Can 2 Registered Nurses (RNs) pronounce death or does a medical provider need to?

Death Pronouncement by Registered Nurses

In most healthcare settings, two registered nurses (RNs) can legally pronounce death without requiring a physician to be present, particularly in settings such as hospice, nursing homes, and for expected deaths with do-not-resuscitate orders.

Legal Framework for Death Pronouncement

Death pronouncement is distinct from death certification, which must be completed by a physician or other authorized provider:

• Pronouncement: The formal recognition that a patient has died, including documentation of absence of vital signs
• Certification: The legal determination of cause and manner of death, which must be completed by a physician, medical examiner, or coroner

Who Can Pronounce Death

The authority to pronounce death varies by:

• State laws and regulations: Each state has specific requirements
• Facility policies: Individual healthcare institutions may have their own protocols
• Practice setting: Different rules may apply in hospitals versus long-term care facilities

Evidence Supporting RN Pronouncement

Research demonstrates that RN death pronouncement is both effective and beneficial:

• A Veterans Health Administration study found that implementing RN/APRN death pronouncement policies significantly reduced delays in pronouncement time from up to 125 minutes to just 7 minutes maximum 1
• This improvement is particularly important during nights, weekends, and holidays when physicians may not be immediately available 1

Best Practices for RN Death Pronouncement

When RNs are authorized to pronounce death, the following protocol should be followed:

1. Verification of death: Confirm absence of:

   • Pulse
   • Respirations
   • Heart sounds
   • Pupillary response
   • Response to stimuli

2. Documentation requirements:

   • Time of death
   • Assessment findings
   • Notification of physician and family
   • Presence of DNR/DNAR/AND orders

3. Family support:

   • Provide time with the deceased
   • Remove medical equipment when appropriate
   • Ensure culturally sensitive treatment of the body 2
   • Offer condolences and emotional support

Special Considerations

Do-Not-Resuscitate Orders

• Modern terminology has evolved from DNR to DNAR (Do Not Attempt Resuscitation) or AND (Allow Natural Death) to better reflect the intent and create a better emotional environment 3
• RN pronouncement is most commonly authorized for patients with established DNR/DNAR/AND orders 1

Training Requirements

• Despite the frequency of death pronouncements, many healthcare providers receive limited formal training in this area
• Only 26% of medical residents reported being observed by faculty during code status discussions, and only 16% while pronouncing death 4
• Healthcare facilities should implement structured training programs for both physicians and nurses in end-of-life care

Potential Pitfalls

1. Legal concerns: Ensure compliance with state laws and facility policies before implementing RN pronouncement protocols

2. Rare cases of error: Although extremely rare, incorrect death pronouncement can occur. In organ donation cases, there have been instances where signs of life were detected after initial pronouncement 5

3. Family perception: How death is pronounced can significantly impact family grief. Physicians should act calmly, maintain appropriate appearance, introduce themselves, explain the cause of death, and use proper examination techniques 6

Conclusion

RN death pronouncement is legally permitted in many healthcare settings, particularly for expected deaths with DNR orders. This practice improves efficiency, reduces unnecessary delays, and maintains dignity in end-of-life care. Healthcare facilities should develop clear policies and provide appropriate training to ensure this process is conducted properly.