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
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
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
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
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.
© 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.