The below article has been reproduced from a BMJ series to help medical students make the leap to budding doctors. In this article, Richard Beasley and colleagues explain why the death of a patient should not be considered the point of cessation of care and describe what you should be aware of after your patient dies.
By necessity, medical training focuses on caring for living patients, which leaves some junior doctors unsure of what to do when a patient dies. Far from being the end of the job, there is a considerable amount of work to be done when a patient dies and often difficult decisions still need to be made.
Confirming death
The first thing to be done when a patient dies is to confirm death. Although this is one of the easiest diagnoses to make in medicine, the process should not be treated with complacency.1 The absence of a pulse or respiration at a specific point is not always consistent with death. Profound hypotension can result in the loss of a radial pulse, and conditions such a hypothyroidism and hypothermia can slow the pulse rate considerably. Cheyne-Stokes breathing (alternating periods of apnoea and hyper-apnoea) is commonly seen in the preterminal phase (the period shortly before death) and can result in apnoeic periods of several minutes. Certain drugs can alter the reactivity of pupils.1
Procedures for confirming death may vary, but generally death can be confirmed if there is:
- Absence of a carotid pulse and heart sounds (listen with a stethoscope for one minute)
- Absence of respiration for three minutes
- Fixed, dilated, and unreactive pupils (to torch light).2
Assessing response to pain is not necessary and may be distressing to any relatives who are present.
Confirmation of death must be carefully documented in the notes. It is particularly important to record the date and time as these are transferred later to the death certificate and cremation form, if applicable. The time documented refers to the time death was declared, rather than the actual time of death. You should sign the entry and print your name and your bleep number underneath.
If the family is present at the time of death, you should speak to them to ensure they understand what has happened and to answer any questions they may have. They may be extremely distressed, even if the death was expected. If the family members are not present, they must be notified. Do not assume the nurses will do this. Sometimes the family will come to the hospital and you will be expected to talk to them. If the patient was not under your care you should find out the details before speaking to the family.
If the death occurs in the middle of the night, it is good practice to inform the appropriate team in the morning. The patient’s general practitioner must be informed at the earliest opportunity either by fax or phone. It can be extremely embarrassing and distressing for a general practitioner not to be informed, especially if they had a longstanding relationship with the patient.
Completing forms
Please note: the below information, while relevant, is intended for a UK audience and may contain technical details and procedures that are not the same in New Zealand. Please see below for links to New Zealand specific information about certifying death and cremation. Your DHB will also have guidelines on certifying death and cremation.
- Ministry of Health: A Guide to Certifying Causes of Death
- Cremation Issues
- MPS Factsheet: Death from natural causes: certification and dealing with funeral directors
Death certificate
The importance of accurate certification of death is generally underestimated by junior doctors. It provides legal documentation of the fact and causes of death. Information from death certificates is also used to calculate mortality statistics. This information may influence public health policies, resource allocation, and research decisions.3
If you were the attending doctor during the last illness of the deceased it is your statutory obligation to complete the death certificate. You should do so only if you are sure of the cause of death. It is important that you state the cause of death rather than the mode of death (see below).3
| Descriptions that give mode rather than underlying cause of death |
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Cardiac arrest is not an accepted cause of death despite the fact that it is inevitably the final event. The cause of death is what caused the cardiac arrest. As a general rule, causes of death are recognised pathological states, such as myocardial infarction. The cause of death must be specific, and “organ failure” is therefore not acceptable. Avoid giving “old age” as a cause of death.
The diseases underlying or contributing to the cause of death are also listed, as well as other diseases which are not directly related to the cause of death but which may have contributed to the death.
Completing cremation forms
Doctors often complete cremation forms inaccurately, with errors ranging from incorrect name, address, or age of the patient to the doctor having never seen the patient.4 One study showed that fewer than half of the forms were completed with enough accuracy to allow cremation to proceed. Junior doctors were responsible for the most errors.5 These avoidable errors cause delays for the family and increase their stress at an already difficult time.
If you complete the cremation form there is a requirement that you have seen the body after death. If you did not verify the death yourself you must visit the body in the mortuary.
