Dealing with Death & Dying in Medical Education and Practice
© 2001 Kirsti A. Dyer, MD, MS
AMSA Convention March 30, 2001
Death Pronouncement and Death Notification:
What the Resident Needs to Know

Death pronouncement is more than the actual declaration of death.  Residents usually learn about death pronouncement by watching a senior resident perform this responsibility.  However, residents have traditionally had little training in examining patients to determine death, notifying families, and in recording proper documentation.

The Phone Call – "Please come and pronounce this patient"

1. Find out the circumstances of the death – expected or sudden?
2. Ask if the family is present?
3. Ask the patient’s age and major diagnosis.
4. Other emergencies take precedence over a pronouncement; however, do not postpone as the time of death is legally the time at which you pronounce the patient dead.
When you get to the floor – Preparation Before You Enter the Room
1. Get the details on the circumstances of death from the RN.
2. Find out if the attending physician has been called.  In general, see the patient before you call the attending, unless there are unusual details surrounding the death that you should discuss prior to seeing the patient or family members in the room.
3. Has the family requested an autopsy?
4. Determine if the death has been reported to your state or regional Organ Procurement Organization to determine suitability for donation.
5. Review the chart for important medical (length of admission, case of death) and family issues:  (Who is family?, Faith?, Is there a clergy contact?) – this will help you put the patient’s death into a context of the hospitalization.
In the Room
    1. You may want to ask the nurse or a chaplain to accompany you, particularly if family members are present;  they can give support to both you and the family.
    2. Introduce yourself (including your relationship to the patient) to the family if they are present.
    3. Empathetic statements are appropriate:
      a. I’m sorry for your loss…"
      b. This must be very difficult for you…"
    4. Avoid over-personalization; examples of statements not to make include:
      a. "I know how hard this is …"
      b. "I would also be upset …"
    5. Explain what you are there to do.  Tell the family they are welcome to stay, if they wish, while you examine their loved one.
    6. Ask if they have any questions.  If you cannot answer questions, call someone who can, e.g., the attending.
    7. Assess the emotional state of the family; Ask if you can contact anyone for them, e.g. other family, clergy; ask if there is anything else you can do. 
The Pronouncement – What you need to do
1. Identify the patient by the hospital ID tag
2. Note the general appearance of the body
3. 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 absolutely inappropriate.
4. Listen for the absence of carotid pulse.
5. Look and listen for the absence of spontaneous respirations.
6. Record the position of the pupils and the absence of pupillary light reflex.
7. Record the time at which your assessment was completed—this is the official time of death.
Documentation in the Medical Record 
1. Called to pronounce (name).
2. Chart findings of physical examination.
3. Note date and time of death.
4. Note if family and attending physician were notified.
5. Document if family declines or accepts autopsy
6. Document if the coroner/medical examiner was notified.
The Coroner’s / Medical Examiner Case—
What is a reportable death?
(Note: state/county rules about reportable deaths may vary)
1. If the patient was in the hospital < 24 hours
2. If the death was unexpected or under unusual circumstances
3. If the death was in any way associated with trauma or a procedure (e.g. death resulting from complications of a recent hip fracture).
4.  Death occurring during surgery or anesthesia
5.  Other—check with your state/county coroners office
Notification by Telephone
    1. Notify the attending physician if you have not already done so.  Decide together whether an autopsy would be appropriate.
    2. Notify relatives.  Next of kin should be notified as soon as possible after you have pronounced the patient dead and notified the attending physician.  The family will want to hear this news from someone that they know.
    3. If neither you nor the attending know the patient, spend a few minutes familiarizing yourself with the patient’s medical history and circumstances of death.  This news is always best delivered in person, but when necessary, you may need to give telephone news:
      a. Identify yourself
      b. Ask the person you are speaking to identify themselves, and their relationship to the patient
      c. Ask to speak to the next of kin
      d. Deliver the message:  "Mrs. Smith, I am sorry to inform you that your husband died at 8:30 this evening."  Avoid euphemisms for death (e.g., passed on, expired).
      e. Offer words of comfort (see examples)
      f. Ask if they would like to come to the hospital to see the patient.  Inform the nurse in charge of this decision
      g.    Refer questions pertaining to funeral arrangements or personal belongings to administrative personnel on the floor
Organ Donation – What is Your Role?
1. All hospital deaths must be reported to the hospital’s organ procurement organization (OPO) (Federal Law).
2.  Only a trained designated requestor can discuss organ/tissue donations. 
A designated requestor or donation coordinator must be contacted for discussions of organ/tissue donation; the nurse, or other administrative personnel, caring for the deceased patient should call them.
3. Your role is to ensure that there is an opportunity to discuss organ/tissue donation and to support the family in making decisions. 
1. Amiel GE, L Ungar, M Alperin.  Using an OSCE to assess primary care physicians’ competence in breaking bad news. Acad Med 2000;75(5):560-561.
2. Buckman R.  How to break bad news: A guide for health care professionals. Johns Hopkins University Press, 1992.
3. Iverson, VK. Grave words: Notifying survivors about sudden, unexpected deaths. Galen Press, Inc., Tuscon, Arizona, 1999. 
4. Iverson, VK.  Pocket protocols—Notifying survivors about sudden, unexpected deaths.  Galen Press, Inc., Tuscon, Arizona, 1999.
5. Marshall SA, Ruedy J.  On Call: Principles and protocols.  Philadephia, W.B. Saunders Company, 1999.
6. Marchand LR, Kushner KP.  Death Pronouncement: survival tips for residents. American Family Physician, July 1998. 
7. Magrane BP, Gilliland MGF, King D, Certification of Death by Family Physicians. American Family Physician, October 1997, 1433-8.
8. Sutton RB.  Supporting the bereaved relative: reflections on the actor’s experience. Medical Education 1998, 32, 622-9.

© November 2000 Charlotte Heidenreich, MD David E. Weissman, MD. Death Pronouncement and Death Notification: What the Resident Needs to Know. Available from: EPERC (End-of-Life Physician Education Resource Center)

Compilation of resources for this presentation and Website © 2001 Kirsti A. Dyer, MD, MS.
Journey of Hearts,
This article may be reproduced for educational purposes provided the Heidenriech and Weissman copyright is included.