What is the proper format for a death summary?

Proper Format for a Death Summary

A death summary should include patient identification, date and time of death, cause of death sequence, contributing conditions, and relevant clinical information organized in a standardized format following Utstein guidelines. 1

Core Components of a Death Summary

1. Patient Identification and Basic Information

• Patient's full name, medical record number, date of birth/age
• Date and time of death
• Location of death (ward, ICU, emergency department)
• Whether an autopsy was performed 1

2. Cause of Death Section

• Immediate cause of death (final disease or condition resulting in death)
• Underlying cause(s) of death (disease or injury that initiated events leading to death)
• Contributing conditions (significant conditions contributing to death but not resulting in underlying cause)
• Avoid listing terminal events (asystole, cardiac arrest) as causes of death 2
• Provide a logical, sequential chain of events leading to death 3

3. Clinical Course Summary

• Reason for admission/chief complaint
• Brief relevant history of present illness
• Key diagnostic findings
• Treatments provided and patient's response
• Clinical progression leading to death 1

4. Circumstances of Death

• How the patient died (multiorgan failure, intractable shock, brain death, withdrawal of life support) 1
• Whether CPR was attempted and when it was stopped
• Whether family was present
• Whether organ donation was considered/performed 1

5. Medical Interventions Prior to Death

• Life-sustaining treatments used (mechanical ventilation, vasopressors)
• Number of defibrillations if applicable
• Use of continuous renal replacement therapy (CRRT) 1, 4
• Temperature management if used 1

Important Laboratory and Clinical Parameters to Include

• Initial and highest serum lactate levels
• Initial, highest, and lowest potassium levels
• Arterial oxygen tension (PaO₂) values if relevant
• Neurological function tests performed 1
• Final vital signs and laboratory values relevant to the cause of death

Documentation Best Practices

1. Use clear, specific terminology rather than vague descriptions
2. Avoid abbreviations that could be misinterpreted
3. Present information in chronological order
4. Differentiate between confirmed diagnoses and suspected conditions
5. Document the time CPR was initiated and stopped if applicable 1

Common Pitfalls to Avoid

• Listing mechanisms of death (cardiac arrest, respiratory failure) as the sole cause of death 2
• Oversimplification of complex medical conditions
• Omitting the underlying cause that initiated the sequence of events
• Using vague terminology like "natural causes" without specification
• Including irrelevant clinical details that obscure the important information 5

Special Considerations

• For trauma-related deaths, include the nature of injuries and circumstances
• For infectious causes, specify the organism if known
• For surgical patients, include the procedure, date, and any complications 4
• For patients with do-not-attempt-resuscitation orders, document this status 1

By following this structured approach to death summaries, healthcare providers can ensure accurate documentation for both medical records and statistical reporting purposes, which ultimately contributes to improved quality of care and more meaningful mortality data.