It should be noted that this document is intended for patients at The Royal Children’s Hospital (RCH) only and other providers should kindly discuss their memento making with their relevant employer.

We would like to acknowledge the generosity of the RCH Foundation who have provided funding towards the supplies required to complete the mementoes cited in this guideline. It is thanks to their support that we can ensure equitable resources across the RCH for bereaved families.

Introduction

Nursing staff’s roles and responsibilities during bereavement varies throughout clinical areas. As healthcare professionals, we can assist in providing dignified and compassionate care to support families in creating lasting mementoes and memories. Providing staff with information on mementoes and memory making during end-of-life care will assist with consistent and comprehensive care to families who are experiencing bereavement.

Aim

• To create a standardised approach to memento and memory making, hospital wide
  
• All families of children with life limiting conditions and bereaved families are given the opportunity to create memories/mementoes.

Definition of terms

• Bereavement: A broad term referring to the objective experience of family members and friends in the anticipation, death and consequent adjustment to living following the death of a loved one.
  
• Mementoes: Mementoes are tangible symbols of the child’s life that help to evoke parents’ memories of a loved one, for example castings of foot and handprints, lock of hair, use of memory box and memory album, photography, jewellery and articles of clothing.
  
• Memory trolley: A trolley used to store all memory making equipment.

Management

Prior to commencing the memento making process always discuss with family and obtain and document verbal consent.

Please document what tangible mementos are created within the EMR ‘End of Life Checklist’ (found on the ‘resus tab’ of a patient profile). A tip sheet to finding this checklist can be found here. 

Please note that in a Coroner’s death seek permission to take ink prints or locks of hair from the Coronial Office on 1300 309 519.

For some cultures and religions, it is not common practice to take part in particular memory making processes. Please speak with the family and consider consulting with Pastoral and Spiritual Care staff, Interpreting Services or Wadja Aboriginal Family Place as appropriate.

In the circumstance where there is a death on the ward and staff would like support with creating the tangible mementoes, please call the Nursing Bed Manager who can arrange for nursing support to be provided from Rosella or Butterfly.

Memory Making Equipment

Memory Trolley

The hospital has three memory trolleys, located inside the Ground Floor and Lower Ground Floor Bereavement Suites and Butterfly.

Wards ideally should use the Lower Ground Floor Bereavement Suite trolley, for memento making. The ED AUM should be notified, and the trolley cleaned before return. Alternatively, if this trolley is unavailable, please access the Ground Floor Bereavement Suite trolley and notify the Rosella AUM or call Butterfly.

Please see the RCH policy and procedure: Bereavement Services at the Bedside Fund here for further information of accessing supplies if restocking is required.

All users are reminded to keep the trolley neat and tidy, so that the resource is easy to use when needed.

Memory Box

A supply of memory boxes is kept in the locked cupboards with the bereavement supplies on the Ground Floor outside the Bereavement Suite. Keys are located in Rosella, Butterfly, ED and PIPER. These boxes are assembled by folding the creases and using the adhesive pads, they do not need adhesive tape. Please ask for assistance if you are unsure of the assembling process.

This box may be filled with mementoes and whatever else the family wishes, including but not limited to:

• Memory album
• Hand and footprints
• Lock of hair
• Embossing prints
• Child’s teddy or favourite soft toy
• Favourite story book
• Arm bands
• Bed cards

Memory Album

A supply of memory albums is in the memory trolley and bereavement rooms. Extra stock is kept in the locked cupboards with the bereavement supplies on the Ground Floor outside the Bereavement Suite, keys are accessible from the Rosella, Butterfly and ED AUM. 

Discuss with the family how they may like to utilise the album. Suggestions are fill with photographs, a lock of hair, hand and/or footprints, bed card, arm bands, or messages and memories.

Consider if needing to provide two albums for parents who are separated.

Lock of hair

Ask the parents if they would like a lock of their child’s hair to keep. A lock of hair can be taken from underneath of the hair where it will not be missed (parents may advise where to cut or do this themselves). It is easiest to tie a ribbon around the hair prior to cutting and place in a velum envelope located in the memory trolley. 

