Clinical Notes : Medico-Legal

170. Death Pronouncement

 

Setting

The act of pronouncing death is recognized as a profound moment for families.

The memories of how the death pronouncement occurred have been recognized as a factor in bereavement and also as a sacred moment.

In the OOH setting, the circumstances for death pronouncement vary :

  • the pronouncing doctor may :

    • be known or unknown to the family

    • know or have previously treated the deceased or not

  • the pronouncement may be :

    • a relatively straightforward procedure in a nursing home when the death is expected and the family is not present

    • conducted in a location where the family is present

    • requested for an expected passing, which may have been more or less traumatic for the deceased and the family 

    • requested for an unexpected passing, which may be from natural or unnatural causes

 

 

Prior to attending

Be familiar with details : (Usually provided by triage. if not provided by Triage, call to obtain the information) 

 

  • patient's location

 

  • if the family is present

 

  • patient's age

 

  • circumstances of the death (expected or sudden)

 

  • degree of urgency

    • anxios/upset family requesting speedy attendance

    • medics or garda at scene awaiting ponouncement

 

On arrival

 

  • If wearing headgear or gloves on journey there, remove them before entering

 

  • Introduce yourself to the family.

 

  • Be alert to their initial reaction (actively grieving, anxious, composed ...).

 

  • Empathetic statements are appropriate,

    • for example, say, “I'm sorry for your loss . . .” or “This must be very hard for you.”

    • but do not overpersonalize them. Avoid saying, “I know what you are going through.” or “He's with God now.”

    • try not to say too much; this is a time to be quiet and comforting.

 

  • Touching or hugging a family member may be appropriate.

  • Explain the pronouncement to the family;

    • For example say "I am here to pronounce the passing.

      • "The family GP will provide a certificate later" (expected passing)

      • "The coroner will provide a certificate later (unexpected passing)

 

  • Ask the family if they wish to be present.

    • For example say "I need to briefly examine (name). You may be present if you prefer"

The pronouncement

 

  • Identify the patient

    • for example, ask "this is (name)"

 

  • Confirm death

    • Rigor mortis is most often self evident (a few hours after passing)

    • If incertain (recent passing)

      • lack of central pulse, breath sounds, and heartbeat will usually suffice

        • auscultation for a minimum 2 to 3 minutes is recommended when body is still warm

      • avoid unnecessary practces such as “assessing for pain” with a sternal rub

      • if checking for pupillary light reflex, use a pocket torch. Never use the light from a mobile phone.

 

  • Depart the room quietly

On departure

 

  • Make an entry in the patient's folder where one is available (nursing homes, palliative care at residence)

    • Date

    • Expected / unexpected passing

    • Pronounced at (time)

    • Signature, Name in print,  Medical Registration Number

 

  • Ask if family present have any immediate need or questions.

Managing Specific Pronouncement Scenarios

 

  • Death of a child with a parent present

    • Be compassionate, humble and comforting in your verbal and nonverbal behavior.

    • Sit down if the parents are sitting down.

    • Use few words and be comfortable with silence and just “being there” for parents.​

    • Examine the child in the parents' arms if they are holding the child.

  • Unexpected death with family present

    • Be compassionate and comforting in your verbal and nonverbal behavior

    • Gather the family together and ask if they have any further questions or concerns.

    • Do not to become defensive if questioned.

    • Defer to attending any questions you cannot answer.

    • Let the family know that the coroner will be notified if circumstances warrant.

      • it is the Coroner's decision if to autopsy in cases of unnatural cause of deaths 

      • the GP may arrange to avoid autopsy by consulting the Coroner in cases of natural death

  • Attendance at scene of failed resuscitation by ambulance paramedics

    • The OOH doctor may be called by garda or ambulance service to attend the scene where paramedics have attempted resuscitation for some time and have not yet called an end to a failed resucitation.

      • Note that the GP is not obliged to call off a resuscitation process which he/she did not start and/or was not involved in.

        • It is the responsibility of the paramedic in charge to call off the resuscitation.

        • It is then the responsibility of the doctor to pronounce.

    • Obtain the names of paramedics in attendance and where based

    • Obtain brief details of resuscitation efforts

  • Attendance at scene of suicide or crime

    • Obtain the names of paramedics and garda in attendance and where based

    • Obtain brief details of apparent events

    • Obtain brief details of resuscitation efforts

    • Note possible forensic details at the scene 

  • Pronouncement of Expected Death by a Registered Nurse: National Policy

    • The National Policy for Pronouncement of Expected Death by Registered Nurses (For use in HSE residential, HSE long-stay and HSE specialist palliative care services only) was published in July 2017

    • Nurses who pronounce must have completed the Pronouncement of Expected Death CPD Educational Program

    • The patient's GP must have previously signed an Advanced Agreement for nurse pronouncement

    • The nurse's protocol requires the nurse to contact the patient's GP by telephone, or face-to-face meeting, before removal of the body to the care of the funeral director. This contact affords the doctor the opportunity to examine the body if desired

    • Where the patient's attending doctor is not immediately available, an OOH doctor is asked to independently pronounce

    • A specific form is available for nurses to complete and requires no input from the patient's GP or the OOH GP

Back at OOH tretment center

 

  • Document in the patient's record :

    • circumstances of the death (expected or sudden)

    • family present / absent

      • family's state of mind

      • family's questions asked and answers

    • means of determining death 

    • details of specific pronouncement scenarios (as above)

    • time of pronouncement (ensure concordance if entered in patients folder on departure)

 

  • Take time to compose yourself if the experience was upsetting for you

 

  • Review the case with a colleague if it presented unexpected or unfamiliar aspects 

 
 
 
 
 

Code of Practice for the Diagnosis and Confirmation of Death

Academy of Medical Royal Colleges

2008

Access

 

Kusakabe, A., Naito, A.S., Hirano, K. et al.

Death pronouncements: recommendations based on a survey of bereaved family members.

J Palliat Med. 2016; 19: 646–651

Access

Hallenbeck, J.

Palliative care in the final days of life: “they were expecting it at any time”.

JAMA. 2005; 293: 2265–2271

Access

Janzen, L., Cadell, S., and Westhues, A.

From death notification through the funeral: bereaved parents' experiences and their advice to professionals.

Omega-J Death Dying. 2004; 48: 149–164

Access

National Policy for Pronouncement of Expected Death by Registered Nurses (For use in HSE residential, HSE long-stay and HSE specialist palliative care services only)

Health Services Executive. HSE

July 2017

Access

 

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