Delegating the Notification of Death to Others

Paramedics were summoned to aid a 70-year-old woman in cardiac arrest. They attempted to resuscitate her, but on arrival at the emergency department the patient was still unresponsive and was pronounced dead. The patient's husband and daughter are waiting for news regarding the outcome of the resuscitation procedure.

Who should notify the family of the death of the patient? Is this part of the physician's responsibility, or can it be delegated to other personnel, such as nurses, chaplains, and morticians? What are the advantages and disadvantages of each approach?


Commentary

Death in the emergency department (ED) typically is sudden and unexpected. Family members often have had no time to prepare themselves for the array of decisions they confront when the death occurs. They frequently are left with no guidance from the deceased relative on her wishes concerning these decisions. Further, they must cope with the shock of the death itself in the unsettling environment of the ED. without the comforting presence of a familiar attending physician, religious advisor, or family friend.

In these cases, the ED staffs communication with the family assumes particular intensity. The staff faces an unpleasant and difficult task: breaking the news to an unprepared family that their worst fears have been realized. Moreover, the staff must proceed to raise a variety of sensitive issues with the customarily shocked and grieving relatives.

IMPORTANCE OF PHYSICIAN'S NOTIFYING FAMILY OF DEATH


The process commences with notifying the family of their relative's death. As a general rule, the physician who examined the patient and pronounced her dead should tell the family.

Two reasons support this presumption of physician notification. First, our society assigns to physicians the function of determining death. Over the years, a convention of physician notification has developed. Thus, families are probably more likely to trust in and accept the news of a death when the message is conveyed by a member of the medical profession.


Particularly in the ED, where death may have been unforeseen and the health caregivers are strangers, the physician's cultural authority lends credibility to the news that must be delivered. Second, the physician who examined the patient can explain relevant medical facts to the family. Professional knowledge and personal contact with the patient again lend credibility to the physician's statements and enable her to answer many of the questions posed by families seeking to understand what has happened.

For these two reasons, the ED physician might also attempt to reach the patient's personal physician. If the personal physician can quickly get to the ED, his prior relationship with the patient and family lends support to the conclusion that it is his duty to notify the family.

Some exceptions exist to the general rule of physician notification, however. The ED physician, at times, is needed to care for other patients. The duty to assist these patients takes immediate precedence over the duty to notify the family. The physician's choices then become to delegate notification to another staff member or to consign the family to a lengthy wait. A decision to delegate could be justified in this situation.


The physician could explain the basic information to another staff member who could relate the news to the family and offer support until the physician can meet with them. This approach reduces the uncertainty that waiting families must undergo in the ED, while allowing physicians to administer care to patients in need of medical attention. The exception must, however, be narrowly applied. Physicians must avoid citing a need to care for other patients as an excuse for delegating the unpleasant duty of notification to another staff member.

Table. Basis of Physician's Responsibility to Notify Family of Death.

1. Physicians determine that death has occurred, so families trust in and accept their news of a death.

2. The physician who examines the patient is best qualified to explain what happened.

VALUABLE CONTRIBUTIONS BY OTHERS


The desirability of physician notification of the family in no way excludes other personnel from the process. Although physicians possess the medical expertise and social authority supporting their role as initial notifiers of death, other professionals are fre­quently better equipped to address the family's emotional needs. Thus, when physicians finish their conversations with families, comfort and assistance can be offered by nurses, social workers, and chaplains.


In addition, these individuals are sometimes the appro­priate persons to discuss with families events and decisions related to the death. Ideally, the staff should constitute a team working with families who must cope with death in the ED. Communication with relatives usually does not terminate with mere notification. The ED staff must frequently continue its contact with families, for both humane and practical reasons.

As a result, relatives ought to be provided a private area in which to grieve, the services of a range of staff members, and sufficient time in which to ponder the practical questions they must resolve. In addition, many persons with experience in working with families believe it is important to provide relatives with a brief opportunity to view the body.

The patient in this case was dead on arrival (DOA) at the hospital. Because questions may exist concerning the cause of death, state law generally requires that such cases be reported to the local medical examiner or coroner. The local official decides whether to exercise jurisdiction over the case. If jurisdiction is assumed, the official becomes responsible for signing the death certificate and determining whether an autopsy and investigation should be conducted.


To assist the medical examiner or coroner, ED personnel must document in the medical record all information available on the cause of death. This official involvement in a patient's death can be disturbing to family members. Besides losing control over their loved one's body, they are often surprised and dismayed that officials view the death with any suspicion. Working with families in DOA cases comprises a special challenge for ED personnel. Careful and sensitive expla­nations of the reasons for the official procedures, as well as understanding of the family's distress, are necessities for staff members in these cases.

AUTOPSY AND ORGAN DONATION


This patient's relatives could be responsible for making decisions concerning two additional potentially upsetting matters. First, there is the possibility of autopsy. If the medical examiner or coroner chooses not to assume jurisdiction over the death, the family retains the power to authorize an autopsy. If hospital personnel believe an autopsy is desirable for medical or teaching purposes, consent must be obtained.


Many state statutes specify a hierarchy of relatives who can consent, usually assigning priority to the spouse. Second is the question of organ donation. An ED staff member should ascertain whether the deceased person made an anatomical gift or whether her relatives want to do so. When death occurs in the ED, requests for autopsy and organ donation are likely to engender greater agitation than they normally do, because the death was unexpected and because the family lacks a prior relationship with the physician and other caregivers.

CONCLUSIONS


Addressing these characteristically painful questions to family members is a delicate and formidable task demanding both skill and institutional planning. Hospitals ought to formulate policies and procedures governing family notification, DOA cases, autopsy, and organ donation. Hospital attorneys should ensure that such policies meet state legal requirements. Hospitals should also assemble teams of persons trained not only to answer a family's medical questions but also to provide emotional and spiritual assistance.


Finally, the ED staff working with family members bears a heavy emotional burden. Staff members themselves may need support and counseling to continue their work. Hospitals should acknowledge this need, as well as the ED staff's contributions, by making these services available to ED personnel.

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