Hand and foot prints – Embossing and Ink

Hand and footprints can be obtained utilising the embossing equipment located in the memory trolley. See Appendix 1 for instructions. A similar technique, using the colour ink stamps, may be used to create ink prints, without the need for the heating gun. 

Hand and footprints – Casting

Stone Casting is available for all children, which is a two-part process using alginate and casting stone. See Appendix 2 for instructions.

Casting can be used for hands and feet although for best results only hands are recommended for children over two years. For this reason, we will continue to stock a small amount of clay. Casts take 1-2 hours to dry-to-touch and 7 days to fully dry.

Some pre-portioned stock will be available on the memory trolleys with the excess alginate and casting stone stock kept on the Ground Floor in a cupboard outside the Bereavement Suite (a key to this cupboard is available from the ED, Rosella and Butterfly AUM).

Hand and footprints – Clay

Casting is the preferable method for prints; however, hand and footprints can also be obtained using clay, which is in the memory trolley. See Appendix 3 for instructions. The amount of pressure that is required for optimal results can be distressing for families to watch, it is important that you discuss this with your family. We recommend offering families to be involved with the embossing print process and offer to do the clay prints whilst the family get something to eat and drink.

Clay casts should be kept flat and can take up to one week to dry. Families should be encouraged to take prints home to avoid loss or damage in hospital environment. If this is not possible, please discuss with Social Work.

Precious Touch Jewellery

Precious Touch is an external commercial company specialising in creation of jewellery mementoes; a flyer is available on the three Memory Trolleys. Alternatively, family may wish to look at the website: www.precioustouch.com.au

The RCH Foundation is providing $250 per bereaved family towards a piece of precious touch jewellery through the RCH Bereavement Services at the Bedside Fund. The funding application (Provision of Service) form can be found here. Staff can offer this service to families at any time.

Instructions on how to take the print used for the jewellery can be found below. Please note the inkless towelette (Appendix 4) is best used for children under 3 months old and the putty (Appendix 5) instructions for all other children.

A copy of the Provision of service form should be filled out for every patient, a copy emailed to Precious Touch and then original sent with the prints in a self-addressed envelope. A copy of the form and the Australian Post tracking number should also be added onto the child’s media tab in EMR by taking a clinical photograph. This equipment can be found on the three Memory Trolleys.

Photography

Photographs can be taken before, during and/or after death. Creating professional photographs of a child prior to or after death is an important aspect of bereavement care for many families. However, do not offer photography services without first ensuring the provider is  available.

Photographs may be of the child and the child’s family. Photographs can be taken creatively to meet the needs of the family e.g. family portraits or child’s hand etc. Some families will decide that they do not want photos taken and their wishes should be respected.

Below are a list of photography services that can be offered.

Heartfelt have created a tip sheet on taking photos and are happy to assist in editing and processing of photos that are taken on the ward camera kits (also accessible from the Heartfelt.org.au website under Resources).

Four options are available:

1. Heartfelt photography

Heartfelt provides the gift of photographic memories to families in a caring, compassionate manner. All services are provided free of charge, which is provided by volunteer professional photographers.

Flyers can be found on Memory Trolley. Staff may contact Heartfelt on 1800 583 768, day or night.

Heartfelt photographers attend the RCH only at the request of staff and must be always accompanied by staff whilst inpatient areas.

Families will be provided with approximately twenty prints and a CD of all images for reprinting. Website: http://www.heartfelt.org.au/

2. Clinical Photography

Clinical Photography is provided to infants who have spent most of their lives in hospital and who have not had family photographs or portraits taken outside of hospital and when Heartfelt are not available.

Clinical Photography is only available during business hours and will consider exceptional requests by negotiation with the Social Work Department. Consent should be obtained using the RCH Consent to Clinical Photography form.

3. Families own camera

Many families who have their own camera/phone may wish to take photos; this should be supported. See below for photo tip sheet. 

