What to Do When a Patient Dies UWMC and HMC Corinne L. Fligner, MD Director, UW Pathology Autopsy and After Death Services (AADS) For UWMC, HMC, SCCA and.

What to Do When a Patient DiesUWMC and HMC

Corinne L. Fligner, MD

Director, UW Pathology

Autopsy and

After Death Services (AADS)

For UWMC, HMC, SCCA and UW Medicine

Who can help you or the family with questions about autopsy, death certificate completion,

disposition of remains?• Harborview Medical Center

• University of Washington Medical Center

Autopsy and After Death Services: 744-3078

Voice mail for non-emergent messagesAfter hours—Paging operator

Autopsy coordinator: Mike HobbsDirector: Corinne Fligner, MD

[email protected], 598-6403, or paging

Autopsy and After Death Services: 598-4205Voice mail for non-emergent messages

After hours—Paging operatorProgram Manager: Jessica Malmberg

Director: Corinne Fligner, [email protected] , 598-6403, or paging

mailto:[email protected]

Case #1

• The Medicine floor calls to tell you that Mr. G has just died.

• Your sign-out reads:– 65 yo male with metastatic lung cancer.

Comfort care. DNAR.

What do you do?

Physician (select PA/ARNP) Tasks • Checklist, instructions, and consents are in the

Expiration packet sent by Admitting—Ask Nursing to help you find the papers which you need

• Pronounce Death—Note date and time• Notify Family/NOK (next of kin)• Notify Attending• NO: Organ Donation (HCP’s do not request)• Determine if the death is a Medical Examiner’s

Case—Report the death if indicated• Request Autopsy and obtain consent• Complete ORCA Physician Death Note—forward

to attending • Complete Death/Discharge Summary• Review and sign death certificate

REQUIRED: ORCA POWERNOTE: PHYSICIAN DEATH NOTE

ALSO REQUIRED IS A DEATH/DISCHARGE SUMMARY



• Pronounce Death—Note date and time (for DC)• Notify Family/NOK (next of kin)• Notify Attending• NO: Organ Donation (HCP’s do not request)• Determine if the death is a Medical Examiner’s



Pronouncing Death (“Pronouncing a Patient”)

• When you are called, find out what happened. – If you do not know the patient, briefly review chart before you

see patient/family– Talk with the nursing staff--they may have information about

the patient and the family that will be helpful to you.– The Red expiration packet sent to the floor by Admitting

contains consents and other paper work• Consider calling the attending before you talk with family

– Do contact the attending at some point based on attending requests, service guidelines, or other discussions

– Call the attending if the death was unexpected• If family is present, introduce yourself, explain your role, and

express sympathy• Identify patient by hospital armband

Pronouncing Death• Examine the patient—

– You may try to arouse by gently calling name, rubbing face or chest, etc

– Listen and feel for heart sounds/respirations– Listen and feel for a pulse—usually carotid arteries– Check response of pupils to light: Mid-position and fixed in

death

• If all are absent, the patient is dead• Time of death = time of your exam, for the most part• Note time of death for your note, and also for the death

certificate

Calling Next of Kin (NOK)

• If family is not present, you will need to call the legal next of kin (usually), or other person identified as medical contact– If the death is anticipated, let your colleagues know who

should be called

• Introduce yourself (use your title) • Deliver the message

– “Ms. Smith, your husband died at 8:30 this evening. I am sorry for your loss.”

– If possible, tell family that patient died comfortably

• If family wishes to see the patient, communicate with the nursing staff—there are systems in place to allow this, but they must be arranged

Organ Donation: Don’t Ask!

Organ Donation

Health care providers are not to request organ/tissue donation, or counsel patients about this

At both UWMC and HMC, Admitting or Nursing Supervisor, respectively, notify the Organ and Tissue Donation Agencies, who will handle requests for organ and tissue donation

Organ Donation

• Timely notification of Admitting is important—deaths must be reported to the Organ and Tissue Procurement Agency within 1 hour of death

• Required for maintenance of accreditation as a transplantation center






AUTOPSY: KING COUNTY MEDICAL EXAMINER OR HOSPITAL (UWMC / HMC)

Medical Examiner’s Case• Determine if death should be

reported to the Medical Examiner before requesting an autopsy– ME does not require autopsy consent

• The provider’s obligation is to report cases to the King County Medical Examiner (KCME)

• Report only those deaths which fall under the jurisdiction of the Medical Examiner—don’t report all deaths

Medical Examiner’s Case: What cases should be reported to the KCME?

• Injury or violence of any type, no matter how long ago injury occurred

• Drug overdose or poisoning• Unexpected death in an apparently healthy

person• Complication of procedure• Death suspicious in any way• Person transferred from an institution

(e.g., jail, detox, etc)• There is NO “24 hour" rule in Washington

What is a “ME case”• Every death reported to the medical

examiner gets a number• NJA number: This means “No jurisdiction

assumed” –the KCME will not investigate. You can request autopsy consent from the family

• Case number: The ME will investigate, and at least review the circumstances.

