Caring for the Caring for the Dead and Actively Dead and Actively

DyingDyingShellie N. Williams, M.D.Shellie N. Williams, M.D.

University of Chicago Medical University of Chicago Medical CenterCenter

Assistant Professor of MedicineAssistant Professor of MedicineSection of Geriatrics and Section of Geriatrics and

Palliative MedicinePalliative Medicine

April 13th Experience:

• ½ Group• Pain Cases• Review pain

assessment and management principles

• 80 minutes

• ½ Group-2 rotations (60min)

• Sp Encounters 2 per group

• Each student has 15 min opportunity to interview; 10min feed back

• Cases: 1.Family meeting discuss goals of care

• 2. Death pronouncement and Notification

• (20Min) Full group debriefing

Schedule of Events• 1-1:25 -->All 25 students:  25min review of afternoon

activity, EOL communication slides, questions • Separate:  1/2 group pain cases; 1/2 SP encounters• 1:30-1:55 1st rotation SP encounters • 2:00-2:25 2nd rotation SP encounters• 2:30-2:50 Debriefing• (2:50-3:00)10min break before switching to pain

cases• 3:00-3:25 1st rotation• 3:30-3:50 2nd rotation• 4-4:20 Debriefing• Home by 4:25

Preparing for April 13th

• Review all these slides• Review the Pain cases and Von

Guten Pain article• Wear professional attire, including

white coat• RELAX!

ObjectivesObjectives• Enhance EOL communication skills with patients Enhance EOL communication skills with patients

and families.and families.• Learn the skill of assessing patient’s goals of care.Learn the skill of assessing patient’s goals of care.• Identify the difference of palliative care vs hospiceIdentify the difference of palliative care vs hospice• Identify steps in pronouncement of deathIdentify steps in pronouncement of death• Recognize procedure for empathetic notification of Recognize procedure for empathetic notification of

death death • Understand the procedural management of a Understand the procedural management of a

patient after death: (organize family view, establish patient after death: (organize family view, establish autopsy/organ donation, certification of death)autopsy/organ donation, certification of death)

• Gain increased knowledge of self care when caring Gain increased knowledge of self care when caring for the dead.for the dead.

Good EOL Good EOL CommunicationCommunication

NegotiateRelations

hip

Empathy

Time

Common Common Communications in Communications in EOL/Palliative CareEOL/Palliative Care

• Establishing goals of care Establishing goals of care • Decisions about treatment options Decisions about treatment options • Discussion about progression of diseaseDiscussion about progression of disease• Decisions about care after death of loved Decisions about care after death of loved

oneone• Discussion about imminent deathDiscussion about imminent death• Discussion of complication of disease or Discussion of complication of disease or

surgerysurgery• Establishing Code StatusEstablishing Code Status

Communication in EOL/Communication in EOL/Palliative Care: Palliative Care:

• You will never have the right words 100% You will never have the right words 100% of time!of time!

• Ask open-ended questionsAsk open-ended questions• Give big picture (Layman, 2-3 major points)Give big picture (Layman, 2-3 major points)• Direct eye contactDirect eye contact• Sit rather than standSit rather than stand• Acknowledging patient/family emotionsAcknowledging patient/family emotions• Empathy (listen, reassurance, respect)Empathy (listen, reassurance, respect)• Utilize support services (SW, chaplain, nurse)Utilize support services (SW, chaplain, nurse)

Keys to Effective Keys to Effective Communication:Communication:Decision MakingDecision Making

• Patient ability to participate in conversation Patient ability to participate in conversation or establishment of surrogate to help in or establishment of surrogate to help in decisionsdecisions

• Diverting stress of decision making Diverting stress of decision making away away from surrogate by: 1) focusing on from surrogate by: 1) focusing on patient’s wishes 2) physician providing patient’s wishes 2) physician providing recommendationsrecommendations

• Clear understanding of prognosisClear understanding of prognosis• Clear understanding of treatment options Clear understanding of treatment options • Discussion of patient values and quality of Discussion of patient values and quality of

life wishes based on above informationlife wishes based on above information

Communicating Goals of Communicating Goals of Care:Care:

• Opportunity for shared-decision Opportunity for shared-decision making process in establishing focus making process in establishing focus of care. of care.