4. Camera kit

Rosella and Butterfly have a camera kit, kindly donated by Heartfelt, for those families that do not have their own camera and do not wish to utilise the Heartfelt Photography professional photography service.

These kits must be returned to the departments after use. As stated above, Heartfelt have created a tip sheet on taking photos and are happy to assist in editing and processing of photos that are taken on the ward camera kits (also accessible from the Heartfelt.org.au website under Resources).

Angel Gowns

Angel gowns, small gowns made from wedding dresses, are available from the Ground Floor Bereavement Supplies Cupboard, outside the Ground Floor Bereavement Suite. 
Keys are available from Rosella, Butterfly and ED AUMs. These come in sizes XXS (Premature Baby) to XL (Approx 10kg) for both boys and girls. These gowns are kindly donated, and commonly used for blessings. Families may choose to keep the gown afterwards or keep the child dressed in it. Website: https://www.angelgownsaustralia.org.au/

Heartbeat recording Stethoscope

Heartbeat recording is offered to patients at end-of-life as a memory making experience, using a recordable stethoscope. Currently a referral may be made through the Music Therapy Department. The recording is provided by email or USB for the family to keep.

Cultural requirements

Families may wish to participate in religious ceremonies with their child, such as a baptism or blessing. If a family wishes to have their own religious leader present this can be facilitated. 
Please consult with Pastoral and Spiritual Care staff or Wadja Aboriginal Family Place if further clarification and/or assistance is required.

Special Considerations

Infection Control

RCH staff should note the following when making memorabilia, there is a small risk of organism transmission during making of mementos. For example, a patient who is colonised with high-risk organisms or MROs. All equipment (for example plastic tray, heat gun, embossing powder container and versa mark handle) is to be wiped with detergent and left in the room for the disinfectant.

Leave extra stock and the trolley outside the patient room.

Used equipment should be cleaned with detergent, and when required disinfected.

Consider during embossed prints:

• Antistatic cloth is used outside the room only and not taken into the patient.
• Only the equipment used for the embossing should be taken into the room and the powder and gun should only be handled by a second 'clean' staff member away from the patient and bed (that is. use a staff member not obtaining the foot/handprint).
• Consider during Precious touch fingerprints for a patient with a high-risk organism:

• Only the putty/towelette required is taken into the room (excess stock left outside clean)
• Once the print is taken, the putty will be placed and sealed in a plastic bag by the bedside nurse. The 'clean' nurse then stands outside the room with a second zip lock bag which the prints are carefully placed into and closed with an sticker over the entry point.
• It can still be sent to Precious Touch immediately however must have a label 'Infection risk’ on the outside of the bag with the date the prints were taken.
• All other equipment should be wiped and left in the room for the disinfectant.

Clay prints can also be taken with the clay rolled out outside patient room and put on hard cardboard with only the clay going into the room.

Casting stone prints may also be obtained – premeasured increments can be found on the memory trollies. Any excess stone or alginate must be discarded into clinical waste bag.

Heartfelt photography is available for infectious patients. Heartfelt will need to be notified the child is infectious. If transmission risk is likely in this circumstance, wipe all equipment with detergent, and equipment remains in the room for disinfection.  For example, suctioning was required during photography session for a patient colonised with MRO.

Companion Documents

• RCH Policies and Procedures
  • Specialist Bereavement Facilities
  • Death and Bereavement Care
  • Bereavement Services at the Bedside

Appendices

Please note the following images have been taken by RCH staff members.

Appendix 1: Hand and Foot Embossing

Equipment in the Memory Trolley, pre made cards in Memory Trolley.

Step 1: Assemble equipment

Step 2: Rub card with anti-static cloth

Step 3: Clean foot/hand with alcohol wipe

Step 4: Place a single-use pad onto the applicator tool (heart shaped with handle) and drop the clear Versamark gel onto the pad until it is covered.

Step 5: Stamp gel over inner hand or foot with gelled pad

Step 6: Put hand/foot onto card and press down all fingers/toes

Step 7: Sprinkle with embossing powder

Step 8: Shake off excess into tray and put back into pot

Step 9: Set with heat gun at least 20cm away from card until powder has melted

Step 10: Clean all equipment

Please use alcohol wipes to wash out tray, put lids tightly on powder and return all equipment back to memory trolley. 