• The KCME will not always perform an autopsy even if they “take jurisdiction” of a case.

• Let them know if the family or you / team would like an autopsy AND PUT THIS IN THE ORCA DEATH NOTE OR CALL THE HOSPITAL AUTOPSY / AFTER DEATH SERVICES!!

Medical Examiner Case?—That is, Should I report?

• 45 yo gentleman hit by car—Yes• 67 yo man in MVA—found to have no significant

injuries, but to have a large acute MI—Yes• 38 yo woman with intentional acetaminophen

overdose—Yes• 66 yo woman with metastatic ovarian cancer and

respiratory arrest 2 hrs after thoracentesis—Yes• 89 yo woman with dementia whose family is being

investigation by APS—Yes• 72 yo gentleman who died of MI within 24 hrs of

admission—No• 83 yo woman, suspected PE after hip fracture--Yes

Questions about the King County Medical Examiner

Page the UWMC or HMC Autopsy coordinator through hospital paging

Call the King County Medical Examiner and speak to an investigator (206-744-3232) OR TO

THE DUTY PATHOLOGISTGeneral information Website:

http://www.kingcounty.gov/healthservices/health/examiner.aspx


Autopsy--UW Medicine• All families should be offered autopsy for in hospital

deaths at UWMC and HMC (and VA, SCH)—in house autopsy rate is approximately 25% at UWMC– Medical Staff Bylaws require this– Families expect this

• Autopsies are provided at no charge to families• In our experience, and in the medical literature, in

around 20-40% of deaths, unexpected and potentially important information will be identified at autopsy—for the family, for physicians, and for the institution– Autopsies provide objective, scientific

information– Autopsies are important for pathology resident

training and for clinical training

Requesting autopsy• “I would like to discuss some issues with you that

we discuss with the families of all patients who die in the hospital.”

• “I would like to discuss the possibility of performing an autopsy on your (mother, father, …)”

• “Even though we have a good idea of what caused your father’s death, an autopsy can give us more information about how to treat others with his disease.”

• “We don’t know exactly why your husband died. An autopsy may help us determine cause of death. Would you give permission for an autopsy?”

• “An autopsy may provide helpful information for other members of your family if hereditary factors are involved.”

• “Allowing an autopsy is a valued way to contribute to medical education and increased understanding of disease, for students, trainees, and practicing physicians and other health care providers.”

Requesting autopsy• Families may want more information or may be

undecided.

• Note this in your death note, and let the family know that someone from Autopsy and After Death Services will call them the next business day.

• If family members would like to speak to a

pathologist, please contact Autopsy and After Death Services, and we can arrange to directly answer their questions

FOR THE FAMILY: AUTOPSY INFORMATION, ALSO AVAILABLE IN HEALTH ON LINEINFORMATION ALSO FOUND IN THE BLUE BEREAVEMENT PACKET


Just like any procedure on a live patient, a procedure on a dead patient (autopsy, or any limited procedure) requires consent, signed or witnessed phone consent

Staff members in Autopsy and After Death Services can assist you in obtaining the Consent from the correct person

Autopsy Consent

• Obtain signed consent—may be signed in person or use a witnessed phone consent (operator may help): Please read the instructions– I read the consent to the family on the phone when I am

doing the consenting, so that I can ask about restrictions, etc• Common restriction: No brain, or No research

– The correct LNOK must sign OR give witnessed phone consent or autopsy cannot be performed

– Durable medical power of attorney (DPOA) ends at death! This is confusing and many providers don’t realize this is true

– If the correct LNOK is not present, you can have the available LNOK or POA sign and provide their contact information, or have them call the Autopsy service with contact information

– If the family is is undecided and would like to be contacted, you can put that in the death note and we will follow up the next day (or leave a voice mail / page).

Autopsy: What happens• Performed on next business day (not weekends)

– We can work with family’s schedules, and are used to working with funeral homes

• Autopsy resident/attending will call prior to autopsy, and after autopsy (or you can contact them)

• Provisional and Final reports are in the Pathology tab in Mindscape and ORCA– Provisional report –2 days after autopsy– Final report-within 3 months after autopsy– You can observe all or part of autopsy, or we

will show the pertinent pathology at our regular Wednesday conference or at a mutually convenient time

– Some cases are presented at Medicine Autopsy conference

Autopsy for out of hospital deaths of a UW Medicine patient

• Autopsy is provided at no charge for UW Medicine patients (at the discretion of the pathologist director)—death may need to cleared by the medical examiner if it is unexpected

• Transportation costs must be paid by family (or rarely, by a division or department). Costs are modest (less than $200 one way in the greater King County region) and must be paid by the family

• UWMC Autopsy and After Death Services can help physicians or a patient’s family by answering questions, obtaining the proper consent forms and/or counseling the family, and facilitating transportation to UWMC






Death certificate (DC)• Legal document which the family will

receive• An important public health document

which is the basis for allocation of health and research funding

• Cause of death statement is considered to be “more likely than not” or “probable”

• If the DC is incorrect when you are asked to sign, please let us know and we will make a correct document

The cause of death statement On the death certificate comes from this section in the Physician Death Note

Death Certificate

• (Insert photo of purple sheet)

Who can sign the Death Certificate?

