Breaking bad news, Death & Its Certification

Question 1

How should the evironment be set up to break bad news in?

Answer 1

1. Make an appointment and ensure no interruptions
2. Ensure that you are up-to-date on all the latest information—about the disease itself and the latest patient condition. (Have you seen them that morning?)
3. Talk in pleasant, homely surroundings, away from busy clinical areas
4. Ensure that you are appropriately dressed (e.g. not covered in blood from a failed resuscitation attempt)
5. Suggest that family members or friends come along to support
6. Invite other members of the MDT (usually a nurse) who are involved in the patients care

Question 2

What communication tips are there for breaking bad news in the set up to tell someone?

Answer 2

• Begin with introductions and context
  
  • (‘I am Dr Brown, the doctor in charge of your mother’s care since arriving in the hospital. This is Staff Nurse Green. I already know Mrs Jones but perhaps I could also know who everyone else is?’).
  • It is sometimes useful to make some ‘ice-breaking’ non-medical comments (e.g. ‘How was the journey?’), but do not be flippant
• Establish what is already known
  
  • (‘A lot has happened here today—perhaps you could begin by telling me what you already know?’
  • or in a non-acute setting ‘When did you last speak to a doctor?’)
• Set the scene and give a ‘warning shot’.
  
  • (‘Your mother has been unwell for some time now, and when she came in today, she had become much more seriously ill’
  • or ‘I’m afraid I have some bad news’)

Question 3

What are some communication tips for explaining the bad news?

Answer 3

1. Use simple jargon-free language to describe events, giving ‘bite-sized’ chunks of information, gauging comprehension and response as you go
2. Avoid euphemisms—
   
   • say ‘dead’ or ‘cancer’ if that is what you mean.
   • Avoid false reassurances and platitudes
3. Allow time for the news to sink in
   
   • long silences may be necessary;
   • try not to fill them because you are uncomfortable
4. Allow time for emotional reactions, and reassure in verbal and non-verbal ways that this is an acceptable and normal response
5. Encourage questions

Question 4

What communication tips are there for breaking bad news for the rest of the conversation once you have said the news?

Answer 4

1. Do not be afraid to show your own emotions, while maintaining professionalism—strive for genuine empathy
2. Summarize and clarify understanding if possible.
   
   • If you feel that the message has been lost or misinterpreted, ask them to summarize what they have been told, allowing reinforcement and correction.
   • Complex medical terms are usefully written down to take away and show to relatives or look up
3. Someone should stay for as long as is needed, and offer opportunity for further meeting to clarify questions that will come up later
4. Document your meeting carefully in the medical notes

Question 5

What cannot be done until a patient is declared dead?

Answer 5

declaring death is not urgent but a patient cannot be transferred into the morturary until they are declared dead

Question 6

What are the 3 stages to delarign death

–> after shouting name/ getting to wake up gently/try and pinch traps, peripheral pulse etc

Answer 6

1. confirm cardiorespiratory arrest
   
   • observe patients for 5 mins
2. confirm absence of motor response
   
   1. pupil response to light (fixed, dilated in death)
   2. corneal reflex
   3. supra-orbital pressure
3. DOCUMENTATION

Question 7

What do you do in your observation of patietns for 5 mins to confirm cardiorespiratory arrest?

Answer 7

For 1 minute of each:

1. Auscultate HS
2. Auscultate HS alternate location
3. Palpate carotids
4. auscultate breath sounds
5. auscultate breath sounds alternate location

Question 8

1a - pulmonary embolism (6hrs)

1b - fractured femur (7days)

1c - osteoporosis (30years)

2 - ischaemic heart disease

what do these represent in declaring death?

Answer 8

• the medical certificate cause of death section
• the cause of death is most complciated part
  
  • (in brackets is ?the amount of time they had the condition for?)
• • may also need to do a cremation form
    
    • (for saying theres no pacemaker?)

Question 9

Under what circustances should a death be reported to a coroner?

