The Death Pronouncement

The Death Pronouncement – Michael J. Neuss

This scenario arises in a variety of contexts, including the units, wards, and cross-cover. You might know the patient and family well, but particularly when cross covering, that may not be the case

This approach to the death pronouncement is based in part on the AAFP’s “Death Pronouncement: Survival Tips for Residents” (Am Fam Physician. 1998 Jul 1;58(1):284-285.)

 

Before Entering:

  • Familiarize yourself with the most important points of the patient’s hospitalization; it is ok to take a moment to read about the patient’s course and inquire about the day’s events with the patient’s nurse or other staff.
  • Inquire as to which family is present prior to entering, including whether the POA is currently at bedside.
  • Be aware of the circumstances of the patient’s death, particularly whether death was expected or sudden.
  • In general, it is best to enter accompanied, ideally with the patient’s nurse. It is rare for the chaplain to be present but that might also be a consideration.
  • Inquire with the nurse if Tennessee Donor Services (TDS) has been notified; often, when death is anticipated, the nurse will already have done this, although that is not always the case. Remember that it is not your position/role to approach the family regarding organ donation, but TDS should have been notified and there should be a case number, which in Epic you will have to document.

 

In The Room:

  • Especially when cross-covering, make sure to introduce yourself to family, and allow them time to introduce themselves to you.
  • Less is more when it comes to what you say: it can be good to be empathetic (consider only short statements such as “I am sorry for your loss”) but focus mainly on the task at hand, allowing time for families to be present with their loved one.
  • Explain that you have been called to examine the patient to confirm that they have passed. Allow a brief time for questions; it is rare (but not impossible) that someone may wish to excuse themselves for the pronouncement, and although I do not commonly inquire if family would like to be present, this is a consideration.
  • Note the location of a working clock when you enter; your watch is ok too but do make sure to avoid looking at your smartphone to check the time of death.

 

The Exam And Pronouncement: 

  • Identify the patient by wrist band.
  • Note general appearance.
  • Confirm that the patient does not respond to stimuli; one discreet way to confirm a lack of response to tactile stimuli is to hold the hand, and apply pressure to a nailbed, appearing to hold the hand while looking at/visually inspecting the face or other part of the body. You should avoid any obvious painful stimuli, out of respect for the deceased as well as out of deference to family who may be present.
  • Confirm the absence of spontaneous respirations.
  • Confirm the absence of heart sounds.
  • Examine the pupils and note the absence of pupillary light reflex.
  • Note the time at which your examination is completed. This is the time of death. It is ok (although not required; this is merely a consideration) to speak the time of death quietly and respectfully, for the family’s reference as well as staff’s.
  • Make sure to ask for an autopsy. This is often overlooked, and as awkward as it might feel to ask for this, it is a requirement and asking later (if overlooked) feels more awkward.
  • Often phrased as something that must always be offered to all families, but not often requested by families of patients.
  • Make sure you have notified the attending of record

 

*Please see further VA- and VUMC-specific guidance below.

 

 

Death Process at the VA

Nurse will notify physician at time of death for pronouncement.

THEN:

 

Physician will arrive to pronounce patient’s death within 1 hour of notification by nursing staff.

THEN:

 

Physician to examine patient and pronounce death—offering family chaplain support and informing family of death. Chaplain is notified by calling the Administrative officer on duty (AOD).  Physician informs nursing staff of time of death so that they can call TN donor services.

THEN:

 

Physicians at time of pronouncement will ask family regarding the request for autopsy. VA pays for the autopsy and this is provided as a benefit to the family if desired.  Family can decline this benefit.  Physician should document if the family agreed to or declined the autopsy benefit.

THEN:

 

Death note is documented in CPRS by physician pronouncing death using the template provided to house staff.  Death note documents the time of death, cause of death, family notified, and autopsy request with family response to the autopsy request.

THEN:

 

Physician pronouncing death will complete additional death report paperwork which includes the cause of death.  This death paperwork is provided to the physician by the charge nurse or clerk and is available at the nursing station.  Once completed, this paperwork is returned to the nursing staff.

THEN:

 

Nursing staff notifies TN donor services.  Nursing staff contacts the VA decedent affairs clerk during business hours.  Nursing staff may contact the AOD instead of the decedent affairs clerk if the death occurs after hours or on weekends.  The decedent affairs clerk or AOD provides information to family regarding veteran death and funeral benefits.

THEN:

 

The body of the patient is removed from the room within 4 hours of death and taken to the morgue to await transfer to the families’ choice of funeral homes

 

 

 

 

Death Process in EPIC

  • The key thing is to ensure that all components are completed in the “Discharge as Deceased” tab under the Transfer-Discharge screen
  • EACH AND EVERY component of this tab must be completed before Decedent Affairs will accept the body

 

Required steps:

  • Cardiopulmonary Death Charting Select “New Reading” and complete.
  • Cardiopulmonary Death Select “+Create Note”
  • Medical Examiner Criteria Select “+New Reading”; note that in general deaths that we expect and have an established medical cause generally do not need to go to the Medical Examiner (ME). If there is any concern for harm, foul play, drug overdose, etc, have a low threshold to contact the ME. The Vanderbilt Operator can assist with connecting you to the ME; alternatively, you can call 615-743-1800 during business hours (M-F 8am – 4:30pm) or the after-hours pager at 800-216-0107.
  • Autopsy Criteria Select “+New Reading”
  • Preliminary Cause of Death and Date/Time of Death Select the ribbon at the top of this and enter a cause of death. Rather than list “Cardiopulmonary arrest” do try to be specific (eg Pulmonary Embolism, Myocardial Infarction, Metastatic Colon Cancer, etc) if you know the underlying cause of death.
  • Deceased’s Info – Report of Death. This will ask many questions.
    • If you need to leave this and return later after collecting information, you can access your partially complete entries by clicking on the date/time text that appears under the ribbon. This is not intuitive because the numbers listing the date/time do not at all appear as though they act like a hyperlink (but they do).
    • Be specific; TDS will want you to have listed the name of the family you notified, the TDS Case Number (which the RN should have or can assist in collecting), and your attending physician’s name (to sign the death certificate; give their pager number in this subsection).
  • Report of Death Note Select “+New Reading” and complete.
  • Complete Synopsis + Hospital Course and then at the very bottom under Summary of Death select “+Create Note.”
  • Once all of this paperwork is finished, be sure to touch base with the patient’s nurse, as s/he is often the contact for Decedent Affairs and can assist in making sure the body is moved expeditiously