Approach to inpatient death

Context

As an inpatient physician, you will be called to “pronounce” a patient’s death. It is important to make sure that there is notification to the appropriate parties and clear documentation.

Application

  • Things to think about before entering the room:
  • Was the death expected or unexpected? Is family present?
  • Are there unusual family dynamics that you should address with the attending prior to entering the room?
  • If the family is present, inform them of what you are doing and ask if they would like to be present for the examination. Offer empathic statements, e.g. “I’m sorry for your loss.”
  • Ask the family if they would like to speak with a chaplain.
  • Ask the family if they would like to request or decline an autopsy.
  • How to pronounce a death:
  • Identify the patient by ID tag
  • Assess for response to tactile or verbal stimuli (avoid overtly painful stimuli, particularly in the presence of family).
  • Listen for absence of heart sounds and feel for the absence of a carotid pulse for a minimum of 60 seconds.
  • Look and listen for the absence of spontaneous respirations for a minimum of 30 seconds.
  • Record the position of the pupils and the absence of a pupillary light reflex.
  • After finishing the above, read the time of death aloud off the wall clock.
  • Who to notify: the phone numbers and appropriate forms for the Organ Donor Network and Medical Examiner are part of the “death packet” to be filled for each patient.
  • The attending physician
  • Organ Donor Network (all deaths must be reported. Organ donation should not be discussed with the family; this will be handled by the Network)
  • Medical Examiner (not all deaths need to be reported to the medical examiner – review indications in the death packet; better to call if any doubt exists. Remember to get the badge number of the person spoken to)
  • A death note must be documented in the chart. Below is a sample of information that should be included:

Called at _____ by _____ to pronounce _____. On exam, no heart sounds or breath sounds were noted after 1 minute of auscultation. Pupils were fixed and dilated without pupillary light reflex.  Patient was pronounced dead on --/--/---- at --:--.  Attending Dr._____ was notified. Family _____ was present/notified by phone and condolences were offered.  The organ donor network was notified and the case was accepted/declined.  The case was/was not reportable to medical examiner. Autopsy was requested/declined.

  • Discharge summary and condolence cards can be deferred to the primary team.

Marchand LR, Kushner KP. Death Pronouncement: survival tips for residents. American Family Physician. July 1998.

Marshall SA, Ruedy J. On Call: Principles and protocols. 4th Ed. Philadelphia, PA: Saunders; 2004.