What should be included in a death summary?

Components of a Comprehensive Death Summary

A comprehensive death summary should include patient identification, date and time of death, cause of death, notification details, and relevant medical information to ensure proper documentation and continuity of care.

Patient Identification and Death Information

• Patient's full name, medical record number, and date of birth should be clearly documented 1
• Date, time, and location of death must be recorded precisely 2, 1
• Document whether the patient died during hospitalization or after discharge 2
• Record the place of death (e.g., hospital ward, ICU, emergency department) 2, 1

Cause of Death Documentation

• Document the underlying cause of death (the disease or condition that initiated events leading to death) rather than just the mechanism of death 3
• Avoid using non-specific terms like "cardiorespiratory failure" which describe mechanisms rather than causes 3
• Specify cardiovascular causes precisely (e.g., myocardial infarction, arrhythmia, cardiogenic shock) 3
• Document how the cause of death was determined (clinical judgment, laboratory findings, imaging) 2
• Note if an autopsy was performed or is planned 2
• Record if a forensic investigation was conducted and its findings 2

Resuscitation and End-of-Life Care

• Document any resuscitation attempts, including methods used (e.g., bag-mask ventilation, intubation, mechanical ventilation) 2
• Note the presence of Do Not Attempt Resuscitation (DNAR) or Not For Resuscitation (NFR) orders if applicable 2
• Record airway and ventilation requirements prior to death 2
• Document removal of medical devices, tubes, and lines (unless autopsy is planned) 1

Clinical Course and Medical Information

• Include a brief summary of the patient's hospital course leading to death 1
• Document vital signs and neurological status prior to death 2
• Record any complicating illnesses that developed during hospitalization (e.g., respiratory distress syndrome, sepsis, acute renal failure) 2
• Note any other injuries or morbidities that contributed to death 2
• Document arterial blood gas analysis and oxygen saturation if available, especially for unconscious patients 2

Family Notification and Support

• Record which family members were notified of the death 1
• Document who provided the notification and when it occurred 1
• Note if family members were present at the time of death 1
• Document time provided to the family to be with the body 1
• Record any cultural or religious considerations addressed in after-death care 1

Administrative and Legal Documentation

• Confirm that the death certificate was filed and by whom 1
• Document forms completed for the funeral director 1
• Record other healthcare providers who were notified of the patient's death 1
• Note if organ donation was discussed and any decisions made 1
• Document any forensic causes identified (e.g., suicide, homicide, child abuse) if applicable 2

Bereavement Support

• Document plans for formal condolences (e.g., card, call) 1
• Record referrals to bereavement services 1
• Identify family members at risk for complicated grief 1
• Note any bereavement resources provided to the family 1

Common Pitfalls to Avoid

• Incomplete documentation of time and cause of death 1
• Using vague terminology for cause of death (e.g., "cardiorespiratory failure") 3
• Failure to document family notification details 1
• Omission of cultural or religious considerations in after-death care 1
• Inadequate documentation of organ donation discussions 1
• Failure to specify whether an autopsy was performed or planned 2