Observing a collective moment of silence when a patient dies is valuable for both staff and the bereaved. This initiative won the Critical and Emergency Care Nursing category in the 2023

Nursing Times Awards. ABSTRACT This article describes the implementation of holding a minute’s silence when a patient dies in Southport Critical Care Unit. It describes the rationale for the

initiative, as well as the words used, and the outcomes for staff and relatives of recently deceased patients when all are given an opportunity to process the event in this way. CITATION:

PINNINGTON M, WESTWOOD A (2024) Introducing the pause after the death of a patient in critical care._ Nursing Times_ [online]; 120: 3. AUTHORS: Melanie Pinnington is practice educator for

and we could not have predicted its impact when we implemented it. We had a heightened awareness of moral injury from nursing dying patients without their families present during the

Covid-19 pandemic. We had, as a unit, put in place several measures to help staff with the trauma and aftermath of these multiple deaths. These included the introduction of local Schwarz

Rounds as a forum for reflection and the development of the professional nurse advocate (PNA) role in the critical care unit. However, it was the experience of holding a minute’s silence at

a set time, to honour a staff member who died during the Covid-19 pandemic that helped us to realise the power of that moment to reflect and value the life of a patient and the work of the

team. The moment of stillness, in what would normally be a bustling and busy environment, was extremely powerful. AIMS We wanted to support the critical care team in recognising the

contribution they make and ally with our Schwarz Round ethos – to make a difference to end-of-life care in what can be a clinical and frightening environment. We only have one chance to get

this right for the families and we believe that, in holding this respectful moment together, it can support the family in starting the grieving process. > _“This project links to the 

fundamentals of nursing care by > providing a respectful, peaceful and compassionate closure after the > death of a patient”_ Judges’ comments WHAT WE DO When we know that a patient’s

death is imminent, the coordinator will prepare the staff by discreetly asking whether they want to take part. We use a butterfly symbol on the bedspace as a visual symbol to be mindful and

keep noise to a minimum. When we are observing the pause, we ensure that all staff are aware. Upon the death of the patient, while the family are present, we use a card with the following

words: * Ask the family: “Do you mind if we observe a moment’s silence with you?” * On consent: “In this pause in time, in our own way, and in this moment of silence, we honour [name of

patient].And we also pay our respects to those who have loved and cared for them.” * Observe one moment of silence. * “Thank you everyone”. IMPLEMENTATION We conducted a literature review

with our Library and Knowledge Service and found this practice was used in palliative care, organ donation and emergency rooms, but not in critical care (National Organ Donation Committee,

nd; Hendrick and Fuller, 2022; Lipke and Perez, 2022). We spoke to our unit coordinators to explain the purpose of pausing the team to allow a minute’s silence for the staff and family.

Having obtained their agreement, we introduced the concept to all nursing and medical staff by explaining, in person, what the initiative might be like and why we wanted to try it. We then

produced the reference card for staff to read at the bedside. We initially proposed a launch date in August 2021 but, by July, staff had independently adopted the pause, as they felt it was

appropriate and were comfortable with the idea. The initiative was embraced by consultants, coordinators and staff nurses, and we supported theatre staff with a pause and received grateful

feedback. REVIEW In December 2021, after about three months of using a poster audit where staff left anonymous comments, we reviewed the pause. Approximately 50% of staff had participated in

a pause by that point, with mostly positive responses. We collated the responses using WordArt to give staff a visual update on the project (Fig 1). At the time we were also enhancing our

offer of end-of-life support initiatives that had already been embedded on the unit, such as making memory boxes and supporting relatives. We had found that putting more personal touches

into our end-of-life care helped staff to support each other and process what can sometimes be an emotionally difficult part of the job. CHALLENGES Due to the nature of critical care nursing

and medicine, patients can have prolonged stays on the unit and staff get to know, not only them, but also their families. This means we form bonds and feel patients’ deaths very keenly,

and there can be a great sense of failure on the part of the team. Staff feedback on the pause has been positive on the whole. Any concerns are addressed in the PNA sessions we hold monthly

as part of our teaching around end-of-life care and organ donation. Discussion in this forum revealed that support was needed and not all staff felt comfortable leading the pause – as a

result, a coordinator is always available to lead the pause. We also reviewed and changed the wording we had initially used on the card so it was simpler and more appropriate to what staff

wanted. We ask staff if they want to participate and give them the opportunity to take part. If they decline, this is respected just as much as a request to be present. OUTCOMES STAFF Staff

feedback, gathered in multiple ways, is sometimes very personal and honest about the experience: _“Initially, when it came in, I found it quite challenging. Since doing the pause quite a few

times, I find it quite rewarding and this is because it gives me time to reflect.”_ Other comments include describing the pause as “an excellent way to show respect” or “a very dignified

way to end their care”. Our ward manager, Kerry Critchley, has summed up the impact: _“Through the pause, we honour the resilience and strength of our healthcare staff who tirelessly care

for patients and their families. We acknowledge the emotional toll that comes with this work and offer support to those who need it most. Together, we stand in solidarity to honour the

humanity of every person who passes through our doors.”_ In a world in which patient flow and bed pressures have become paramount, staff may feel that respect for our patients is lost. The

pause re-establishes this respect, helping to restore our faith in the concept of caring and compassion. Also, as in healthcare we often strive for recovery, we can feel that we have let

people down when there is a death. To recognise the processing of end-of-life care is very cathartic and appears to reduce emotional burnout among staff. FAMILY AND FRIENDS Feedback from

families comes from various avenues such as: * Letters to the executive board; * Emails and letters to the matron; * Cards to the staff; * Local social media comments. Although we started

the initiative to support staff, we have been overwhelmed by the humbling responses from families who have fed back to us. They described staff as showing such respect, outstanding care and

compassion, and told us that the moment of the whole team coming together to pay their respects in silence will stay with them forever. CONCLUSION The pause initiative costs absolutely

nothing financially but has been so valuable in creating a personalised and respectful end-of-life experience for both the staff involved and the bereaved families. A minute’s silence is

eco-friendly, priceless in its value and can be bespoke to your own area, whether that be critical care, a ward, the emergency department or a hospice. We only get one chance to get this

right. KEY POINTS * A moment of silence is often observed as a gesture of respect, particularly in mourning for those who have died recently * A silent pause contains no statements or

assumptions about belief or religion * The occasion allows all the participants to come together * When used in organ donation, the practice is known as a full-team moment of honour *

Introducing the pause in a care setting is infinitely transferable to any end-of-life circumstances ADVICE FOR A SIMILAR PROJECT * It is vital to make your team feel valued when delivering

care at the end of life * Introduce the idea of the pause to staff and ask their opinion first * Move forward with staff who feel comfortable supporting both other staff and bereaved

relatives * Review the initiative regularly by asking staff for their opinions and ideas. Most often, it is their creativity that moves projects forwards * Feed back to staff regularly on

the impact they are having. Usually this will be through your own channels of communication REFERENCES HENDRICK J, FULLER T (2022) The pause: utilizing a moment of silence after a patient

death #432. _Journal of Palliative Medicine_; 25: 2, 329-330. LIPKE A, PEREZ R (2022) Taking a moment: implementation of the pause initiative. _institutionalrepository.aah.org_, 9 November

(accessed 6 February 2024). NATIONAL ORGAN DONATION COMMITTEE (nd) Moment of honour. _nhsbtdbe.blob.core.windows.net_ (accessed 6 February 2024).   HELP NURSING TIMES IMPROVE HELP US BETTER

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