Answer 9

1. a doctor did not treat the person during their last illness
2. a doctor did not see or treat the person for the condition from which they died within 28 days of death
3. the cause of death was sudden, violent or unnatural such as an accident, or suicide
4. the cause of death was murder
5. the cause of death was an industrial disease of the lungs such as asbestosis
6. the death occurred in any other circumstances that may require investigation

(basically if its unexpected e.g. from a disease a dr didnt treat or murder/accident/suicide/working conditions)

Question 10

When should a death in a hospital be reported?

Answer 10

• if there is a question of negligence or misadventure about the treatment of the person who died
• they died before a provisional diagnosis was made and the GP is not willing to certify the cause
• the patient died as the result of the administration of an anaesthetic

Question 11

When should a death be reported to a coroner by the police?

Answer 11

• when a dead body is found
• death is unexpected or unexplained
• a death occurs in suspicious circumstances

Question 12

In what place should the death of a person always be reported no matter the cause?

Answer 12

A death should be reported by the Governor of a prison immediately following the death of a prisoner no matter what the cause of death is.

Question 13

Who are coroners?

Answer 13

• Coroners are officers appointed by the Council to investigate any sudden or unexplained death.
• They are independent of both local and central government.
• The police, a doctor, or the registrar may report a death to the coroner.
• The registrar must await the outcome of the coroner’s enquiries before registering the death, so families should delay making funeral arrangements

Question 14

What is a “part A” certificate?

Answer 14

• Part A certificate is issued by the coroner & permits the doctor to write a death certificate.
  
  • –> if the body has needed reporting to the coronor
• A part A certificate records that you have discussed the case (?for what to write for cause of death) with them but more commonly informal telphone advice is given
• • if you feel that the case is contentious ensure that a “Part A” is issued to protect you
    
    • if in doubt discuss your case with the coroner
    • Only a minority of deaths that that are reported will end up with a coroners post-mortem or an inquest

NB: the coroners officers can advise you about acceptable causes of death on a certificate but are not medically qualified

Question 15

Should the following be discussed with the coroner?

• Cases of pressure sores or severe malnutrition at home (neglect is possible)
• Cases of falls, especially where the incident is not fully explained or where injury from the fall contributed to death
• Post-operative cases
• Mesothelioma and occupational disease (compensation may rely on a post-mortem)
• Have a low threshold for reporting deaths when relatives are unhappy with social care or pre-hospital or hospital care, or are overtly litigious

Answer 15

these are not under UK law but should be considered

Question 16

Should the following be discussed with the coroner?

• Death occurred in police custody or in prison
• No doctor has treated the deceased during the last illness
• The attending doctor did not see the patient within 14 days of death
• Death occurred during an operation or before recovery from anaesthesia
• Death was sudden and unexplained or in suspicious circumstances
• Death may be due to an industrial injury or disease, or to accident, violence, neglect, or abortion, or to any kind of poisoning (this may include injurious falls and head injuries)
• Some coroners also like to be informed when death occurred <24h after admission to hospital, but this is not a legal requirement

Answer 16

yes under UK law these must be reported

Question 17

Who can verify death?

Answer 17

• Confirmation that death has occurred and may be performed by an appropriately trained professional before a body can be moved to the mortuary.
  
  • doctor,
  • nurse, or
  • paramedic

Question 18

How is death verified and documented?

Answer 18

Verification of death:

• Absence of response to pain/stimulation
• Fixed dilated pupils
• Absence of a pulse, heart sounds, respiratory movements, and breath sounds (examine for at least a minute) [min 5 mins total]
  
  • Some of these tests can be done simultaneously to save time.

Always record your findings in full, along with:

• the time of death,
• persons present,
• time of verification.

Question 19

What is the certification of death?

Answer 19

medical certificate of cause of death

aka death certificate

Question 20

Why is the Medical certificate of cause of death (MCCD) AKA death certificate important?

Answer 20

It is an important duty and legal requirement of the doctor that has recently been looking after the patient

—it allows the family to arrange a funeral and provides very important statistics for disease surveillance and public health.

