What information should be included in a sample pronouncement of death note?

Sample Pronouncement of Death Note

A comprehensive death pronouncement note should include patient identification, precise date/time/location of death, cause of death, resuscitation status, family notification details, and administrative documentation. 1, 2

Essential Patient and Death Information

Patient Identification:

• Full name, medical record number, and date of birth 1, 2
• Precise date and time of death 1, 2
• Location of death (e.g., hospital ward, ICU, emergency department, home) 2
• Name and credentials of the physician pronouncing death 3

Death Pronouncement Details:

• Time of pronouncement (if different from estimated time of death) 3
• Clinical findings confirming death: absence of pulse, respirations, heart sounds, and pupillary reflexes 4
• Method used to confirm death (e.g., cardiac monitor showing asystole, physical examination) 2

Cause of Death Documentation

Specify the underlying cause of death rather than just the mechanism:

• Document the disease or condition that initiated events leading to death 2
• Avoid non-specific terms like "cardiorespiratory failure" which describe mechanisms rather than causes 2
• For cardiovascular deaths, specify precisely (e.g., acute myocardial infarction, ventricular arrhythmia, cardiogenic shock) 2
• Document how the cause was determined (clinical judgment, laboratory findings, imaging, autopsy) 2

Resuscitation and End-of-Life Care

Document resuscitation status:

• Note presence of Do Not Attempt Resuscitation (DNAR) or Not For Resuscitation (NFR) orders 1, 2
• If resuscitation was attempted, document methods used (e.g., CPR, intubation, defibrillation, medications administered) 1, 2
• Record vital signs and neurological status prior to death 2

Medical device management:

• Document removal of tubes, lines, and medical devices unless autopsy is planned 1, 3

Family Notification and Support

Notification details are critical for family grief processing:

• Document which family members were notified, when, and by whom 1, 2, 3
• Record whether family was present at time of death 2
• Note time provided to family to be with the body 1, 3
• Document any emotional support provided to family members 1

Cultural and spiritual considerations:

• Record any cultural, religious, or spiritual practices addressed in after-death care 1, 2, 3
• Document how the body was prepared with dignity and respect 1

Research demonstrates that compassionate death pronouncement behaviors significantly affect family-perceived physician compassion and trust, including explaining patient information received, performing examination respectfully, and reassuring families about the patient's comfort. 4

Administrative and Legal Documentation

Required administrative tasks:

• Confirm death certificate was filed and by whom 1, 2, 3
• Document forms completed for funeral director 1, 2, 3
• Record whether death requires reporting to medical examiner/coroner 3
• Note if autopsy was offered to family for non-medical examiner cases 3

Healthcare provider notification:

• Document notification of primary care provider and other relevant healthcare providers 2, 3
• For pediatric deaths, ensure notification of appropriate subspecialty providers 3

Organ donation:

• Document any organ donation discussions or decisions 1, 2, 3

Bereavement Support Planning

Document bereavement interventions:

• Plans for formal condolences (card, call, letter) 1, 2, 3
• Referrals to bereavement services 1, 2, 3
• Identification of family members at risk for complicated grief 1, 2, 3

Common Pitfalls to Avoid

Critical documentation errors:

• Incomplete documentation of exact time and cause of death 1, 2
• Using vague terminology for cause of death (e.g., "cardiorespiratory failure" instead of specific underlying disease) 2
• Failure to document family notification details, which can complicate grief processing 1, 2
• Omission of cultural or religious considerations in after-death care 1, 2
• Inadequate documentation of organ donation discussions 1

Special circumstances requiring additional documentation:

• For brain death cases, death is declared after confirmation and completion of the second clinical examination and apnea test 3
• For sudden unexpected deaths in young patients (<40 years), consider circumstances suspicious for genetic etiology (drowning in experienced swimmers, unexplained seizures, family history of sudden death) and document appropriately for potential genetic testing 5