• Particularly difficult in near the end Particularly difficult in near the end of life situations.of life situations.– Patients/Surrogates Patients/Surrogates wantwant an an

opportunity to discussopportunity to discusswhat is happening. “what is happening. “Big PictureBig Picture .” .”– Can be emotionally volatileCan be emotionally volatile

7 Steps Towards Goals 7 Steps Towards Goals of Careof Care

Preparation Preparation for discussionfor discussion IntroductionsIntroductions Assess patient/family Assess patient/family Understanding Understanding of of

condition & prognosiscondition & prognosis Assess Assess expectationsexpectations of disease, hopes of life of disease, hopes of life DiscussionDiscussion of realistic goals of care (GOC) of realistic goals of care (GOC) Address Address emotionsemotions and listen empathetically and listen empathetically Establish /documentation GOC with additional Establish /documentation GOC with additional

focus on treatment priorities and plan.focus on treatment priorities and plan.

Von Guten , JAMA 2000

PREPARATIONPREPARATION

• Where: Quiet, comfortable environment, Where: Quiet, comfortable environment, seatedseated

• Prepare: Review patient case and discuss Prepare: Review patient case and discuss with other health care members prior to with other health care members prior to meeting.meeting.

• Establish who should be present at Establish who should be present at meeting.meeting.

• What is the focus of the meeting? What is the focus of the meeting? (Prioritize)(Prioritize)

• Assure time for discussionAssure time for discussion

INTRODUCTIONSINTRODUCTIONS• Introductions of family, health team and relation to patient.Introductions of family, health team and relation to patient.• Introduce ground-rules: Introduce ground-rules: 1. Clarify purpose of meeting1. Clarify purpose of meeting

2. Establish how much the patient is comfortable 2. Establish how much the patient is comfortable discussingdiscussing3. Clarify primary decision maker & how to dessiminate 3. Clarify primary decision maker & how to dessiminate information.information.

• If limited relationship with patient/family gain knowledge: If limited relationship with patient/family gain knowledge: Tell me about your father’s life before the hospitalization.Tell me about your father’s life before the hospitalization. I know a lot about your father’s medical condition, can you share a I know a lot about your father’s medical condition, can you share a

bit about his life and values?bit about his life and values? Has Mr. ___ ever discussed his wishes in the event of serious medical Has Mr. ___ ever discussed his wishes in the event of serious medical

illness. illness.

UNDERSTANDINGUNDERSTANDING

• Establish patient’s/family’s Establish patient’s/family’s understanding of condition, prognosis:understanding of condition, prognosis:

• ““What have the doctors told you?What have the doctors told you?• ““Tell me what your understanding of Tell me what your understanding of

your disease is?”your disease is?”• ““What is your understanding of the What is your understanding of the

state of your disease?”state of your disease?”• Clarify misunderstandingsClarify misunderstandings

EXPECTATIONS:EXPECTATIONS:

• Time for patient/family to voice values & Time for patient/family to voice values & priorities priorities

• Stress that family focus on Stress that family focus on patient’spatient’s wishes wishes not family’snot family’s

• Examples:Examples: Given the severity of Mr. X’s Given the severity of Mr. X’s illness, what is most important for us to focus? illness, what is most important for us to focus? What makes life worth living for Mr. X?What makes life worth living for Mr. X?

• What are hoping for, given the course of What are hoping for, given the course of illness? What do they fear?illness? What do they fear?

• Ask family if similar situations where family Ask family if similar situations where family member has expressed their wishes if in member has expressed their wishes if in current medical state.current medical state.

DISCUSSION:DISCUSSION:

• Give Give BIG PICTUREBIG PICTURE of medical condition of medical condition• Provide small pieces of information in Provide small pieces of information in

LaymanLayman• Stress to family that the decisions are Stress to family that the decisions are

focused on the focused on the patient’spatient’s values/wishes values/wishes not not family’sfamily’s

• Stop and reassess understanding Stop and reassess understanding frequentlyfrequently

• Allow individual questions and clarify Allow individual questions and clarify misunderstanding.misunderstanding.