Appendix 2: Casting

Hand and foot casts

Mould: Alginate (mint scented)

Casting stone:

Casting is ideal for baby’s hands and feet.  Foot casts are not recommended in children over 24 months as, we recommend hands or family hand casts in older children.

For the mould: Please NOTE the process of mixing to setting time is only about 1 minute. Therefore, you need to mix the Alginate at the bedside for one limb at a time.

Alginate Mould Ratios *Note you may need to double ratios if a larger container being used.

1. Ensure the patients hand or foot can fit in the container, deep enough to submerge the whole hand or foot without touching the bottom or sides of the container.
2. Measure the Alginate powder into the plastic container and measure the water in a separate container according to the above chart.

Volume for large hand see above table for other sizes.

3. Add measured water to powder and mix with a tongue depressor until combined (it will turn purple). Note: you only have about 45 seconds to do this before the mixture begins to start setting and change colour. Mix slowly until powder begins to combine, then much more rapidly to ensure a fairly smooth mixture.

4. Once mixed, place the hand/foot into the mixture immediately by initially dipping in and out then fully submerging the limb ensuring that it does not touch the sides or bottom. Hold it there until it slowly sets over 1-2 mins. The alginate will change from purple to pink as it starts to set, then white when it is fully set. Check that it has hardened by gently prodding the top. It should be firm and bouncy but not wet.

5. Once it has set, gently break the seal all the way around the base of the limb. Wriggle the limb and gently pull out. Rinse the inside of the mould out with water (ensure all water is drained out). The mould is now complete. Repeat process each time for each limb.

Once all moulds are complete, they are ready to be filled with the casting stone. This can be done away from the patient.

For casting stone:

Note: Be careful not to get this on your skin as it may cause irritation, wearing gloves is recommended. It is advised to also wear a surgical mask to avoid accidental inhalation of powder.

1. Measure Casting Stone and water according to above chart. Pour water into casting stone and mix until well combined, this should be a smooth mixture with no lumps.
2. Once combined, pour a small amount of the mixture into the mould (about ¼ full) and swirl it around getting it into all the fingers and toes. Then slowly fill the rest of the mould to the top (or as far up the wrist, arm, ankle or leg as desired, tapping mould on a hard surface as you fill to ensure air bubbles are released.)

3. Once full, moulds can be set aside to dry. This takes about 1-2 hours however, moulds can be gently opened after 45 mins if urgent.

4. Please DO NOT pour left over casting liquid down any drains. 

After the casts have set, the moulds can be removed from the containers. Gently break away the mould piece by piece to reveal the cast. Take extra care around fingers and toes as these can be delicate. Use some string or cotton tip stick to remove the small pieces of alginate between fingers, toes and creases. The casts are then ready to go home with families however, will continue to dry out over the next few days. Wrap the completed castings in bubble wrap and place in a box with tissue paper.

Examples

Appendix 3: Clay Moulds

Step 1: Assemble equipment.

Clay, Wooden board, cling wrap, knife, circle template to cut clay to desired size, clean hands/feet.

Step 2: Cover wooden board with cling wrap.

Step 3: Open clay and kneed to soften.

Step 4: Roll out clay evenly using rolling pin to a thickness of approximately 0.5cm no thinner.

Step 5: Ensure clay is smooth and has no bubbles.

Step 6: Use plate or circle template to cut out circle.

Step 7: Smooth cut edges with finger.

Step 8: Press foot or hand down into clay need to press firmly. May need two people.

Step 9: Lift clay board using cling wrap and place onto firm surface (ie. Cardboard). Takes approximately 1 week for clay to dry fully and turn white. Pack carefully for families to transport home.

