March 15, 2011

The Last Hours of Living: Practical Advice for Clinicians: Pronouncing Death

Medscape - Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Jamie H. von Roenn, MD

7. Pronouncing Death

In teaching hospitals, medical students and residents are typically called to "pronounce" death.[58] In nonteaching settings, the attending physician or nursing staff may be the professionals to do this task. When a patient dies at home with hospice care, it is usually a nurse who confirms the absence of vital signs. Although local regulations differ, if an expected death occurs at home without hospice care and the patient has a physician or other clinician willing to sign a death certificate, then transportation to a hospital for a physician to confirm death may not be needed.

The telephone call.
The process often begins with a telephone call: "Please come; I think the patient has died." Begin by asking a few key questions:
  • Find out the circumstances of the death -- expected or sudden?
  • Is the family present?
  • What is the patient's age?
Before entering the room.
  • Confirm the details on the circumstances of death with other health professionals or caregivers. Review the chart for important medical (length of illness, cause of death) and family issues. (Who is family? What faith? Is there a clergy contact?)
  • Find out who has been called. Other physicians, nurse practitioner or physician's assistant? The attending physician?
  • Has an autopsy been requested? Do you see a value in requesting an autopsy?
  • Has the subject of organ donation been broached? Has the Organ Donor Network been contacted?
In the room.
  • You may want to ask the nurse, social worker or chaplain to accompany you; he/she can give you support and introduce you to the family.
  • Introduce yourself (including your relationship to the patient) to the family if they are present. Ask each person their name and relationship to the patient. Shake hands with each.
  • Say something empathic: "I'm sorry for your loss..." or "This must be very difficult for you..."
  • Explain what you are there to do. Tell the family they are welcome to stay, if they wish, while you examine their loved one.
  • Ask the family if they have any questions. If you cannot answer, contact someone who can.
The pronouncement of death.
  • Identify the patient. Use the hospital ID tag if available. Note the general appearance of the body.
  • Test for response to verbal or tactile stimuli. Overtly painful stimuli are not required. Nipple or testicle twisting, or deep sternal pressure, are inappropriate and unnecessary.
  • Listen for the absence of heart sounds; feel for the absence of carotid pulse.
  • Look and listen for the absence of spontaneous respirations.
  • Record the position of the pupils and the absence of pupillary light reflex.
  • Record the time at which your assessment was completed.
Documentation in the medical record.
  • Note that you were called to pronounce the death of (name); chart findings of physical examination.
  • Note date and time of death; distinguish the time family or others noted death from the time you confirmed the absence of vital signs. Note whether family and attending physician were notified.
  • Document whether family declines or accepts autopsy; document whether the coroner was notified.
Telephone Notification

There will be situations in which the people who need to know about the death are not present.[59-63] In some cases, you may choose to tell someone by telephone that the patient's condition has "changed," and wait for them to come to the bedside in order to tell the news. Factors to consider in weighing whether to break the news over the telephone include: whether death was expected, what the anticipated emotional reaction of the person may be, whether the person is alone, whether the person is able to understand, how far away the person is, the availability of transportation for the person, and the time of day (or night). Inevitably, there are times when notification of death by telephone is unavoidable. If this is anticipated, prepare for it. Determine who should be called and in what fashion. Some families will prefer not to be awakened at night if there is an expected death.

Get the setting right. Determine the facts before you call. Find a quiet or private area with a telephone. Identify yourself and ask the identity of the person to whom you are talking and their relationship to the patient. Ask to speak to the person closest to the patient (ideally, the healthcare proxy or the contact person indicated in the chart). Avoid responding to direct questions until you have verified the identity of the person to whom you are speaking. Ask whether the contact person is alone. Do not give death notification to minor children.

Ask what the person understands. Ask what the person understands about the patient's condition with a phrase like, "What have you been told about M's condition?"

Provide a "warning shot." One approach may be to begin with a sentence such as "I'm afraid I have some bad news."

Tell the news. Use clear, direct language without jargon. For example, you could say, "I'm sorry to have to give you this news, but M just died." Avoid words like "expired," "passed away," and "passed on." They are easily misinterpreted.

Respond to emotions with empathy Most importantly, listen quietly to the person and allow enough time for the information to sink in. Elicit questions with a phrase like, "What questions do you have?" Ascertain what support the person has. Ask if you can contact anyone for them. Consider other support through the person's church, Red Cross, local police, or other service agencies if it is needed.

Conclude with a plan. If the family chooses to come to see the body, arrange to meet them personally. Provide contact information for the physician, nurse, or other professional who can meet with them and/or make arrangements.

Immediately after the death, those who survive will need time to recover. A bereavement card from the physician, nurse, or healthcare professional and attendance at the patient's funeral may be appropriate.[64] Many members of the professional team consider it a part of their professional duty of care to encourage follow-up visits from bereaved family members in order to assess the severity of their grief reactions and the effectiveness of their coping strategies, and to provide emotional support. Professional members of the interdisciplinary team can also offer to assist family members in dealing with outstanding practical matters, such as helping to secure documents necessary to redeem insurance, find legal counsel to execute the will and close the estate, find resources to meet financial obligations, etc. Bereavement care for the family is a standard part of hospice care in the United States.

REFERENCES
58. Weissman DE, Heidenreich CA. Fast Facts and Concepts #4: Death Pronouncement in the Hospital. Milwaukee, Wi: End of Life Physician Education Resource Center. Available at: http://www.eperc.mcw.edu/ff_index.htm. Accessed August 1, 2006.
59. Osias RR, Pomerantz DH, Brensilver JM. Fast Facts and Concepts #76 and Telephone Notification of Death. Milwaukee, Wi: End of Life Physician Education Resource Center. Available at: http://www.eperc.mcw.edu/ff_index.htm. Accessed August 1, 2006.
60. Marchand LR, Kushner KP. Death pronouncement: survival tips for residents. Am Fam Physician. 1998;58:284-285. Abstract
61. Magrane BP, Gilliland MG, King DE. Certification of death by family physicians. Am Fam Physician. 1997;56:1433-1438. Abstract
62. Iserson KV. The gravest words: sudden death notification and emergency care. Ann Emerg Med. 2000;36:75-77. Abstract
63. Iserson KV. The gravest words: notifying survivors about sudden unexpected deaths. Resident Staff Physician. 2001;47:66-72.
64. Irvine P. The attending at the funeral. N Engl J Med. 1985;312:1704-1705. Abstract

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