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Death Note

Residents have traditionally had little formal training in examining patients to determine death, notifying families, and recording proper documentation.

The phone call: "please come and pronounce this patient"

1. Find out the circumstances of the death. Was it expected or sudden? Is the family present? What is the patient's age?
2. Prepare before you enter the room.
3. Get the details on the circumstances of death from the nurse.
4. Find out whether the attending physician has been called. In general, see the patient before you call the attending, unless there are unusual family dynamics or details surrounding the death that you should discuss before you walk into the room.
5. Has the family requested an autopsy? Do you see value in requesting one?
6. Determine whether the patient or family has already been contacted by the organ donor network.
7. Review the chart for the important medical facts (length of admission, cause of death) and the family issues (who is family, faith, whether there is a clergy contact).

In the room

1. You may want to ask the nurse or chaplain to accompany you. They can give you support and introduce you to the family.
2. Introduce yourself, including your relationship to the patient, to the family if they are present. Ask each person their name and their relationship to the patient.
3. Empathetic statements are appropriate. "I'm sorry for your loss." "This must be very difficult for you."
4. Explain what you are there to do. Tell the family they are welcome to stay while you examine their loved one, if they wish.
5. Ask whether the family has any questions. If you cannot answer one, contact someone who can.

The pronouncement

1. Identify the patient by the hospital ID tag. Note the general appearance of the body.
2. Ascertain that the patient does not rouse to verbal or tactile stimuli. Avoid overtly painful stimuli, especially if family members are present. Nipple or testicle twisting, and deep sternal pressure, are inappropriate.
3. Listen for the absence of heart sounds. Feel for the absence of a carotid pulse.
4. Look and listen for the absence of spontaneous respirations.
5. Record the position of the pupils and the absence of the pupillary light reflex.
6. Record the time at which your assessment was completed.

Documentation in the medical record

1. Called to pronounce (name). Chart the findings of the physical examination.
2. Note the date and time of death. Note whether the family and the attending physician were notified.
3. Document whether the family declines or accepts an autopsy. Document whether the coroner was notified.