Dealing with Death & Dying in Medical Education and Practice
© 2001 Kirsti A. Dyer, MD, MS Email:griefdoc@kirstimd.com
AMSA Convention March 30, 2001
Declaring Patient Death

Patient found unresponsive
Begin CPR immediately if there is any uncertainty about patientís DNR status or if you are not sure how to verify death. 

Death of a DNR patient or unsuccessful CPR

  • Check for absence of respiration, femoral and carotid pulse, and pupillary reflexes. Once these are confirmed to be absent, death is pronounced. Note the exact time, e.g. 7:02, and confirm the time with the nurse.
  • Inform the resident of the death.
  • Write a brief death note on the progress sheets to document the circumstances of the death (see sample below). 
  • Contact the next of kin ASAP (never leave a message on an answering machine!) and inform him/her of the death. If you cannot reach the next of kin, call the Admitting Office and arrange for a telegram. Include in your note the name of the family member you spoke to or the name of the person in Admitting who was to arrange the telegram.
  • Always ask for an autopsy but only the next of kin can give permission, not (in NY) a common-law spouse or a friend. If the next of kin is reluctant, ask for a partial autopsy, an abdominal incision for inspection without organ removal, or for isolated organ biopsies. If no one claims the body, autopsy can be authorized by the hospital. 
  • Sign the death certificate as soon as possible after you are called to Decedent Affairs. Donít sign if you are still trying to get an autopsy.  
  • Write a death summary within 24 hours, similar to a transfer summary.   
Sample Death Note
Patient is a 78-year old woman, with metastatic breast cancer, in the hospital for palliative therapy. She was found unresponsive by a nurse at 7AM. Respirations, femoral and carotid pulses and pupillary reflexes were all absent. In accordance with DNR order, no CPR was initiated. She was pronounced dead at 7:12 AM. The patientís husband, John Smith, was notified of the death. He will come to the hospital to sign consent for autopsy.
 
 Tips on death notification
  • Review the chart enough to answer likely questions from the family. Figure out if the death was expected or not. If completely unexpected, get help with notification.
  • Identify yourself as Dr. X from hospital Y.
  • Ask for next of kin by name or relationship, e.g. "Iíd like to speak to Mrs. Smithís husband, please.
  • Verify the relationship before you begin. "Iím calling about Mrs. Mary Smith who is a patient at hospital Y. Is this the right number?"
  • Think before you speak. A family member may remember this conversation for the rest of his/her life. How you deilver the news can impact their grieving and recovery process.
  • Fire a "warning shot" before you deliver the news: "Iím very sorry to disturb you at this time of night, particularly with the kind of news I have" or "Iím very sorry to say that I have some bad news to give you."
  • Speak slowly and say the words "has died" clearly and distinctly.  Repeat the message another time and give the exact time. "Iím sorry to tell you that your wife, Mrs. Smith, has died. She died at 7:05 this morning."
  • If you were present: "I was with her when she died. She died very peacefully and she was not in any pain" or "I was there when she died. It was very sudden and she did not have any pain or distress."
  • If patient was found dead by a nurse: "The nurse called me immediately and it was clear to me that she died quietly in her sleep."    
  • Pause for the personís reaction. Try to identify (to yourself) the emotion the person is exhibiting, e.g. anger or sadness, and try for an empathic response: "I know this is terribly sad for you and your family" or "You sound very angry and I can certainly understand that." Answer questions as calmly as you can. Do not argue or contradict. 
  • Ask if he/she would like to come to the hospital to speak to someone in person.
  • Ask for an autopsy last Ė preferably in person.  
Source      
© June 2000, Internís Handbook, Jeanne Macrae, MD. SUNY Downstate Medical Center. Available from: EPERC (End-of-Life Physician Education Resource Center)  www.eperc.mcw.edu.

Compilation of resources for this presentation and Website © 2001 Kirsti A. Dyer, MD, MS.
Journey of Hearts, www.journeyofhearts.org