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Palliative Care Perspectives : Chapter 7: Communication : Pronouncing the Patient

"By the power invested in me by the State of California, I pronounce you dead." I do not know if a physician has ever actually said these words, but I have heard the tale of the "pronouncing resident" several times. A resident shows up at the door of a patient whom he has been called to pronounce. The family is grieving at the bedside. The resident may ask the family to leave the room while he performs the ceremony. In one variation the resident calls out this pronouncement from the doorway. Although I hope this is just a myth, it would not surprise me at all if it were true. The very sad fact is that most physicians learn nothing about how to pronounce a patient during their years of clinical training. They may watch a more senior resident do it once or twice or may follow instructions from a handbook, but they never actually receive training.38,39

Why include a section on death pronouncement in a chapter on communication? After all, the patient is usually, well, dead. The issue in death pronouncement is less "diagnosing death" than it is acknowledging the passing of a human being and helping grieving loved ones. The ritual of death pronouncement requires exquisite communication skills on the part of the clinician. Family and loved ones in their grief turn to the physician for consolation. Just as families remember how a birth is handled, so, too, will they long remember how a death is handled. This will be one of the most important moments in the lives of survivors. Beyond this, like birth, if any time in the lifecycle is sacred, it is this time.

When called to pronounce a patient, if the patient is unknown to you, first inquire about the circumstances of the death. Was it expected or not, traumatic or not? Inquire about the status of family and loved ones. Are they present or not? Did they expect the death or not? What does the caller know of their emotional state? Do they seem at peace, in shock, or angry? Such knowledge will help prepare you for notification and consolation of the family.

There is no established, "official" procedure for pronouncement. Technically, you must "certify" that the patient has died. This is usually the simplest part of the process. Death is an easy diagnosis. The first step in pronouncing a patient begins within you. This is a time to set aside other concerns, a time to focus. Try to find a calm and peaceful place within yourself before going to the bedside. It may help to pause for a moment outside the room to take a few quiet breaths, then enter the room respectfully with an open mind as to what you may find. If no one else is present, you can confirm that the patient has died and, in your own way, say goodbye. Confirming death is usually easy. In fact, in approaching most people who have died, it is obvious that they are dead. Many clinicians have shared this same experience-they cannot say exactly how they know, but they do. We can sometimes be fooled, so for confirmation and as a part of our medical ritual we tend to feel for a pulse, listen for a heartbeat, and watch for respirations. The lack of a pulse is not specific to death. People with low blood pressure frequently loose their radial pulse hours to days before they die. Prolonged periods of apnea, not breathing, and Cheyne-Stokes respirations can also be deceptive. People close to death may breath shallowly or intermittently, sometimes with pauses that last minutes. Examination of pupils is not important and may be seen as invasive by family members. Assessing response to pain or noxious stimuli, as some physicians have learned, can be incredibly offensive if done in the presence of family members and seems to me to be disrespectful of the deceased.

If family, friends, or other clinicians are present, watch for a moment and assess how they are handling the death. Some may already have acknowledged the death and be actively grieving. In such cases your main job is one of consolation. Others may not have recognized that death has come, or, more commonly, they may need your official confirmation that the person has died in order to acutely grieve. In the latter case I may listen with my stethoscope ritually (knowing that I will not hear breathing or heart sounds) before informing those present that the person is gone.

Sensitivity is necessary to assess the needs of those present at the deathbed. If people are actively grieving, we must bear in mind that this is an exceedingly private moment in which we are privileged to participate. Figuring out how to come "into sync" with acutely mourning families is most difficult. Sometimes families are engaged in very important rituals or are expressing their most personal thoughts. In such cases we must stand on the periphery and look for an opening for when they will need our assistance. In other cases there is an openness to the grief that invites participation. We are called to the circle to share and bear witness to a passing. Sometimes people seem to call out to us: "You, you doctors. You are the masters here. We are overwhelmed and on foreign soil. Help us find safe passage." Although we must acknowledge to ourselves that we, too, are on "foreign soil" and do not really understanding what death is about, we must know when to take the lead.

For example, because the immediate grief reaction is so intense, there may be a tendency for participants to hurry the first few moments of acute grief. I recall a wife who was just beginning a great sob, when she pulled it all together, cut off her grief, and asked, "I'm sure there must be some forms for me to sign." While I try to avoid telling people how they ought to grieve, it seemed she was pushing away a part of herself that really wanted to wail for a few minutes, so I said, "There will be time for all that. I want you just to sit here for a few moments to let this all settle a bit." She accepted this lead and sat, letting her grief come.

There is a time in this process when words do no justice. I think of this as the "sacred silence." This silence opens a space in which the living join the dead, together in the mystery of life and death, becoming and unbecoming.