A cremation form has two parts. The first part must be completed by the doctor who attended the patient during their last illness. The second part is completed by a registered practitioner of five years standing who is not working on the same firm as the doctor completing the first part and who has not been responsible for the patient’s care.4 Usually this doctor should be of consultant status. The doctor who signs the second part will need to contact you to discuss the case. Therefore, if you are about to go off duty or on holiday, you should contact the relevant doctor before you go to avoid unnecessary delays.
Remember that patients cannot be cremated with a pacemaker or radioactive implant in situ; cremation forms have statutory questions regarding this. Half of British crematoriums have had explosions after the inadvertent cremation of pacemakers. This can result in structural damage or injury to staff.6 In the study of 1000 cremation forms, 64 had incomplete or inaccurate information about pacemakers.4 You will be asked whether the patient has a pacemaker, and if they do it should be removed (see below). Sometimes this is done by a junior doctor, and at other times the mortician will remove it for you. Discuss this with the mortuary staff.
| Handy tips to check for pacemakers |
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Hospital postmortem examination
A hospital postmortem examination is done for a more complete understanding of the patient’s illness and to increase medical knowledge. It is not done to identify the cause of death, which has already been ascertained and stated on the death certificate. Unlike a coroner’s postmortem examination, which is done by law, hospital postmortem examinations require the consent of the patient’s family. This should be discussed with tact and sensitivity, with a full explanation of why it is being requested. It will be either a full examination of all the organs or a limited examination of the organs relevant to the terminal illness. Ten percent of postmortem examinations have findings that would have been of therapeutic relevance if they had been known about before death. Huge educational gains can therefore be made by watching these examinations, and junior doctors should try to be present when possible.7
Organ donation
Organ donation is a highly emotive issue, but it is becoming increasingly important. There is a continuing lack of organ donors and hundreds of people die each year while on the transplant register.
Because of the need to maintain an oxygenated blood supply to the organs being considered for transplant, most patients who end up being organ donors are artificially ventilated in either the intensive care unit or the emergency department. However, it is worth remembering that tissues such as skin can be donated up to 24 hours after death (see below).
| Organs and tissues suitable for donation |
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In some cases, the patient’s underlying condition prevents the possibility of donation. The decision on organ donation is often helped by the patient carrying a donor card, but the wishes of the next of kin can override the donor card. For artificially ventilated patients, brain death must be confirmed, and this is done at two different times by two different consultants, who must not be part of the transplant team. Once the decision has been made that the patient is suitable for organ donation the transplant service is contacted. Arrangements are usually made by the local donor transplant coordinator, who will liaise with the transplant teams.8
Generally speaking, house officers should not make decisions on organ donation independently. However, awareness of the issues can be helpful, especially when talking to relatives.
Conclusion
When a patient has died there is much to be done, and decisions need to be made quickly and with consideration for the grieving family. Junior doctors should familiarise themselves fully with local policies and requirements so that medicolegal errors are not made at this important time.
Original authors:
Sarah Aldington. Senior research fellow, Medical Research Institute of New Zealand, Wellington, New Zealand.
Geoffrey Robinson. General physician and chief medical officer, Capital and Coast District Health Board, Wellington, New Zealand.
Richard Beasley. General physician, Wellington Hospital, Wellington, New Zealand
We gratefully acknowledge the BMJ for permission to reproduce this article.
References
- Hallenbeck JL. Palliative care perspective.sOxford: Oxford University Press, 2003.
- Donald A, Stein M. The hands-on guide for house office.rLsondon: Blackwell Science, 1996.
- Office for National Statistics. Completion of the medical certificate of cause of death. http://www.clinicalschool.swan.ac.uk/wics/itugl/dcert2.htm (accessed 6 Jan 2006).
- Hawkley C. Crisis in cremation. BMJ 1999;318:811.
- Horner JS, Horner JW. Do doctors read forms? A one year audit of medical certificates submitted to a crematorium. J R Soc Med 1998;91371-6.
- Gale CP, Mulley GP. Pacemaker explosions in crematoria: problems and possible solutions. J R Soc Med 2002;95:353-5.
- Joint Working Party of the Royal College of Pathologists, the Royal College of Physicians of London and the Royal College of Surgeons of England. The autopsy and audit. http://www.rcpath.org/resources/pdf/AUTOPSYANDAUDIT.pdf (accessed 6 Jan 2006).
- NHS UK Transplant website: http://www.uktransplant.org.uk (accessed 6 Jan 2006).
