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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.

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Presentation on theme: "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."— Presentation transcript:

1 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 UW Medicine

2 Who can help you or the family with questions about autopsy, death certificate completion, disposition of remains? Harborview Medical CenterHarborview Medical Center University of Washington Medical CenterUniversity of Washington Medical Center Autopsy and After Death Services: Voice mail for non-emergent messages After hours—Paging operator Autopsy coordinator: Mike Hobbs Director: Corinne Fligner, MD , or paging Autopsy and After Death Services: Voice mail for non-emergent messages After hours—Paging operator Program Manager: Jessica Malmberg Director: Corinne Fligner, MD , or paging

3 Case #1 The Medicine floor calls to tell you that Mr. G has just died. Your sign-out reads:Your sign-out reads: –65 yo male with metastatic lung cancer. Comfort care. DNAR. What do you do?

4 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 needChecklist, 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 timePronounce Death—Note date and time Notify Family/NOK (next of kin)Notify Family/NOK (next of kin) Notify AttendingNotify Attending NO: Organ Donation (HCP’s do not request)NO: Organ Donation (HCP’s do not request) Determine if the death is a Medical Examiner’s Case—Report the death if indicatedDetermine if the death is a Medical Examiner’s Case—Report the death if indicated Request Autopsy and obtain consentRequest Autopsy and obtain consent Complete ORCA Physician Death Note—forward to attendingComplete ORCA Physician Death Note—forward to attending Complete Death/Discharge SummaryComplete Death/Discharge Summary Review and sign death certificateReview and sign death certificate

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8 REQUIRED: ORCA POWERNOTE: PHYSICIAN DEATH NOTE ALSO REQUIRED IS A DEATH/DISCHARGE SUMMARY

9 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 needChecklist, 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 (for DC)Pronounce Death—Note date and time (for DC) Notify Family/NOK (next of kin)Notify Family/NOK (next of kin) Notify AttendingNotify Attending NO: Organ Donation (HCP’s do not request)NO: Organ Donation (HCP’s do not request) Determine if the death is a Medical Examiner’s Case—Report the death if indicatedDetermine if the death is a Medical Examiner’s Case—Report the death if indicated Request Autopsy and obtain consentRequest Autopsy and obtain consent Complete ORCA Physician Death Note—forward to attendingComplete ORCA Physician Death Note—forward to attending Complete Death/Discharge SummaryComplete Death/Discharge Summary Review and sign death certificateReview and sign death certificate

10 Pronouncing Death (“Pronouncing a Patient”) When you are called, find out what happened.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 familyConsider 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 sympathyIf family is present, introduce yourself, explain your role, and express sympathy Identify patient by hospital armbandIdentify patient by hospital armband

11 Pronouncing Death Examine the patient—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 deadIf all are absent, the patient is dead Time of death = time of your exam, for the most partTime of death = time of your exam, for the most part Note time of death for your note, and also for the death certificateNote time of death for your note, and also for the death certificate

12 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 contactIf 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)Introduce yourself (use your title) Deliver the messageDeliver 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 arrangedIf family wishes to see the patient, communicate with the nursing staff—there are systems in place to allow this, but they must be arranged

13 Organ Donation: Don’t Ask!

14 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

15 Organ Donation Timely notification of Admitting is important—deaths must be reported to the Organ and Tissue Procurement Agency within 1 hour of deathTimely 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 centerRequired for maintenance of accreditation as a transplantation center

16 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 needChecklist, 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 timePronounce Death—Note date and time Notify Family/NOK (next of kin)Notify Family/NOK (next of kin) Notify AttendingNotify Attending NO: Organ Donation (HCP’s do not request)NO: Organ Donation (HCP’s do not request) Determine if the death is a Medical Examiner’s Case—Report the death if indicatedDetermine if the death is a Medical Examiner’s Case—Report the death if indicated Request Autopsy and obtain consentRequest Autopsy and obtain consent Complete ORCA Physician Death Note—forward to attendingComplete ORCA Physician Death Note—forward to attending Complete Death/Discharge SummaryComplete Death/Discharge Summary Review and sign death certificateReview and sign death certificate

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

18 Medical Examiner’s Case Determine if death should be reported to the Medical Examiner before requesting an autopsyDetermine 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)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 deathsReport only those deaths which fall under the jurisdiction of the Medical Examiner—don’t report all deaths

19 Medical Examiner’s Case: What cases should be reported to the KCME? Injury or violence of any type, no matter how long ago injury occurredInjury or violence of any type, no matter how long ago injury occurred Drug overdose or poisoningDrug overdose or poisoning Unexpected death in an apparently healthy personUnexpected death in an apparently healthy person Complication of procedureComplication of procedure Death suspicious in any wayDeath suspicious in any way Person transferred from an institution (e.g., jail, detox, etc)Person transferred from an institution (e.g., jail, detox, etc) There is NO “24 hour" rule in WashingtonThere is NO “24 hour" rule in Washington

20 What is a “ME case” Every death reported to the medical examiner gets a numberEvery 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 familyNJA 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.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.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!!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!!

