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. Harborview Medical Center
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:
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:
65 yo male with metastatic lung cancer. Comfort care. DNAR.
Do not forget to call the attending for unexpected deaths.
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 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

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 need
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 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

10. 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
If you are present at a death where there is no code (i.e. vent withdrawal in the ICU), don’t be afraid to wait quite a long period of time when listening/feeling for breath sounds. Disconcerting when patient breaths again after death declared. Take your time.
Call the attending for unexpected deaths. They will want to know early on.

11. 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
If you are present at a death where there is no code (i.e. vent withdrawal in the ICU), don’t be afraid to wait quite a long period of time when listening/feeling for breath sounds. Disconcerting when patient breaths again after death declared. Take your time.

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 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
Sign out family member if you anticipate a patient will die while you are not in the hospital.
Stop to see if anyone has questions about this or experiences with telling family already. Have Fligner and me role play a call.

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 death
Required for maintenance of accreditation as a transplantation center 15

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 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

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 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

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 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

20. 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!!

21. 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

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:

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 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

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 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.”

26. 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

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 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). 30

31. 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

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 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

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 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

34. 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

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)
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
(Insert photo of purple sheet)
Practice for our patient. 30 yo male with CF & PNA. Comfort care. DNAR. 36

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. CAUSE OF DEATH: NOT!! Mechanisms of death cannot stand alone
Cardiorespiratory arrest
CAUSE OF DEATH: NOT!!
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

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
Upper gastrointestinal hemorrhage
Esophageal and gastric varices
Cirrhosis of the liver
Morbid obesity. Chronic obstructive pulmonary disease
1. List the underlying cause of death last
List the immediate cause of death in 34 A
Work through the chain of events in between and add contributory factors
IS THIS AN ADEQUATE DEATH CERTIFICATE? NO

41. 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
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

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

43. Esophago-gastric hemorrhage
Esophageal & gastric varices
Cirrhosis of the liver, etiology undetermined
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”

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
Thanks for this slide

45. You will only certify natural deaths, unless instructed by the Medical Examiner—usually in the case of an accidental fall
Be careful about these check boxes—don’t check them unless you are sure of the answer, and do proof read them!

46. PLEASE DON’T USE ABBREVIATIONS—THIS IS A LEGAL DOCUMENT
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
for instructions for Washington Or
For a tutorial on death certification

49. Harborview Medical Center
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:
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