Certifying and attending physician are different

Certifying physician must have knowledge of the death, which can be conveyed by information from the attending physician or medical record

MD, DO, PA-C, ARNP and Nurse midwives can certify death, based on lawAt UWMC, selected ARNP and PA-C can certify

Death certification is “backwards”—the underlying cause of death is at the endYou don’t have to have four linesYou don’t have to list every contributory factor

Cardiorespiratory arrest

Mechanisms of death cannot stand alone

You don’t have to list any mechanisms (like cardio-respiratory arrest, shock, metabolic acidosis

There must be an underlying cause of death

CAUSE OF DEATH: NOT!!

Completing the death certificate--figuring out the

cause of death• 52 year old woman who died of massive upper

gastrointestinal hemorrhage from esophageal and gastric varices.

• She is known to have cirrhosis. • She has type 2 diabetes and morbid obesity. • She is a long time cigarette smoker with a clinical

diagnosis of COPD, although this did not directly cause her death

• She has never drunk alcohol, and her hepatitis viral serologies are negative

• How should you complete the death certificate?

1. List the underlying cause of death last

2. List the immediate cause of death in 34 A

3. Work through the chain of events in between and add contributory factors

4. IS THIS AN ADEQUATE DEATH CERTIFICATE? NO

Upper gastrointestinal hemorrhage

Esophageal and gastric varices

Cirrhosis of the liver

Morbid obesity. Chronic obstructive pulmonary disease

IS THIS AN ADEQUATE DEATH CERTIFICATE? YES—it states the etiology for the Hepatic cirrhosis

You must be specific about the underlying cause of death (etiology) or you will receive an inquiry letter from WA Vital Statistics.

List the cause of the cirrhosis like this certificate


Esophageal and gastric varices

Hepatic cirrhosis due to probable steatohepatitis

Morbid obesity. Chronic obstructive pulmonary disease

Here’s another way to do it !!

Cirrhosis of the liver


Hepatic cirrhosis

Probably due to non-alcoholic steatohepatitis

Morbid obesity

Severe chronic obstructive pulmonary disease.

What if you don’t know the underlying etiology—ie, you don’t know the cause of the cirrhosis? Indicate that!

This death certificate lists contributory causes, but does not indicate that NASH is the probable cause of the hepatic cirrhosis

Same guideline for “Metastatic carcinoma”—indicate the site, or indicate the probable site, or “undetermined primary”

Esophago-gastric hemorrhage

Esophageal & gastric varices

Cirrhosis of the liver, etiology undetermined

Morbid obesity. Severe chronic obstructive pulmonary disease.

Natural death is…

Due to disease alone.Injury did not contribute or

cause the deathYou will only certify natural

deaths—report Un-natural deaths to the

KCME

Be careful about these check boxes—don’t check them unless you are sure of the answer, and do proof read them!

You will only certify natural deaths, unless instructed by the Medical Examiner—usually in the case of an accidental fall

PLEASE DON’T USE ABBREVIATIONS—THIS IS A LEGAL DOCUMENT! Family members, insurance agents, lawyers, etc, will read this document. Write out the words!

UGIB

ESLD

PROBABLE NASH

COPD

Complete the death certificate like this instead!!


End stage liver disease (cirrhosis)

Probable non-alcoholic steatohepatitis

Chronic obstructive pulmonary disease

Resources for Death Certification

• http://www.doh.wa.gov/ehsphl/chs/chs-data/Public/pubMain.htm#Handouts

for instructions for Washington

Or

https://netforum.avectra.com/eweb/DynamicPage.aspx?Site=NAME&WebCode=DeathCert

For a tutorial on death certification

http://www.doh.wa.gov/ehsphl/chs/chs-data/Public/pubMain.htm%23Handouts






Who can help you or the family with questions about autopsy, death certificate completion,

disposition of remains?• Harborview Medical Center

• University of Washington Medical Center

Autopsy and After Death Services: 744-3078

Voice mail for non-emergent messagesAfter hours—Paging operator

Autopsy coordinator: Mike HobbsDirector: Corinne Fligner, MD

[email protected], 598-6403, or paging

Autopsy and After Death Services: 598-4205Voice mail for non-emergent messages

After hours—Paging operatorProgram Manager: Jessica Malmberg

Director: Corinne Fligner, [email protected] , 598-6403, or paging

mailto:[email protected]

Thanks for your attention

Please contact us at Autopsy and After Death Services if we can help you or the families of

deceased patients

What to Do When a Patient Dies UWMC and HMC Corinne L. Fligner, MD Director, UW Pathology Autopsy and After Death Services (AADS) For UWMC, HMC, SCCA and.

Documents

pronouncing death

parttime of death

dead time of death

sign death certificate

sign death certificatereview

death certificate completion

death services aads

paging slide