Question 21

What is key with recording cause of death?

Answer 21

• Always record as much information as possible, e.g.:
  
  • Ia Aspiration pneumonia
  • Ib Left total anterior circulation infarction
  • Ic Non-insulin-dependent diabetes, atrial fibrillation
  • II Parkinson’s disease, peripheral vascular disease i.e. other diagnoses
• Be as precise as possible, e.g.:
  
  • When stating cardiac/renal/liver ‘failure’, qualify it with a more precise cause (e.g. heart failure due to ischaemic heart disease)
• When a patient died of a septicaemic syndrome, where possible, state the causative organism and source
  
  • (e.g. ‘Escherichia coli bacteraemia due to ascending urinary tract infection’)

Question 22

When is old age an acceptable cause of death?

Answer 22

in the very elderly person

who has had a non-specific decline

and reasonable assessments to exclude serious treatable disease

Question 23

What are the cirteria for a doctor to be able to write a death certificate for a patient?

Answer 23

• You must have seen the patient alive during their recent illness to write a certificate
• (usually in the last 2 weeks)
  
  • sometimes the GP writes a certificate for a hospital patient
    
    • and vice versa if the patient has recently moved between sites

Question 24

NB:

The process of death certification is currently being reformed in the UK to incorporate a medical officer who will issue all certificates in a locality.

Once the system (of medical officer) is introduced, cremation forms will no longer be required

In the meantime… how many parts are there to a cremation form?

Answer 24

There are two parts to a cremation form, completed by different doctors who should not be related or work on the same team.

• You must have looked after the patient in their terminal illness to complete Part I –> If you do not know the patient well, examine the body, the CXR, and the ECG for evidence of a pacemaker.
• In contrast, a Part II doctor should not have known the patient and is required by law to be an impartial examiner of the case before the evidence (the body) is cremated. You must be a senior doctor (2 years post-MRCP/FRCS) to complete Part II
  
  • Ensure that you have seen the medical notes and have personally questioned the Part I doctor and one other person who knew the deceased (another doctor, nurse, or relative).
  • If there are problems with the certificate or Part I, they can be corrected or reissued. Sometimes you may need to suggest the case is discussed with the coroner

Question 25

Where can families go in hospitals for help with coordinating the paperwork required after a death & for information about registration and funeral arrangements?

Answer 25

Brereavement services

most hospitals now have a bereavement office

• Bereavement officers provide a friendly, easily accessible interface between the hospital and relatives
• and can refer to voluntary bereavement support groups

Question 26

Who can obtain consent for/co-ordinate post-mortems with the family?

Answer 26

the bereavemement officers

If no family comes forward or if they are incapable/unwilling to arrange a funeral, the hospital (usually via the bereavement office) will arrange and pay for a low-cost cremation

Question 27

Can the family of a deceased pt refuse post mortem?

Answer 27

if The coroner wants to initiate a post-mortem for legal reasons or where no doctor is able to write a certificate

—the family cannot veto this

Question 28

What is the point of a consented hopsital post mortem?

Answer 28

This IS at the familys discretion

& consented hospital post-mortems are useful for education and audit:

• especially in unusual or difficult cases.
• The rate of hospital post-mortems is declining, but careful discussion with relatives ↑ the likelihood of consent.
  
  • often coordinated by the bereavement services team
• A limited examination (e.g. restricted to the torso or one organ) is sometimes more acceptable

Question 29

If a family consents to a post-mortem can the hospital keep organs/tissue for teaching?

Answer 29

• After the Alder Hey scandal
  
  • (retention and disposal of organs from children without parental consent; Liverpool, UK, 1990s),
• –> the new laws require a separate, explicit consent for retention of tissue for examination/teaching

Question 30

What is the registrar regarding death certification?

Answer 30

• The registrar is responsible for recording all births and deaths
• The relatives have to register the death within 5 working days and this usually involves making an appointment
• The death must be registered before a funeral can be arranged
• If there is an error on the death certificate, they can refuse to register the death and will refer the case back to the certifying doctor