Death PE

Question 1

A palliative care patient had just died. He has a DNR order.

Tasks:
1. Talk to the wife
2. Explain your PE to the medical student
3. How do you break the news of death

Answer 1

I. Introduction
- Introduce yourself
- Inquire if she is the medical decision maker
- Ask for the advance care directive
- We’ll do a physical examination to confirm the death

II. General Appearance
- Visible respiration
- Cyanosis
- Pallor
- Level of consciousness by GCS score
	○ Call the patient for verbal stimulus
	○ Can you hear me?
	○ Open your eyes to see eye movements
	○ What's your name? to check verbal response
	○ Squeeze my fingers to check motor response
	○ If no response, can do a sternal rub/painful stimulus
	○ When I check the GCS, I'll document it

III. Inspection
- Chest wall movements
- Spontaneous movements

IV. Palpation
- Check pulses, radial pulse then carotid pulse

V. Auscultation
- Heart sounds: auscultate for 1 minute
- Lung sounds: auscultate for 3 minutes

VI. Pupil
- Check light reflex: fixed and dilated
- Corneal reflex: use a cottonwool to stimulate the cornea, if alive there is blinking
- Gag reflex

- Optional: ECG shows no rhythm
- Document examination findings

Death Certificate
- I need to complete a death certificate, which is a legal document to confirm the death
- I will not complete the death certificate if:
○ The identity is unknown
○ If cause of death is unknown
○ If there is any violent, unnatural, suspicious circumstances
○ If death was unexpected
○ If death was a result of an accident or injury
○ If patient was in custody of police or any legal authority
○ If related to healthcare and not reasonably expected
○ If within 24 hours of a medical procedure
- Notify the coroner instead in these circumstances
- If none of these circumstances are present, you need to document the death
○ Demographics:
§ Full name
§ Gender
§ Date of death
§ Place of death
§ Age of death
§ Indigenous status
○ Cause of death:
§ Part I:
□ condition that is directly related to death
® Interval between onset and death
□ Antecedent causes which are conditions present before death which gives rise to conditions leading to death
® Interval between onset and death
§ Part 2:
□ Other significant conditions contributing to death but not related to the disease/condition causing it
- I’d like to lodge it to Birth, Death, Marriages registrar of the state
——————
Explanation of Death to Relatives
- When you explain the death to the relatives, you want to use the SPIKES protocol
- Get the physical context of the conversation correctly
- Provide a private and quiet environment
- Assess how much the relatives know already about the patient’s situation and condition
- Find out how much the relatives want to know about the death and causes of the death
- Provide information about the diagnosis, treatment received, situation of the last minutes
- Offer support, respond to the relatives’ questions, and feelings; respect cultural and religious beliefs
- Prepare relative for what is expected from them now; practical advice on the matters of death and after the death