Appendix 4: Precious Touch for under 3 months old (Inkless Towelette)

INSTRUCTIONS FOR OBTAINING A FOOT OR HAND PRINT USING THE DACTEK INKLESS TOWELETTE

PLEASE READ CAREFULLY BEFORE PROCEEDING

The Dactek disposable inkless towelette has been supplied to us from Precious touch Jewellery and is another way to provide a very detailed print of a child’s hand and feet. This can then be scanned and used by Gail to create jewellery and also given to the family as a keepsake.

This should be used on children less than 3 months as it is difficult to obtain a good fingerprint cast.

Important – paper is best to be placed on a flat hard surface such as a clip board or hard book when taking prints.  Only one side of the paper is coated in the special formula to enable you to take prints.  The best way to determine which side is the usable side, please open the wipe, smear a little on your own forefinger and thumb and pinch the corner of the paper to see which side shows the darkest print.  The darkest side is the usable side.

• Ensure that the child’s hand/foot is clean.
• Unfold the wipe completely after it is opened, and then re-fold it into half.  Ensure the skin is wiped very well with the inkless wipe provided.  The wipe will appear slightly dry (this is normal) – give the wipe a very good coverage over the skin.
• Apply the foot or hand directly on to the paper and press and hold for a second or two.
• The print will appear slowly in a few seconds
• The print will be fully developed within a couple of minutes. Please see handprint example below as a reference of a successful print.

Tips:

• One wipe can be used for numerous prints. This means that for one child you will only need to open one wipe.
• It may feel like there is not enough on the hand/foot as it feels quiet dry, this is normal but not much is needed to leave a print
• The paper and wipes are quiet expensive. Gail has provided this to us free of charge as part of her service, please use only as much as you need.
• Please don’t worry too much about smudging as this can be edited out in order to make the jewellery – just try to ensure that all fingers and toes are visible.

Appendix 5: Precious Touch for over 3 months old (Putty)

INSTRUCTIONS FOR OBTAINING A FINGERPRINT CAST

If the child is less than 3 months please use the Dactek inkless towelette as it is difficult to obtain a fingerprint cast.

Obtaining a fingerprint cast is a straightforward process.  However, please note that the putty supplied is only pliable when warm – please take all necessary precautions to ensure that you do not injure yourself when handling the heated putty. Please read these instructions all the way through before starting the process.  Please also note, that the process can be repeated as many times as necessary to obtain a satisfactory print so it is not a problem if you are unhappy with the first attempt.

1.  Immerse the putty in a cup of just boiled water for 1 minute

2.  Extract the putty from the just boiled water using a spoon or tongs to ensure that you do not burn yourself on the hot putty.

3.  Pat the putty dry with a clean tea towel and it should then be cool enough to handle.

4.  While the putty is still warm, and using a book or hard surface on which to press down,  press the finger firmly into the putty and hold for 30 seconds (or until the finger comes away easily from the putty which may take up to a minute and a half in warm, muggy conditions). 

5.  Carefully remove finger from the putty and set the putty aside on the hard surface to cool and harden.  It is important to leave the putty on the hard surface you have chosen as, if you try to remove it while the putty is still soft, a crease will form through the print.

6.  If you are not happy with the print you have obtained, you can re-do the print by re-submerging the putty in boiling water for a further minute removing as before, drying and rolling into a smooth ball between the palms of your hands.

Please note that the quality of the piece of jewellery is dependent on the quality of the print obtained - if you do not see a clear impression of the fingerprint in the putty when it has cooled, the putty can be immersed in hot water again and the process repeated.  For a successful cast, you are looking for a nice deep fingerprint impression, almost to the bottom of the putty and you should be able to see visible print lines and swirls when you hold the mold up to the light.  If you cannot see these, please repeat the process to avoid disappointment with the finished product.

Please return the cast in the envelope supplied together with the completed information sheet to Gail Johnson, Precious Touch Jewellery, 14 The Close, Beaumaris, Vic, 3193.

Any questions, please do not hesitate to call Gail Johnson on 0414604622. 

Please remember to read the disclaimer

The development and subsequent revisions of this nursing guideline was coordinated by Jess Rowe, CNS, PIPER, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2024.