Background   Physicians traditionally have little formal training in examining patients to determine death, notifying families, and in recording proper documentation.  This Fast Fact reviews key steps in the death pronouncement and notification process.  See also Fast Facts #76, 77 on telephone notification of death.

The Phone Call    “Please come and pronounce this patient”

• Find out the circumstances of the death from the nurse – expected or sudden? Is the family present?

Preparation Before You Enter the Room

• For residents, find out if the attending physician has been called.  In general, see the patient before calling the attending, unless there are unusual family dynamics or details surrounding the death that you should discuss with the attending.
• Determine if the family has requested or if you believe there is value in requesting an autopsy.  Some institutions have specific policies about autopsy requests.
• Determine if the patient/family has already been contacted by the Organ Donor Network (see Fast Fact #79 Discussing Organ Donation).
• Review the chart for important medical (length of admission, cause of death) and family issues (Who is family? Faith? Is there a clergy contact?).

In the Room

• You may want to ask the nurse or chaplain to accompany you; he/she can give you support and introduce you to the family.
• Introduce yourself (including your relationship to the patient) to the family.  Ask each person their name and relationship to the patient.
• Empathetic statements are appropriate:  “I’m sorry for your loss…” Or –  “This must be very difficult for you….”
• Explain what you are there to do.  Tell the family they are welcome to stay while you examine their loved one.
• Ask if family members have any questions or if they wish to speak with a chaplain.

The Pronouncement

• Identify the patient by the hospital ID tag. Note the general appearance of the body.
• 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, or deep sternal pressure are inappropriate.
• Listen for the absence of heart sounds; feel for the absence of carotid pulse.
• Look and listen for the absence of spontaneous respirations.
• Record the position of the pupils and the absence of pupillary light reflex.
• Record the time at which your assessment was completed.

Documentation in the Medical Record

• Called to pronounce (name); Chart the findings of physical examination.
• Note date and time of death; Note if family and attending physician were notified.
• Document if family declines or accepts autopsy
• Document if the death was natural and if the coroner was notified.
• For the purposes of filling out the death certificate (see FF #155): document cause of death; length of time between onset of condition and death; and whether tobacco or alcohol may have contributed to the death.

References:

1. Marshall SA, Ruedy J.  On Call: Principles and protocols.  4th Ed. Philadelphia, PA: Saunders; 2004.
2. Marchand LR, Kushner KP.  Death Pronouncement: survival tips for residents.  American Family Physician.  July 1998.  Available at : http://www.aafp.org/afp/980700ap/rsvoice.html.  
3. Magrane BP, Gilliland MGF, King D.  Certification of Death by Family Physicians.  American Family Physician. 1997; 56:1433-8.

Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published July 2005; 3rd Edition May 2015. Current version re-copy-edited May 2015.