You will have patients that die. There is a specific physical exam you need to perform in order to verify this. The conversation you have when you break the news to family contains specific information and questions. Following these events, there is a specific death note you must write. We’re here to walk you through each of these.
In speaking with Dr. Jason Green, DO a Pulmonary and Critical Care fellow, he offers a few reminders before beginning the process of declaring someone dead, telling the family, and documenting properly. When pronouncing someone dead, the most time is spent gathering information, preparing for the conversation with family and questions they may have, and then documenting the death of the patient. The actual physical exam and conversation with family are fairly brief.
First step when being asked to pronounce someone is to determine the patient’s location, and if it’s urgent. Speak with nursing staff, RT, and everyone involved in the patient’s care to learn what happened before going to see and examine the patient as the family may be present during your exam. If you were caring for the patient, this step is easier, but still seek updates from nursing and other staff. In the middle of the night, you’ll be called to pronounce someone dead that you’ve never met prior.
Determine if the death was expected or unexpected as these are two different conversations with family. Did they know this was coming? You’ll want to find out if organ donation is a possibility and if it’s been discussed with the family prior. Also determine who the appropriate person is to notify in this situation. You are to have one, at most two talks, and you’ll likely not have time to keep repeating the same story. Now would be a good time to notify the attending.
Now, let’s walk through the physical exam.
- Verify the identify of the patient via their wristband.
- Their pupils should be fixed and dilated – that is, showing no responsiveness to light and remaining fully open.
- They should not have a blink reflex when something brushes against the cornea of the eye.
- They should have no heart sounds for one minute of listening.
- Pulse should be absent when checking the carotid.
- They should have no breath sounds, and no other evidence of breathing.
- They should be unresponsive to deep painful stimuli (e.g., pushing down sharply and rubbing the sternum – the middle of the chest).
- Especially if they have been brought from somewhere else rather than dying in the hospital, they are “not dead until they are warm and dead”, because hypothermia can mimic death by slowing down and dampening down all bodily functions.
- Announce the time of death, say it like this, “Time of death: eleven fifteen pm.”
- If family is not present, now would be the time to remove tubes and lines, and clean up the patient before family sees them.
Speaking with Family
You need to identify yourself clearly, “My name is Dr. _____, I am here/calling to inform you that Mr. First Name Last Name has died. I am very sorry for your loss.” Use very clear, concise language, and be direct and say “he died” instead of “passed away” or “He’s gone to be with God” or any terms that would not convey precisely what has happened. Use definitive terms so there’s no ambiguity.
At this point, offer to contact pastoral care and try to understand their faith needs. This is a good time when consulting chaplaincy is very helpful.
After you’ve delivered the news to a family of a deceased loved one, you’re supporting them. Tell them “Please let me know if there’s anything else I can do.” If you have pronounced, you must offer an autopsy, but most people decline. If they’re relying on benefits like in black lung, they’ll say yes because they need proof to get the benefits.
Next, offer family time to spend with their loved one, one last time. Nursing will come and assess what plans are (funeral home, etc.), and if they cannot, social workers can come to figure this out.
Always notify your attending and primary team via nursing who’s caring for them. The primary team will do the discharge summary. Also, now would be the time to contact the coroner if the patient was in the hospital less than 24 hours, the circumstances were unusual, or if the death was related to trauma. Every trauma death must go through the coroner.
Dr. Daniela Lamas, MD wrote an article in The New York Times we feel you might connect with about pronouncing someone dead.
The Death Note
- Date and time of pronouncement – this will be the official time of death that you list, so try not to delay too much.
- Name of provider pronouncing death.
- Brief statement of cause of death.
- Note physical exam findings of absence of pulse, respiration, pupil response, etc.
- Note if family present or informed.
- Note family response if indicated.
- Note notification of attending, pastoral care, social work, coroner or others as appropriate.
- Note if family accepts or declines autopsy.
- Be sure to sign the note as either MD or DO, because a physician is the only person who can pronounce someone dead.
- Locate sample death certificate on unit.
- Complete marked sections. Write neatly in black ink. It will not be accepted otherwise.
- Begin again if you make an error (cross-outs not allowed).
- List the cause of death.
– Primary and Secondary
– Primary: pneumonia
– Secondary: advanced Alzheimer’s dementia
- Fill out the contributing but not primary section.
– List other illnesses possibly linked to patient’s disability or service-connection (e.g., Agent Orange, asbestosis).
– This documentation assists family to obtain benefits.
May your words be kind, gestures gentle, and compassion at the peak of your emotional capacity as a human when talking with families in these moments.