DISCUSSION:DISCUSSION:

• Non-consensus common. When exists:Non-consensus common. When exists: • Re-state goals: What would your father say Re-state goals: What would your father say

if he could speak? **substituted judgment**if he could speak? **substituted judgment**• Give time for family to discuss privately Give time for family to discuss privately

and reconvene later. **Multiple meetings and reconvene later. **Multiple meetings may be necessarymay be necessary

• Utilize resources: Minister, SW, PCP, Utilize resources: Minister, SW, PCP, NurseNurse

• Tell me more...Tell me more...• TIME and TRUST keyTIME and TRUST key

EMOTIONS:EMOTIONS:

• Strong emotions are common and often due to Strong emotions are common and often due to

uncertainty, remorse, loss, guilt.uncertainty, remorse, loss, guilt.• Acknowledge responses:Acknowledge responses: “ “ You seem ________” (angry, bewildered, sad)You seem ________” (angry, bewildered, sad) ““Tell me more about how you’re feeling.”Tell me more about how you’re feeling.”

• Silence is OK Silence is OK • Give time: more than one meeting may be Give time: more than one meeting may be

neededneeded• Offer: tissues, time, other team members Offer: tissues, time, other team members

(chaplain, sw, nurse)(chaplain, sw, nurse)

ESTABLISHING ESTABLISHING GOC/PLAN:GOC/PLAN:

• Summarize: Restate understanding of wishes Summarize: Restate understanding of wishes and medical care consistent with wishes.and medical care consistent with wishes.

• Focus on Positive Therapy: we will Focus on Positive Therapy: we will aggressively treat pain and comfort aggressively treat pain and comfort continuously.continuously.

• Examples:Examples: “You are stating that your father “You are stating that your father would want to be comfortable and at home would want to be comfortable and at home when the time comes. We will avoid therapies when the time comes. We will avoid therapies which are not beneficial and may inhibit this which are not beneficial and may inhibit this such as breathing tubes or recurrent such as breathing tubes or recurrent hospitaliztions”hospitaliztions”

ESTABLISHING ESTABLISHING GOC/PLAN:GOC/PLAN:

• Give medical recommendations based on GOCGive medical recommendations based on GOC• Focus on what we Focus on what we can docan do to help keep to help keep

patient’s quality of life good for remainder of patient’s quality of life good for remainder of life. life.

• Document: family spokesperson, line of Document: family spokesperson, line of ongoing communication, wishes stated.ongoing communication, wishes stated.

• Establish treatments not in line with GOCEstablish treatments not in line with GOC

““We will continue maximal medical therapy We will continue maximal medical therapy focused on comfort; however, if he dies despite focused on comfort; however, if he dies despite everything we will not use machines or chest everything we will not use machines or chest compressions to prolong his death.”compressions to prolong his death.”

What Do Families Want What Do Families Want to Know?to Know?

• How long do we have?How long do we have?• What if God intends a Miracle?What if God intends a Miracle?• Isn’t this giving up?Isn’t this giving up?• Should we go to ____ Treatment Centers of Should we go to ____ Treatment Centers of

America?America?• Why didn’t Dr.____ find this earlier?Why didn’t Dr.____ find this earlier?• If my pain gets bad will you help me end If my pain gets bad will you help me end

this?this?• What would you do if you were in my shoes?What would you do if you were in my shoes?

Words That MatterWords That Matter

• ““I can’t predict a date, but given the course I can’t predict a date, but given the course of most patients with your disease we are of most patients with your disease we are probably looking at days-weeks, weeks-probably looking at days-weeks, weeks-months..”months..”

• ““If a miracle is what you believe and what If a miracle is what you believe and what your God intends it will happen no matter your God intends it will happen no matter what, I can only recommend care for what is what, I can only recommend care for what is happening now.”happening now.”

• ““We are not holding back any care that will We are not holding back any care that will help or reverse this process.” “If we had help or reverse this process.” “If we had other treatments, I would not hesitate to other treatments, I would not hesitate to offer, but unfortunately we don’t.”offer, but unfortunately we don’t.”

Words That MatterWords That Matter

• ““I can’t imagine how difficult these I can’t imagine how difficult these decisions must be for you and your decisions must be for you and your family. If it helps there is not a right or family. If it helps there is not a right or wrong answer, only what is most wrong answer, only what is most important to you in your life.”important to you in your life.”

• ““Our medical team will support you thru Our medical team will support you thru every step of your illness, making sure every step of your illness, making sure to adjust any care and medications to adjust any care and medications needed to alleviate your suffering.”needed to alleviate your suffering.”