21 Medical Examiner Case?—That is, Should I report? 45 yo gentleman hit by car—Yes45 yo gentleman hit by car—Yes 67 yo man in MVA—found to have no significant injuries, but to have a large acute MI—Yes67 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—Yes38 yo woman with intentional acetaminophen overdose—Yes 66 yo woman with metastatic ovarian cancer and respiratory arrest 2 hrs after thoracentesis—Yes66 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—Yes89 yo woman with dementia whose family is being investigation by APS—Yes 72 yo gentleman who died of MI within 24 hrs of admission—No72 yo gentleman who died of MI within 24 hrs of admission—No 83 yo woman, suspected PE after hip fracture--Yes83 yo woman, suspected PE after hip fracture--Yes

22 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 ( ) OR TO THE DUTY PATHOLOGIST General information Website: h/examiner.aspx

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

24 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 UWMCAll 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 familiesAutopsies 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 institutionIn 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

25 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 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, …)”“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.”“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?”“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.”“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.”“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.”

26 Requesting autopsy Families may want more information or may be undecided.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.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 questionsIf 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

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

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

29 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

30 Autopsy Consent Obtain signed consent—may be signed in person or use a witnessed phone consent (operator may help): Please read the instructionsObtain 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 researchCommon 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).

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

32 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 unexpectedAutopsy 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 familyTransportation 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 UWMCUWMC 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

33 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 needChecklist, 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 timePronounce Death—Note date and time Notify Family/NOK (next of kin)Notify Family/NOK (next of kin) Notify AttendingNotify Attending NO: Organ Donation (HCP’s do not request)NO: Organ Donation (HCP’s do not request) Determine if the death is a Medical Examiner’s Case—Report the death if indicatedDetermine if the death is a Medical Examiner’s Case—Report the death if indicated Request Autopsy and obtain consentRequest Autopsy and obtain consent Complete ORCA Physician Death Note—forward to attendingComplete ORCA Physician Death Note—forward to attending Complete Death/Discharge SummaryComplete Death/Discharge Summary Review and sign death certificateReview and sign death certificate

34 Death certificate (DC) Legal document which the family will receiveLegal document which the family will receive An important public health document which is the basis for allocation of health and research fundingAn 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”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 documentIf the DC is incorrect when you are asked to sign, please let us know and we will make a correct document

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

36 Death Certificate (Insert photo of purple sheet)(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 law At UWMC, selected ARNP and PA-C can certify

37 Death certification is “backwards”—the underlying cause of death is at the end You don’t have to have four lines You don’t have to list every contributory factor

38 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!!

39 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?

40 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

41 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 Upper gastrointestinal hemorrhage Esophageal and gastric varices Hepatic cirrhosis due to probable steatohepatitis Morbid obesity. Chronic obstructive pulmonary disease

42 Here’s another way to do it !! Cirrhosis of the liver Upper gastrointestinal hemorrhage Hepatic cirrhosis Probably due to non-alcoholic steatohepatitis Morbid obesity Severe chronic obstructive pulmonary disease.

43 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.

44 Natural death is… Due to disease alone. Injury did not contribute or cause the death You will only certify natural deaths— report Un-natural deaths to the KCME

45 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

46 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

47 Complete the death certificate like this instead!! Upper gastrointestinal hemorrhage End stage liver disease (cirrhosis) Probable non-alcoholic steatohepatitis Chronic obstructive pulmonary disease

48 Resources for Death Certification s- data/Public/pubMain.htm#Handoutshttp://www.doh.wa.gov/ehsphl/chs/ch s- data/Public/pubMain.htm#Handoutshttp://www.doh.wa.gov/ehsphl/chs/ch s- data/Public/pubMain.htm#Handoutshttp://www.doh.wa.gov/ehsphl/chs/ch s- data/Public/pubMain.htm#Handouts for instructions for Washington Or https://netforum.avectra.com/eweb/Dy namicPage.aspx?Site=NAME&WebC ode=DeathCert https://netforum.avectra.com/eweb/Dy namicPage.aspx?Site=NAME&WebC ode=DeathCert For a tutorial on death certification

49 Who can help you or the family with questions about autopsy, death certificate completion, disposition of remains? Harborview Medical CenterHarborview Medical Center University of Washington Medical CenterUniversity of Washington Medical Center Autopsy and After Death Services: Voice mail for non-emergent messages After hours—Paging operator Autopsy coordinator: Mike Hobbs Director: Corinne Fligner, MD , or paging Autopsy and After Death Services: Voice mail for non-emergent messages After hours—Paging operator Program Manager: Jessica Malmberg Director: Corinne Fligner, MD , or paging

50 Thanks for your attention Please contact us at Autopsy and After Death Services if we can help you or the families of deceased patients


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