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After the death of a patient, the clinician is called upon to perform a number of tasks, both required and recommended. The clinician must plainly and directly inform the family of the death, complete a death certificate, contact an organ procurement organization, and request an autopsy. Providing words of sympathy and reassurance, time for questions and initial grief and, for people who die in the hospital or other health care facility, a quiet private room for the family to grieve is appropriate and much appreciated.

THE PRONOUNCEMENT & DEATH CERTIFICATE

In the United States, state policies direct clinicians to confirm the death of a patient in a formal process called “pronouncement.” The diagnosis of death is typically easy to make, and the clinician need only verify the absence of spontaneous respirations and cardiac activity by auscultating for each for 1 minute. Attempting to elicit pain in a patient who has died is unnecessary and disrespectful and should be avoided. A note describing these findings, the time of death, and that the family has been notified is entered in the patient’s medical record. In many states, when a patient whose death is expected dies outside of the hospital (at home or in prison, for example), nurses may be authorized to report the death over the telephone to a physician who assumes responsibility for signing the death certificate within 24 hours. For traumatic deaths, some states allow emergency medical technicians to pronounce a patient dead at the scene based on clearly defined criteria and with physician telephonic or radio supervision.

While the pronouncement may often seem like an awkward and unnecessary formality, clinicians may use this time to reassure the patient’s loved ones at the bedside that the patient died peacefully and that all appropriate care had been given. Both clinicians and families may use the ritual of the pronouncement as an opportunity to begin to process emotionally the death of the patient.

Physicians are legally required to report certain deaths to the coroner and to accurately report the underlying cause of death on the death certificate. Circumstances and causes of death that must be reported to the coroner vary between jurisdictions, and clinicians should be familiar with these. When in doubt, it is prudent to contact the coroner and document in the medical record as part of the death note the outcome of the conversation as well as the name of the person in the coroner's office with whom the clinician spoke. This reporting is important both for patients’ families (for insurance purposes and the need for an accurate family medical history) and for the epidemiologic study of disease and public health. The physician should be specific about the major cause of death being the condition without which the patient would not have died (eg, “decompensated cirrhosis”) and its contributory cause (eg, “hepatitis B and hepatitis C infections, chronic alcoholic hepatitis, and alcoholism”) as well ...

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