Goals of Care: SummaryGoals of Care: Summary

• A ProcessA Process May require >1 meeting May require >1 meeting• Listen more than you talkListen more than you talk• Silence is OKSilence is OK• Realize emotions run high and often just Realize emotions run high and often just

allowing time to express feelings helpful. allowing time to express feelings helpful. • Reassure and listenReassure and listen• Give the same Respect and Time you’d Give the same Respect and Time you’d

want for yourwant for yourloved ones.loved ones.

If we don’t continue If we don’t continue with dialysis or do the with dialysis or do the breathing tube, Then breathing tube, Then aren’t we stopping all aren’t we stopping all

care?care?

PALLIATIVE/EOL CARE:PALLIATIVE/EOL CARE:Traditional ViewTraditional View

Life Prolonging/Curative Care

End of Life Care

(Hospice)

D

E

A

T

HDisease Progression

PALLIATIVE/EOL CARE:PALLIATIVE/EOL CARE: TodayToday

Palliative Care

Therapies to modify disease Hospice

Presentation Therapies to

relieve suffering and/or improve quality of life

Bereavement Care

6m Death

Definition of Palliative Definition of Palliative CareCare

• Interdisciplinary specialty that aims to Interdisciplinary specialty that aims to relieve suffering and improve quality relieve suffering and improve quality of life for patients with advanced of life for patients with advanced illness.illness.

• Focus is pain relief, symptom Focus is pain relief, symptom management and support services.management and support services.

• Also called comfort care, supportive Also called comfort care, supportive care, and symptom management care, and symptom management

• It is provided simultaneously with all It is provided simultaneously with all other appropriate curative medical other appropriate curative medical treatmenttreatment..

Definition of Hospice Definition of Hospice CareCare

Interdisciplinary service for terminally ill Interdisciplinary service for terminally ill patients/families when beyond cure.patients/families when beyond cure.

Includes pain relief, symptom management Includes pain relief, symptom management and support services, physician and nursing and support services, physician and nursing services, in-home care, SW, therapy, and services, in-home care, SW, therapy, and counseling. counseling.

To be eligible for hospice an individual must To be eligible for hospice an individual must be diagnosed as terminally ill with a life be diagnosed as terminally ill with a life expectancy of six months or less.expectancy of six months or less.

Settings: Home, Inpt Hospice, Nursing homeSettings: Home, Inpt Hospice, Nursing home

Hospice Qualifying Conditions

• Advanced Respiratory disease • >10% weight loss/6 months• ALS (Lou Gherig's Disease) • Congestive heart failure • Neurological disorders • End-stage Alzheimer's disease • End-stage liver and/or kidney disease • Cancer

Palliative Symptom Management

Common Symptoms at the End-of-Life

Symptom Domain Symptoms

Physical Symptoms Pain VomitingDyspnea NauseaAnorexia PruritisFatigueConstipationIatrogenic symptoms

Psychological Symptoms DepressionGriefAnxietyPanicPost traumatic stress syndromeAgitation

Social Symptoms Isolation/lonelinessAnger/hostilityFinancial issues and challenges (Institute of Medicine ; Covinsky ) Fear of being a burden to loved ones (Institute of Medicine)

Spiritual Symptoms Loss of meaning, Angst

Communication: Communication: Death Death

Pronouncement & Pronouncement & NotificationNotification

Pronouncement of deathPronouncement of deathNotification of deathNotification of death

Empathetic Address of person Empathetic Address of person notifiednotified

Death Note DocumentationDeath Note Documentation

Death Notification: Death Notification: The Initial StepThe Initial Step

• Your team is on-call and you Your team is on-call and you have just completed your 5have just completed your 5thth admit on the floor. You receive admit on the floor. You receive a page from 5 NE informing you a page from 5 NE informing you of a 60 yo man with CAD and of a 60 yo man with CAD and recent MI who is non-responsive recent MI who is non-responsive and is DNPD (do no prolong and is DNPD (do no prolong death) code status. What do you death) code status. What do you want to know prior to ending want to know prior to ending the call?the call?

Death Notification: Death Notification: The Initial Call from The Initial Call from

NurseNurse

• Establish circumstances: Expected Establish circumstances: Expected death? Family Present?death? Family Present?