Usually families want some time to themselves after a pronouncement visitation. My hospice nurses have taught me some of their art of giving space while staying connected with families and loved ones during this private time, which may last minutes to hours. Our nurses remain highly alert, just on the edge of the family's space and awareness. They watch for a sign that this family time has passed and their assistance is needed. A family member may stagger toward the door with a "what do we do now" expression. Just then, usually with impeccable timing, our nurses are there to help guide them through the business at hand. This amazing dance between the nurses and the family tends to go unnoticed, yet it never ceases to fill me with admiration. If there were a scene I would like to be able to show people about what makes hospice different, it would be this one-a synchrony so perfect that I suspect families and outsiders do not even notice that something special is happening. It takes great skill and compassion to do something so special that it seems to be nothing special.

When calling a family member at home to notify of a death in the hospital or nursing home, different skills are required. Physicians dread having to call people to notify them of the death of a loved one. This is particularly awful if the death is unexpected by the family. Sometimes this cannot be helped. Some people die with absolutely no warning. More often, I believe, families could be made aware that death is imminent if clinicians were more skilled in recognizing the signs of impending death. Too often families are not informed of this by clinicians, which unnecessarily compounds the shock of the phone call.

Especially if the death is unexpected by the recipient of the call, this is usually a "bad news" episode of communication. The reader may wish to review the steps in sharing bad news and consider how these steps might be modified, given that the news is not being shared in person. Consider that the person may be completely unprepared to receive bad news. You are not in control of the setting in which the news is being received. You cannot assess nonverbal communication nor show empathy with body language. You do not know who else is on the other end of the line. Given all this, it is obvious that sharing bad news by telephone stinks, but sometimes we cannot help it.

When calling to notify someone of a death, it is often difficult to assess what the recipient's understanding was of the deceased's prior condition, but it is worth trying to figure out. Will this phone call be expected or not? Getting an unexpected telephone call, especially at an awkward hour, usually implies bad news, so the introduction and advance alert should be brief. Having given the news, it can be very difficult to judge reactions over the telephone. If wailing is heard, what does that mean? You may ask questions about what is happening-who is there, what are people doing. People tend to ask a barrage of questions on the telephone. It is usually best to give only simple, short answers and let the other person know that you can discuss things in more detail at the hospital (or wherever the death happened). A common mistake is to ask the family member to come to the hospital right away. In fact, there is no hurry, and acutely distraught people can be a safety hazard on the road. Inquire whether someone is with the person or if someone can come to the hospital with the family member.

I do not think this is common practice, but it makes sense to me to give the name of a contact person at the hospital (or nursing home) for the bereaved person to ask for upon arrival. Acutely grieving people need to keep things very simple and personal. That person may be you, the caller, but may be someone else, after a change in shift, for example.

I remember being called by the nursing home when my father died. We were told to come in "right away." We knew my father was dying and suspected this was what had happened, but we were never really told. With my brother and mother, I headed for the nursing home. As we approached the nursing desk, the nurses seemed to huddle closer to one another. "Here they come, the Hallenbecks!" - they seemed to be whispering. Being the physician-son, I took the lead in approaching my father's room. In my heart I already knew Dad was dead before opening the door. He was gone. We grieved, and we were OK. However, it occurred to me later that what had happened was not OK. People should not have to "find" their fathers dead. People should not have to try to locate someone who knows something about their dead loved one when they come to the hospital or nursing home. People should be told to connect with a particular person who can guide them into the presence of the deceased and offer assistance as needed.

Follow-Up

If you had a close relationship with a patient and call to offer your condolences a few days later, such a call is almost always highly valued by family members. Indeed, this is considered exceptional for a physician, above and beyond the call of duty. Even if you do not personally call, it seems it should be the minimum standard of care that someone from your healthcare organization call, at least as a courtesy. You might also consider writing a condolence letter.40

Pronouncing a patient and consoling the bereaved immediately following a death is hard work. To do it well takes energy and great attention. If we are truly empathetic, we will encounter deep emotions such as sadness, anger, and despair, all while we are overwhelmed with other tasks and often sleep deprived as well. Pronouncing a patient reminds us that we, too, are mortal. In the faces of the deceased we may see reflected our grandmothers, grandfathers, parents and even ourselves. Clinicians may feel guilty: If only we had done this or that, then perhaps he or she would not have died. In addition, we may feel angry over the circumstances of the death. We may feel trapped by a system and a society that has not come to grips with dying. Often, we feel helpless. If you have such feelings, it only proves that you are still human. Clinicians also grieve. You may need to take some time out following a pronouncement. Even a few minutes outside in a garden may refresh you. If you are really struggling with some issue that a death raises for you, consider finding someone you trust to talk to. As a profession of healers, we do a terrible job of supporting and healing one another.

In touching death we experience a common humanity that transcends our roles as clinicians. None of us understands much about death, but in bearing witness to the passing of a fellow human being, our humanity is affirmed. In this we can all find solace.

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Palliative Care Perspectives

James L. Hallenbeck, M.D.

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Copyright 2003 by Oxford University Press, Inc.

The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.