special subjects
The Dying Patient
Supporting Caregivers after Death
A physician, nurse, or other authorized person should pronounce the patient dead in a timely way to reduce the family's anxiety and uncertainty. The physician should complete the death certificate as soon as possible because funeral directors need a completed death certificate to make final arrangements. Even when death is expected, physicians may need to report the death to the coroner or police; knowledge of local law is important. Telling family members about death, particularly unexpected death, requires planning and composure. The physician should use clear language when informing the family that death has occurred (eg, using the word "died"). Euphemisms (eg, "passed on") should not be used because they are easily misinterpreted. If the family was not present near death, clinicians should describe what happened, including resuscitative efforts and the patient's absence of pain and distress (if true). (If resuscitation is done, family or caregivers may prefer to witness it; no evidence indicates that their presence worsens resuscitative outcomes or family grieving.) Prudence calls for trying to ensure that close kin do not hear the news alone. When told about death, especially unexpected death, family members may be overwhelmed and unable to process information given to them or to formulate questions. Physicians, nurses, and other health care practitioners should respond to the psychologic needs of family members and provide appropriate counseling, a comfortable environment where family members can grieve together, and adequate time for them to be with the body. Before family members see the body, stains and tubes should be removed and odors should be masked whenever possible. When feasible, it may help for a clinician to be with the family members as they enter the room with the newly dead body because the situation is so unfamiliar to most people. Sometimes it is best to leave family members alone for a while, then return and offer explanations of treatments provided and give the family a chance to ask questions. Friends, neighbors, and clergy may be able to help provide support. Clinicians should be sensitive to cultural differences in behavior at the time of death. The patient can decide about organ and tissue donation, if appropriate, before death, or family members and the clinical care team can discuss organ and tissue donation before or immediately after death; such discussions are ordinarily mandated by law. The attending physician should know how to arrange for organ donation and autopsy, even for patients who die at home or in a nursing home. Autopsy should be readily available regardless of where the death occurred, and decisions about autopsies can be made before death or just after death. A substantial minority of families welcome an autopsy to clear up uncertainties, and clinicians should appreciate the role of autopsy in quality assessment and improvement. 