• Confirm the documented code Confirm the documented code status?status?

• Establish patient status: breathing, Establish patient status: breathing, pulse?pulse?

• Establish brief history of medical Establish brief history of medical issues and any important events of issues and any important events of day.day.

• Establish if attending notified yet.Establish if attending notified yet.• Confirm room#, nameConfirm room#, name

Death Notification: The Death Notification: The Initial Chart InteractionInitial Chart Interaction

• Review of chart or speak with nurse Review of chart or speak with nurse prior to contacting survivors:prior to contacting survivors:

• Reason admitReason admit• Past historyPast history• Important tests/diagnostics pendingImportant tests/diagnostics pending• Important events of dayImportant events of day• Establish Probable causes of deathEstablish Probable causes of death• Note primary spokesperson/contactNote primary spokesperson/contact• Note if crucial family issuesNote if crucial family issues

SIGNS DEATH HAS OCCURRED:

Eyes Fixed & Dilated PupilsOpen Eyes

Heart No heart tones

Muscles Incontinent Stool & UrineLimp musclesStiff (Rigor Mortis >4 hr)Jaw Falls open

Skin Pale color & Waxen skin

Fluids Trickling body fluids

Lungs No breathing or Final chest rise

Death Notification: Death Notification: Pronouncing Patient Pronouncing Patient

• IDENTIFY patientIDENTIFY patient• Check response to name and touch Check response to name and touch

of handof hand• Describe patient color and Describe patient color and

appearance of bodyappearance of body• Note lack of response to verbal Note lack of response to verbal

stimulistimuli• Note size pupils and lack of reflexNote size pupils and lack of reflex• Look/listen for absent breath Look/listen for absent breath

sounds/chest movementsounds/chest movement• Lack of carotid pulse, heart tonesLack of carotid pulse, heart tones• Note time of death pronouncementNote time of death pronouncement• Dignify the patient: cover Dignify the patient: cover

body/secretionsbody/secretions

Death Notification: Death Notification: Deciding to Call (Indirect) Deciding to Call (Indirect)

or Not?or Not?

• Face-face notification always Face-face notification always best.best.

• Except: Family long distance, Except: Family long distance, expectation of death, wish to expectation of death, wish to know immediately.know immediately.

• Ask for support during call if Ask for support during call if uncomfortable: Nurse, uncomfortable: Nurse, chaplain, SW.chaplain, SW.

• Never leave message of death Never leave message of death on machine.on machine.

Notification of DeathNotification of Death(Indirect) Telephone(Indirect) Telephone

Notify inpatient attending and/or speak Notify inpatient attending and/or speak with nurse prior to notification of family. with nurse prior to notification of family.

Identify yourself/relation to patient.Identify yourself/relation to patient. Establish their relationship to the patient Establish their relationship to the patient

and provide warning.and provide warning. Deliver the message and allow silence to Deliver the message and allow silence to

internalize info.internalize info. Offer words of comfort.Offer words of comfort. Ask if they have questions or concerns.Ask if they have questions or concerns. Ask if they’d like to come to hospital to see Ask if they’d like to come to hospital to see

patient?patient? Ask if they are safe coming or need Ask if they are safe coming or need

someone contacted?someone contacted? Instruct to go to nurse’s station and Instruct to go to nurse’s station and

establish timing.establish timing. Prepare the nurse with events and page Prepare the nurse with events and page

instructions.instructions.

Death Notification: Death Notification: Family Care (Phone)Family Care (Phone)

Establish quiet roomEstablish quiet room I am dr. ____ the intern. May I ask your I am dr. ____ the intern. May I ask your

relation to the patient?relation to the patient? ““I have some bad news regarding mr./mrs. I have some bad news regarding mr./mrs.

_________”. Is there someone you’d like _________”. Is there someone you’d like present while we talk?present while we talk?

I’m sorry to have to give you the news, I’m sorry to have to give you the news, Mr/Mrs.________ DIED at ______ this eve. Mr/Mrs.________ DIED at ______ this eve.

SilenceSilence is golden. is golden. Allow time to express Allow time to express reflectivereflective thoughts. thoughts. ReassureReassure: this was not preventable, there : this was not preventable, there

was no sufferingwas no suffering Ask if there are additional family to provide Ask if there are additional family to provide

support/to be contacted for them.support/to be contacted for them.

