Death documentation

Background

• Death pronouncement and documentation is a routine but important responsibility of the emergency physician
• Proper documentation is required for legal, medicolegal, and public health purposes
• State laws vary regarding who may legally pronounce death and requirements for death certification
• The medical examiner/coroner must be notified in specific circumstances (varies by jurisdiction)

When to Notify Medical Examiner/Coroner

• Deaths due to trauma or injury
• Deaths of unknown cause
• Deaths not attended by a physician
• Deaths occurring in custody or detention
• Suspected homicide, suicide, or accidental death
• Deaths related to occupational hazard
• Deaths occurring during or after a surgical/medical procedure
• Deaths of children (especially those <3 years old)
• Deaths occurring within 24 hours of hospital admission (jurisdiction-dependent)
• Suspected abuse or neglect

Key Documentation Elements

• Date and time of death pronouncement
• Identity of pronouncing physician
• Method of confirmation: absent heart sounds, absent breath sounds, fixed dilated pupils, absence of response to stimuli
• Duration of examination (e.g., "auscultated for 1 full minute")
• Family notification: who was notified, by whom, and when
• Medical examiner notification: whether notified, case accepted or declined
• Organ/tissue donor services contacted per institutional protocol
• Whether an autopsy was discussed with family
• Personal effects disposition

Pronouncement of Death (Non-Code)

Sample Documentation

I was called to pronounce patient @NAME@ (DOB: ___; MRN: ___).

At [TIME], I examined the patient and found: no spontaneous respirations, no heart sounds auscultated for >1 minute, pupils fixed and dilated bilaterally, no response to verbal or tactile stimulation, and no corneal reflexes.

Time of death: [TIME].

Family member(s) ___ were present at bedside / were notified by phone at [TIME] by [NAME].

Medical examiner was notified / not notified (not a reportable death). Organ procurement organization was notified per institutional protocol. Attending physician: ___.

Death After Resuscitation (Code Death)

Sample Documentation

Patient @NAME@ presented to the ED in cardiac arrest with initial rhythm of ___. ACLS protocol was initiated including ___ rounds of CPR, epinephrine x___, defibrillation x___ at ___ joules.

Despite aggressive resuscitative efforts for ___ minutes, the patient did not achieve ROSC. Given the clinical scenario including ___ (e.g., prolonged downtime, refractory asystole, no reversible causes identified), the decision was made to terminate resuscitative efforts.

Time of death: [TIME].

Family was present at bedside / notified at [TIME] by [NAME]. The circumstances of the patient's death and resuscitation efforts were discussed with the family.

Medical examiner was notified at [TIME] and the case was accepted/declined. Organ procurement organization contacted at [TIME].

Total critical care time: ___ minutes (exclusive of separately billable procedures).

Termination of Resuscitation

For guidelines on termination of resuscitation, see Cardiac arrest

• Document:
  • Clinical rationale for terminating resuscitation
  • Duration of resuscitative efforts
  • Any reversible causes considered and addressed (H's and T's)
  • Family input if applicable (family presence, request to stop)

See Also

• Diagnosis of death
• Cardiac arrest
• ACLS

Documentation Pages

• General
  • Documentation for emergency physicians
  • Billing
• Components of the Medical Record
  • Review of systems documentation
  • Physical exam documentation
  • Differential diagnosis documentation
  • MDM for different chief complaints
  • MDM for different chief complaints (peds)
• Procedure and Reexamination
  • Procedure sample documentation
  • Reexamination sample documentation
• Special Documentation
  • Critical care documentation
  • Observation documentation
  • Against medical advice
  • Discharge documentation
  • Death documentation
  • Informed consent documentation
• Reference
  • Ophthalmology abbreviations