff will be able to advise.
- Should a family wish or agree to a post-mortem examination, guidance is available for staff as to how this can be carried out[xix]. Families whose relative has bequeathed their body to a Scottish Medical School should be aware that bequests have been suspended during the COVID-19 crisis.
- Bereavement support services are offered by various groups, nationally and locally (notes ii-iv below). These are available to provide kindness, compassion and advice to grieving families.
[i] Patients and Family at the End of Life. Scottish Academy 15 April 2020. https://www.scottishacademy.org.uk/covid-19-allow-families-equal-access-visit-dying-relatives
[ii] NHS Education for Scotland Turas learn. https://learn.nes.nhs.scot/28674/coronavirus-covid-19/death-and-bereavement
[iv] Bereavement charter for children and adults in Scotland. https://scottishcare.org/wp-content/uploads/2020/04/Bereavement-Charter-1.pdf
[v] COVID-19 and funerals. UK Inter Faith Network 28 Apr 2020https://www.interfaith.org.uk/news/covid-19-funerals
[vi] Guidance for care of the deceased with suspected or confirmed coronavirus (COVID-19), Public Health England. Published 31 March 2020. https://www.gov.uk/government/publications/covid-19-guidance-for-care-of-the-deceased/guidance-for-care-of-the-deceased-with-suspected-or-confirmed-coronavirus-covid-19
[vii] Guidance for Remote Verification of Expected Death (VoED) Out of Hospital https://www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2020/covid19/RCGP-guidance/BMA-RCGP-Guidelines-For-Remote210420.ashx?la=en
[ix] Guidance for Medical Practitioners during the COVID-19 Pandemic – Electronic Transfer of Medical Certificates of Cause of Death (MCCD) from Health Services to Registrars and Next of Kin https://www.gov.scot/binaries/content/documents/govscot/publications/advice-and-guidance/2020/04/coronavirus-covid-19-transfer-of-medical-certificates-of-cause-of-death---guidance-for-doctors/documents/coronavirus-covid-19-transfer-of-medical-certificates-of-cause-of-death---guidance-for-doctors/coronavirus-covid-19-transfer-of-medical-certificates-of-cause-of-death---guidance-for-doctors/govscot%3Adocument/COVID%2B19%252C%2BMCCD%2Band%2Bremote%2Bregistration%252C%2Bsupplementary%2Bguidance%252C%2B6%2BApril%2B2020.pdf
[x] NRS Updates: Coronavirus (COVID-19) Information. National Records Scotland. https://www.nrscotland.gov.uk/about-us/service-status
[xi] About the Death Certification Review Service. Healthcare Improvement Scotland http://www.healthcareimprovementscotland.org/our_work/governance_and_assurance/death_certification.aspx
[xii] Core COVID-19 Information and Guidance for General (Non-Healthcare) Settings. Health Protection Scotland 14 Apr 2020. https://hpspubsrepo.blob.core.windows.net/hps-website/nss/2973/documents/1_covid-19-guidance-for-non-healthcare-settings.pdf
[xiii] Guidance. COVID-19: cleaning in non-healthcare settings Public Health England, Updated 26 March 2020. https://www.gov.uk/government/publications/covid-19-decontamination-in-non-healthcare-settings/covid-19-decontamination-in-non-healthcare-settings
[xiv] Managing infection risks when handling the deceased. Guidance for the mortuary, post-mortem room and funeral premises, and during exhumation. Health and Safety Executive, July 2018. https://www.hse.gov.uk/pubns/books/hsg283.htm
[xv] Reporting deaths to the Procurator Fiscal. Crown Office & Procurator Fiscal Service, 2015. https://www.copfs.gov.uk/images/Documents/Publications/Reporting%20Deaths%20to%20the%20Procurator%20Fiscal/Reporting%20Deaths%20to%20the%20Procurator%20Fiscal%20-%20Info%20for%20Medical%20Practitioners%20May%2019.pdf ; advice also at https://www.copfs.gov.uk/investigating-deaths/our-role-in-investigating-deaths
[xvi] The Health Protection (Coronavirus) (Restrictions) (Scotland) Regulations 2020 Scottish Statutory Instruments, 2020 No. 103 Clause 8 (5) g
[xvii] The Regulations do not define ”close family member” but there is no stated limit to the numbers of household members or “close family members” who may attend.
[xviii] Coronavirus (COVID-19): guidance for funeral services. Scottish Government. https://www.gov.scot/publications/coronavirus-covid-19-guidance-for-funeral-services/
[xix] Autopsy practice relating to possible cases of COVID-19. Royal College of Pathologists, 17 Feb 2020. https://www.rcpath.org/uploads/assets/d5e28baf-5789-4b0f-acecfe370eee6223/447e37d0-29dd-4994-a11fe27b93de0905/Briefing-on-COVID-19-autopsy-Feb-2020.pdf