Notification of Death:Notification of Death:(Face: Face)(Face: Face)

You may want to ask the nurse or a chaplain to You may want to ask the nurse or a chaplain to accompany you, particularly if family members are accompany you, particularly if family members are present.present.

Introduce yourself and role in care.Introduce yourself and role in care. Empathetic statements are appropriate: Empathetic statements are appropriate:

a. I’m sorry for your loss…" a. I’m sorry for your loss…" b. This must be very difficult for you…"b. This must be very difficult for you…"

Explain what you have come to do.  Tell the family Explain what you have come to do.  Tell the family they are welcome to stay, if they wish, while you they are welcome to stay, if they wish, while you examine their loved one. examine their loved one.

Ask if they have any questions.  If you cannot answer Ask if they have any questions.  If you cannot answer questions, call someone who can, e.g., the attending, questions, call someone who can, e.g., the attending, nurse. nurse.

Ask if you can contact anyone for them, e.g. other Ask if you can contact anyone for them, e.g. other family, clergy; ask if there is anything else you can do. family, clergy; ask if there is anything else you can do.

Notification of Death: Notification of Death: Family Care (Face:Face)Family Care (Face:Face)

• Ask if they would or wouldn’t want to stay Ask if they would or wouldn’t want to stay in room. Make in room. Make arrangement to viewarrangement to view..

• Prepare the familyPrepare the family regarding patient regarding patient appearance and grant permission to touch appearance and grant permission to touch patientpatient

• Request if Request if additional needsadditional needs: chaplain, : chaplain, family/religious rituals for body.family/religious rituals for body.

• After address of immediate needs, discuss After address of immediate needs, discuss autopsy, organ donationautopsy, organ donation

• Arrange Arrange support support for survivor after you for survivor after you leave.leave.

• Offer availability if additional questions or Offer availability if additional questions or special rituals to be observedspecial rituals to be observed

What Families Need to What Families Need to KnowKnow

• Did he suffer? Was he in pain?Did he suffer? Was he in pain?• Did they delay hospitalization too long?Did they delay hospitalization too long?• Was he alone?Was he alone?• Can I touch him?Can I touch him?• Can I stay with him?Can I stay with him?• What will I do without him?What will I do without him?• Special considerations: Religious Special considerations: Religious

rituals for body or in the roomrituals for body or in the room

Words That MatterWords That Matter

• If you have knowledge of the patient being If you have knowledge of the patient being peaceful or without s/s distress, state to family.peaceful or without s/s distress, state to family.

• Reiterate that death is something that can’t be Reiterate that death is something that can’t be predicted and this would have happened whether predicted and this would have happened whether he’d come to hospital 1 week ago or today.he’d come to hospital 1 week ago or today.

• Remind them they may hold hand or touch.Remind them they may hold hand or touch.• Be aware of hospital policy for length of time body Be aware of hospital policy for length of time body

may stay on floor. Usually 3-6 hrmay stay on floor. Usually 3-6 hr• Allow them to reflect on life together or digest Allow them to reflect on life together or digest

infoinfo

• Offer to contact familyOffer to contact family, , call chaplain or SW call chaplain or SW

Death Notification: Death Notification: SummarySummary

• Verbal tone importantVerbal tone important• Arrange supportsArrange supports• Empathetic gestures: Tissue, Touch, Empathetic gestures: Tissue, Touch,

allow time for reflection, offer allow time for reflection, offer chaplainchaplain

• Limited dialogue, ListenLimited dialogue, Listen• Ask if special rituals or needs of Ask if special rituals or needs of

patient/familypatient/family

After Death CareAfter Death Care

• Be respectful of the remains Be respectful of the remains • Establish care for familyEstablish care for family• Establish donation and autopsy wishesEstablish donation and autopsy wishes• Establish with team timing for morgue Establish with team timing for morgue

transfertransfer• Document death: chart, hospital form, Document death: chart, hospital form,

certificatecertificate• Care for yourself: Discuss with Care for yourself: Discuss with

colleague, exercise, state condolenscencecolleague, exercise, state condolenscence

Death Note Death Note Documentation:Documentation:

• Date/time of pronouncement.Date/time of pronouncement. • Called to pronounce_________Called to pronounce_________, a ___ , a ___

old male with ____________ disease old male with ____________ disease died of ______.died of ______.

