I was sent this tale at 10pm today. It concerned a doctor who had wrongly
stated that the patient was dead. The
GMC was scathing but we all know
GMC Towers are full of the living dead so they would get a bit touchy about those who failed to identify them adequately.
Nevertheless, I remembered a tale from North
Staffordshire NHS Trust. I was told this tale in the dead of night by one of the
oncall nurses on Ward 80. It essentially detailed the trials of a junior doctor who was asked to certify a patient dead on one of the elderly wards. The
Pre-Registration House Officer complete with white coat and Oxford Handbook trotted off to do the dead. He drew the curtains around the patient. Apparently, the shadows told the nursing staff at the desk that this junior took the easy way out and didn't examine the patient. He then emerged through the curtains to certify the patient dead in the notes.
Carol Black has many ideas about death certification. For every junior doctor, it is vital you get it right.
Patient.co.uk has some interesting basic ideas.
The Code of Practice for diagnosing death can be
downloaded here.So back to our intrepid house officer who certified the old lady dead one night. The mortuary attendant was called and the body placed it a body bag. The bagged up body was zipped up and placed on the trolley. While the mortuary attendant was talking to the nursing staff, the body bag began to move with muffled sounds. The sounds became louder and louder. The patients around the ward called for help. There was a scream " Let me out of here". Finally, the old man in the bed opposite, got up and unzipped the bag. There was the old lady, hair
aflap, screaming "What the fuck is happening? I am not dead, I am not dead". She got up, jumped off the trolley, walked to her bed, opened her own bag, got a brolly out and promptly went after the mortuary attendant. He was last seen running out of the ward in horror.
So it turned out that the patient had developed
bradycardia. She had originally been admitted for hypothermia. Apparently, the relatives mentioned that she often "looks dead" when asleep. Apologies and tea were circulated everywhere and that was the end of the matter.
I have probably certified too many people dead while on call. Certifying someone dead for the first time is always a little daunting. The
Student BMJ describes it. For me, I think I examined everything twice just to be sure. Even then, you always have this niggling suspicion that the spirit of the body is hovering above you and going "
Hey doc, you are seriously rubbish at doing that". I have no idea whether I believe in the afterlife, there isn't enough evidence but no matter how scientific you are, there is a
earie feeling to certifying someone dead minutes after they have passed away. After a while you get used to it and it become very practical. People die in various phases and it is the look of death that is the most interesting. Some people are peaceful, others die mid screaming, some die with their eyes open, others with their eyes shut. Some have a wicked or an evil glint in their eye and I think those are the ones you really have to worry about :). Once you have got over these ideas, certifying someone dead is pretty simple. It isn't rocket science, you just have to make sure you get it right.
I think the most important issues to remember are the following
1. Ensure you go through the motions of diagnosing death. You should ensure that you document everything in the
patient's notes.
2. Ensure the relatives asked to sit away from the patient while you do your examination.
3. If the relatives are there, it is important to give them your condolences. You should also say that if they wish to ask any further questions, the team should be able to respond in the morning. If the patient is one of yours, you should ask them to come back after they have mourned if they wish to ask any further questions. I always found it good practice to ensure the nursing staff provided the relatives with a
leaflet on bereavement which contained the relevant contacts. A good website is
Cruise Bereavement Care. It is amazing how far a little bit of kindness goes especially with relatives who are severely traumatised after a difficult death of a loved one.
4. Some relatives may wish to complain, in which case a good method is to refer them to the Patient Advice
Liaison department at the hospital.
With respect to reporting deaths to the Coroner,
the MPS has some good advice. This should though be discussed with all your team. The
MPS might be an oddity in terms of a defence union but they have some excellent
factsheets for medical students and junior doctors. The S
tudent BMJ also has some interesting directives. In North
Staffordshire NHS Trust, the only good thing there was the Bereavement Officer Joan. She was lovely, always had a nice smile on her face when you were bleeped the next morning to complete the death certificate [ if relevant] and or the cremation forms. Doctors do get a cremation fee for completing the forms. This is known as ash cash. I believe I often donated some of my ash cash to the relatives or families or it ended up at some charitable cause. There is something morbid about spending the money from the dead. I think the identification of the dead the next day at the mortuary was probably the most difficult issue. No one gets used to it. The Mortuary at North
Staffordshire NHS Trust is essentially the arctic. There is always an attendant resembling Igor who always has some sort of a limp. He then walks you to the body, the body is drawn out, you say it is the dead person and you walk out again. You had to then go to Joan, drink strong coffee and feel a bit queasy, you get your paperwork done and your bleep goes for yet another cardiac arrest - this time on Ward 87 :).
