Nothing is certain but death (…and paperwork)
If you asked any friend or family member to consider the question of how they imagine their final moments of their life – most would conjure up an image of themselves at home, in a comfortable white bed with rays of sunset haze filtering through the window as they are surrounded by generations of loved ones. Although a bit gratuitous in its detail, the scenario reflects the consistent finding that approximately 70% of Australians would prefer to die at home. Yet, as most healthcare practitioners would know, this a far cry from reality with over 54% of deaths in Australia occurring in hospitals and 32% in residential care.
Given the above, it stands to reason that death is commonplace in the hospital setting and therefore inevitably a key component of a junior medical officer’s day to day work. Indeed it is an expectation that JMOs become intimately familiar with not only the physiological but also the administrative aspects of the dying process. In this blog we touch on the latter, in particular, on the topic of death certification which encompasses the important responsibility of declaring life extinct to citing the cause of death on the death certificate. Readers should note that the information contained here, although general in some aspects, pertains largely to Australian hospitals and may also vary slightly between institutions.
Part I: Verifying death
Declaring life extinct
Declaring death is both a duty and a privilege that has been bestowed selectively onto doctors who are expected by society to fulfil this role in a professional and respectful manner. The majority of the time on the wards, an intern or resident is called by nursing staff to verify the presumed death of a patient known to have been deteriorating or was expected to die. Occasionally, JMOs may also be involved in unexpected deaths but in such circumstances are usually guided by senior registrars or consultants.
The process of verifying death begins before entering the patient’s room. The first step should be to inquire as to whether any family members are present. It is always a good point to remember that whenever dealing with family members about a death, one should try to be as sensitive and respectful by leaving their pager outside with a colleague or nurse. After entering and expressing your condolences, you should inform the family about what you are about to do at which point they are invited to stay or briefly step outside.
The next step involves the examination. Although the examination of death has been expanded by increased technological capacity in determining brain death, the legal definition of brain death actually remains quite simple – the irreversible cessation of circulation of blood or brain function. Apart from the exceptional circumstances of organ-supported brain death in a potential transplant candidate (which JMOs are not involved with anyway), the verification of death practically translates to confirming absence of brainstem reflexes, circulation and respiration. The following is a suggested routine:1. Confirm patient’s identification details by their arm-band
1. Confirm patient’s identification details by their arm-band 2. Check for lack of response to painful stimulus e.g. trapezius squeeze, supraorbital pressure, sternal rub
2. Check for lack of response to painful stimulus e.g. trapezius squeeze, supraorbital pressure, sternal rub
3. Check for absence of central reflexes
– Pupillary reflexes – usually non-reactive and mid-dilated (early) or dilated (late)
– Corneal reflex (optional)
4. Check for absence of respiration
– No effective chest wall movements
– No breath sounds on auscultation for 2 minutes (can be done simultaneously with heart sounds)
5. Check for absence of circulation
– No palpable carotid pulse or asystole on ECG monitor
– No heart sounds on auscultation for 2 minutes
6. Lastly, check the body for implantable devices such as pacemakers or defibrillators which will be required on the cremation certificate.
At the end of the examination, once death is confirmed, record the time – the official time of death is the time at the end of your examination.
Notify the relevant parties
After completing the examination, you need to ensure that firstly the next of kin has been contacted and is informed. Sometimes this can be done before the examination as soon as you are aware that there has been a deterioration and that death is imminent.
Next, notify the team – if it is an unexpected death, the consultant or senior registrar on call should be notified immediately as they can give guidance as to the possible cause and whether this may be a coronial enquiry. Otherwise if expected, the consultant should be notified at the earliest convenient time. If the death occurred during a night shift, a reasonable time would be 7:30 am. If unsure whether or not a death is expected – seek advice from the registrar on call.
Lastly, the patient’s general practitioner should be contacted during working hours. If the death occurred overnight, this duty may be handed over to the treating team during the day. This is a professional responsibility of high importance and should not be neglected! It is not unusual for GPs to have cared for patients (and often their families) for several decades before their final hospital admission.
Document, document, document
Once the above has been completed, the findings should be noted in the patient’s medical records. Namely the following details should be included:
In Part II I will cover the key areas of when to report to the coroner and how to fill out the death certificate.