• Findings upon examination (no pulse, Findings upon examination (no pulse, no heart tone, no respirations/chest no heart tone, no respirations/chest rise &fall)rise &fall)

• Document family/inpatient attending Document family/inpatient attending notified.notified.

• Document if coroner needed.Document if coroner needed.• Document autopsy/donation wish.Document autopsy/donation wish.• Document special request/plan for Document special request/plan for

viewview

Death Notification: Death Notification: Contact Medical Contact Medical

ExaminerExaminer

• Hospitalized <24hrHospitalized <24hr• Unusual circumstancesUnusual circumstances• Death association with trauma Death association with trauma • Death during/within 24 surgery Death during/within 24 surgery

or anesthesiaor anesthesia

Death Notification:Death Notification:AutopsyAutopsy

• Establish with family during end of Establish with family during end of notification if autopsy wishesnotification if autopsy wishes

• If phone notification await family If phone notification await family arrival on floor to discuss autopsy arrival on floor to discuss autopsy wisheswishes

• Document in death note Document in death note • Check with charge nurse or unit Check with charge nurse or unit

secretary for death packet secretary for death packet

Death Notification:Death Notification:Organ DonationOrgan Donation

• Uniform Anatomical Gift ActUniform Anatomical Gift Act• Generally wishes documented on Generally wishes documented on

driver’s license, Notify family of donate driver’s license, Notify family of donate wish. wish.

• Family may donate if not previously Family may donate if not previously designateddesignated

• Donation post-mortem of organs has few Donation post-mortem of organs has few hours windowhours window

• Post-mortem organs: skin, bone, corneaPost-mortem organs: skin, bone, cornea

Death CertificateDeath Certificate

• Permanent record of deathPermanent record of death• Lists in sequential order below:Lists in sequential order below:• Immediate cause of death (End disease Immediate cause of death (End disease

complication which lead to death (pulmonary complication which lead to death (pulmonary embolus), embolus), not mechanismnot mechanism (respiratory arrest) (respiratory arrest)

• Conditions that resulted in the immediate cause of Conditions that resulted in the immediate cause of death (e.g., gunshot wound, DVT, lung ca)death (e.g., gunshot wound, DVT, lung ca)

• Other significant medical conditions (e.g., Other significant medical conditions (e.g., hypertension, atherosclerotic coronary artery hypertension, atherosclerotic coronary artery disease, or diabetes)disease, or diabetes)

Important for statistical data of disease and allocation of funding for prevention.

Important to have 1 dx per line

http://www.cdc.gov/nchs/data/dvs/blue_form.pdf

•Recognition that an important event has occurred•Discussing your feelings with colleagues and loved ones•Documenting your relationship with patient/family via condolence letter or call•Saying good-bye or praying for patient •Taking time for you: exercise, painting, good coffee

PHYSICAN HEAL THYSELF!

Bibliography:Bibliography:• Fast Facts and Concept #76 #77: Telephone Fast Facts and Concept #76 #77: Telephone

Notification of Death Part 1 and 2 Notification of Death Part 1 and 2 http://eperc.mcw.edu..• Von Guten, C. Ensuring Competency in EOL Care. Von Guten, C. Ensuring Competency in EOL Care.

JAMA; 2000, 284 (24) 3051-57.JAMA; 2000, 284 (24) 3051-57.• Marchand, Lucille, etal. Death Pronouncement: Marchand, Lucille, etal. Death Pronouncement:

Survival Tips for Residents. Am Fam Phy; 1998 (58): Survival Tips for Residents. Am Fam Phy; 1998 (58): 284-85.284-85.

• Conducting a Family Meeting: Fast Facts and Concept Conducting a Family Meeting: Fast Facts and Concept #16 #16 http://eperc.mcw.edu

• Quill, Timothy. Initiating EOL Discussions with Quill, Timothy. Initiating EOL Discussions with Seriously Ill Patients. JAMA; 2000 284 (19) 2502-2507.Seriously Ill Patients. JAMA; 2000 284 (19) 2502-2507.

• Medical Certifier Instructions for US Standard Medical Certifier Instructions for US Standard Certificate of Death. November 2003 revision.Certificate of Death. November 2003 revision.