Death and Pronouncement

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Pronouncing death is not technically difficult but can be emotionally taxing and intense. The deceased and the bereaved both ought to be treated with dignity and respect. When performed with reverence, the ritual of pronouncement can provide comfort, granting permission to mourn for the bereaved, and also reassuring an end to whatever suffering endured in the course of illness or life.

Protocol and Procedure

Know Before You Go

  • In general, exercise restraint. Respect privacy. Avoid overly invasive examination.
  • Maintain appropriate reverence and composure. If lacking confidence that this is possible, ask someone else to perform in your place.
  • If you are not familiar with the patient or family, recognize that passions and tension may be high. Potential for conflict or argument may equally be high. Know and review the current state of affairs with nursing or support staff before entering. Family may not wish to be present during pronouncement.
  • Individuals and cultures can express grief in many ways. Respect the beliefs and practices of the patient and the bereaved.
  • Respect the religious and spiritual beliefs of the patient and the bereaved.
  • If conflict arises interfering with patient care and/or medical staff, call for security and hospital administration as necessary.

Examination

  • Introduce yourself. No need to greet everyone in attendance individually.
  • Observe telemetry if available. Asystole is not a requirement. Electrical activity can frequently persist after death for some time.
  • It is unnecessary to shout at or shake the patient to confirm unresponsiveness.
  • Confirm absence of spontaneous breathing and chest rise. On rare occasions, this may take several minutes.
  • It is reasonable to palpate for a peripheral, carotid, and/or precordial pulse. Femoral pulse is usually unnecessary.
  • Perform a standard cardiac auscultation and confirm absence of heart sounds.
  • It is reasonable to auscultate the apical lung fields anteriorly to confirm absent breath sounds.
  • It is usually unnecessary to assess pupillary response. Avoid if patient's eyes have already closed spontaneously.
  • Avoid testing of noxious stimuli such as sternal rub or fingernail pinch.
  • Patient's eyes and/or jaw may remain open. If this is the case, avoid manual manipulation, as it is highly likely they will remain open despite attempts to close.

Postmortem

  • Do not discuss or offer autopsy without clarifying with attending.
  • Absolutely notify the primary attending as soon as possible. If unavailable notify the hospitalist or nocturnist on call. This is important because there are time constraints for completing the death certificate.
  • If pronouncing at night, notify the nocturnist. News of the death is also typically passed in the morning email. Primary attending can then be notified by phone before leaving in the morning.
  • Notify next of kin if none are present at time of death.
  • Offer condolences as appropriate. "I am sorry for your loss" is a simple and standard expression.
  • Offer chaplin/spiritual services if appropriate.
  • It may be appropriate to provide initial grief counseling. Avoid an extended or prolonged encounter.
  • Call for a bereavement cart if not ordered.
  • Clarify time and preliminary cause of death with nursing. No need to overly scrutinize a precise time of death.
  • Charge nurse or house supervisor generally help to contact the funeral home and release the body. There should be no discharge orders to complete.
  • If funeral arrangements have not been decided or if the patient needs an autopsy, body will be kept in the hospital morgue.
  • Primary team/resident are responsible for writing the death summary. A death summary is nearly the same as a discharge summary. Disposition is listed as "deceased" or "expired". Cause and time of death should be in the hospital course or listed separately. For reasons that should be obvious, do not include a discharge exam or discharge medications.

Sample Note

SIGNIFICANT EVENT

Requested to see patient for unresponsiveness. Monitor reads asystole. At bedside the patient is not responsive to verbal or physical stimuli. Absent spontaneous respiratory effort. Absent heart and breath sounds on auscultation. Absent central and precordial pulse on palpation. Pupils fixed and dilated. Patient pronounced. Time of death is @NOW@ @TD@. Preliminary cause of death is ___.

Family present at bedside. Attending physician, @ATTPROV@, notified.

Autopsy

Texas law regarding autopsy and examination of the deceased is outlined in Article 49 of the CODE OF CRIMINAL PROCEDURE (CCP 49). Deaths that may require medical examiner investigation and possible autopsy include:

  • A body was found and the cause and circumstances of the death are unknown.
  • The death occurred in prison or in jail.
  • The death occurred without medical attendance.
  • The death is believed to be an unnatural death from a cause other than a legal execution (accident, suicide, or homicide).
  • The physician is unable to certify the cause of death.
  • The deceased is under six (6) years of age.
  • The death occurred within 24 hours of admission to a Hospital

Insurance is for the living, and as such, autopsies are not covered by insurance, Medicare, or Medicaid. Autopsy can cost several thousands of dollars. The hospital will generally pay for an autopsy if death occurs within 24 hours of admission, but each case should be reviewed individually with risk management. Next of kin may otherwise request an autopsy, but should understand it will likely come out of pocket. Autopsy may take several weeks to complete before all results return and body can be released for funeral.

Protected Health Information and the Deceased

HIPAA protects the health information of a decedent for 50 years following the date of death of the individual. During the 50-year period of protection, the person under applicable law with authority to act on behalf of the decedent or decedent's estate has the ability to exercise rights with regard to the decedent’s health information, such as authorizing certain uses and disclosures of, and gaining access to, the information. HIPAA permits disclosure of relevant protected health information of the decedent to family members or staff involved in the patient's care or payment for care prior to death.

Permitted disclosures of a decedent's health information may include:

  1. Law enforcement when there is a suspicion that death resulted from criminal conduct.
  2. Coroners or medical examiners and funeral directors
  3. Research that is solely on the protected health information of decedents
  4. Organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the purpose of facilitating organ, eye, or tissue donation and transplantation.
  5. Family member, or other person who was involved in the individual’s health care or payment for care prior to the individual’s death, unless doing so is inconsistent with any prior expressed preference of the deceased individual that is known to the covered entity. This may include disclosures to spouses, parents, children, domestic partners, other relatives, or friends of the decedent, provided the information disclosed is limited to that which is relevant to the person’s involvement in the decedent’s care or payment for care.

Resources

Stanford Palliative Care guide
NYT Article on pronouncing death
Texas Code of Criminal Procedure