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Am Fam Physician. 1998;58(1):284-285

Where do residents learn about death pronouncement? The hit medical shows on television glamorize life-saving high drama, not the business of declaring someone dead—by yourself in the middle of the night. Medical students and residents receive mixed and varied unofficial training in death pronouncement. Residents in our program report everything from watching senior residents perform full neurologic examinations on patients to determine that they were, in fact, dead, to feeling inadequate in providing comfort to families and in recording proper documentation.

The death pronouncement involves more than the actual declaration of death. It may be a relatively straightforward procedure when the death is expected and the family is not present. However, when the resident is interacting with a grief-stricken family, dealing with the death of a child, or coming to terms with the death of a personal patient, a death pronouncement is far from simple.

Where can residents turn to for help or information? The resources are scarce. A notable exception is a chapter on death pronouncement in the resident survival handbook titled On Call.1 Many of our residents found this chapter helpful in guiding them through the process.

Schmidt, Norton and Tolle offer a training program for residents about dealing with families after sudden death of a family member in the emergency department.2 They present useful guidelines for notifying families and survivors of the death of a patient.

To fill the void in our formal curriculum, we devised a workshop for residents on death pronouncement, combining didactic information, group discussion and role play. The workshop is presented in the first few weeks of internship. The protocols and role plays are excerpted in the accompanying tables.

The phone call (what you need to find out before you go to the bedside)
Determine the patient's location.
Find out if the family is present.
Ask the patient's age.
Find out the circumstances of the death (expected or sudden).
Ask if you need to be there immediately.
The patient floor (what to determine before you go into the room)
Interview the nurse: get details on the circumstances of the death, especially if the death was unexpected.
Find out if the attending physician has been called.
Ask if an autopsy is desired.
Determine if organ donation was discussed earlier with the patient and family.
Review the chart for other medical and family issues.
In the room
If the coroner is not involved and the family is not yet present, remove tubes and clean the body before family arrives.
Introduce yourself to the family.
Empathetic statements are appropriate, but do not overpersonalize them: For example, say, “I'm sorry for your loss . . .” or “This must be very hard for you.” Avoid saying, “I know what you are going through.” or “He's with God now.”
Try not to say too much; this is a time to be quiet and comforting.
Touching or hugging a family member may be appropriate.
Explain the pronouncement to the family; ask if they wish to be present.
Ask if they have any questions.
The pronouncement
Identify the patient (hospital identification tag).
Note general appearance of the body.
Note no reaction to verbal or tactile stimulation.
Note no pupillary light reflex (pupils will be fixed and dilated).
Breathing and other lung sounds will be absent.
No carotid pulse or heart sound can be heard.
Documentation
Called to pronounce___________.
Chart findings of physical examination.
Note date and time of death pronouncement (the physician time of pronouncement is the official time of death—do not delay unnecessarily).
May note that the family and attending physician were notified.
Document if the coroner was notified.
Chart if the family accepts or declines autopsy
When to call the coroner
Call if the patient was in the hospital less than 24 hours.
Call if the death had unusual circumstances.
Call if the death was associated with trauma regardless of the cause of death.
Expected death without family members present
Request that the nurse accompany you to the first few death pronouncements. For the first few death pronouncements, some residents feel uncomfortable being alone with a dead body.
Examination and documentation per protocol.
Death of a child with a parent present
Have the nurse accompany you for support and to introduce you to the family.
Be compassionate, humble and comforting in your verbal and nonverbal behavior. Sit down if the parents are sitting down. Use few words and be comfortable with silence and just “being there” for parents. A sample introduction would be, “I'm Dr. Smith. I'm terribly sorry about the death of your child. I am here to examine him/her.”
Examine the child in the parents' arms if they are holding the child.
Ask if the parents have any questions. Comfort parents. For example, say, “You can hold (child's name) as long as you want. The nurses and I are here if you need us.”
Depart the room quietly.
Unexpected death with family present
Request that the nurse accompany you for support and to introduce you.
Find out from the nurse and chart the details of the case so you can answer questions that the family may have. Defer to attending any questions you cannot answer.
Be compassionate and comforting in your verbal and nonverbal behavior. Try not to become defensive if questioned. Explain your purpose.
Ask the family if they want to be present for the examination.
Gather the family together and ask if they have any further questions or concerns. Let them know you are available if any questions arise later.
Let the family know that the coroner will be notified if circumstances warrant.

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