How hard can that be?
They paged me just after midnight. As I took the elevator to that floor I realized that... I had no idea how to pronounce someone dead.
OH, SHIT!
My medical school had covered all kinds of stuff about diagnosis and treatment of the living, and, in retrospect, zilch about how to tell if someone is dead.
My stomach sank as I realized I'd be learning on the fly. I buttoned my brand-new white coat and made sure I had my stethoscope.
I got to the room. Mercifully, the family had gone home for the night and there were just 2 nurses straightening things up.
The ex-patient's eyes were wide open. He stared straight ahead, pining for the fjords.
Trying to look like I knew what I was doing, I strode confidently over to the bed... then stopped as I realized I had no idea where to start.
Finally, I waved my hand in front of his eyes.
He didn't blink.
The nurses began laughing. I began sweating.
Realizing I was hopelessly lost, and blanking, one took pity on me and suggested checking his pulse and perhaps use my stethoscope. At that point I began remembering things like vital signs (or the absence thereof) and other basic proof/disproof of life.
"He's dead, um, what's your name?"
I lay in my call room the rest of the night, waiting for a page from the morgue that the guy had woken up and was wondering what kind of idiot had pronounced him dead.
Does more...current medicine teach pronouncement of death? Nursing school taught us that since we are allowed to sign a death certificate we had best know what the hell we were doing, and here's where to start--first pronounce, then deal with the family, then take away all the controlled drugs in the house, etc.
ReplyDeleteWe were sent to all "unattended deaths", and had to treat them as potential crime scenes: check for signs of break-in or violence, take all (yes, all) prescription drugs into evidence, call the coroner, notify NOK, etc. EMS would have to come out and pronounce the person dead and transport him/her. It was quite a production.
ReplyDeleteAt least you didn't say "By the power vested in me, I now pronounce you dead."
ReplyDeleteAs a geriatric nurse aide, there were several instances in which I was personally in attendance when a patient died. We were instructed to wash the patient and cover them with a sheet after the nurse assess the situation. That was our part in the process, as well as tidy up the room in anticipation of the funeral home attendant who received the body.
ReplyDeleteI don't think I was present when a patient's family was there because it was important for the family to have some sort of closure. Sometimes the doctor was called, or in later years we had a geriatric nurse practitioner who came to pronounce death, or sometimes no one was called.
However, I do recall that one of the dear, and fully empathetic but overzealously conscientious detail-oriented nurses was on duty when one of her patients died. I could see the disaster coming when the policeman was called on a Saturday morning and he came roaring up to the nursing home, sirens blaring, and into the nursing home almost swaggering through the front door, loud voice, demanding, and so on, and oh so unsympathetic. The nurse was in tears as he had made it seem as if she should have done something different than usual to maintain the patient's life and then expected her to provide everything with a snap of his fingers.
Other times, as a pharmacist, I attended many CODES, and I can surely tell about some of them, but best left unsaid for the general audience, but the most moving one was when it was getting toward the end and one of the nurses broke into singing a hymn, and we all joined in. Not a dry eye, of course.
So, I can see when a person who's not confronted the situation before, has second thoughts about the gravity of the situation in which he's supposed to 'be in charge'.
The first thing I thought of was that famous coroner's verdict: “As coroner, I must aver, I thoroughly examined her. And she’s not only merely dead, she’s really, most sincerely dead.”
ReplyDeleteI hope someone says that when I die. :)
Mom, the former ADON, tells a story from when she was just a whippersnapper nurse. Because she was taking classes at Boston College, she worked the 11-7 shift.
ReplyDeleteShe was also the only RN on her ward. Licensed less than a year. Let that one sink in.
Anyway, she had seven, yes, seven deaths on her watch one night. All were pts who were not doing well, that the head nurse on the ward had told other staff members (INCLUDING the MDs)might not last the night.
Yes, experienced nurses know things like that.
Anyway, pts 1-5 expired. As per procedure, a house MD had to pronounce the pt dead. (I know RNs do that now, but this was the Dark Ages.) Mom had already woken the MD up five times, and she says she was running out of body bags or whatever it was that expired pts were sheathed in. It was not a good night for her.
Anyway, this MD caught her as they were leaving the fifth former pt's bedside and hissed, "Don't call me again."
Mom says she resisted hissing back, "That's your job."
However, she STILL smiles slightly when recounting the last two calls to the on-call room.
I found an opthalmoscope, to look for cattle-trucking, more use than a stethoscope in this context. Also there's a big difference between recognition that life is extinct and certifying the cause of death.
ReplyDeleteIt isn't always so complicated. Recently, an elderly relative passed. She had been receiving hospice care at home. Hospice nurses only come by every few days and they were not there then. Only a pastor and myself, both medical laymen, were present. I watched her take her last breath as the pastor was reading from Psalms, and I noted the time. When he finished, I told him I thought she had left us and he said I could be right. I phoned other family members who had stepped out and they returned. Two of them checked for a pulse and signs of breathing, but I was sure anyway. We called the hospice center first, as we were instructed to do, and they told us it wasn't necessary for a medical person to confirm death. She was cleaned up by the person who had been providing home care, and we called the undertaker to pick her up. Her personal physician wrote the death certificate without having seen her -- he knew her medical history. We disposed of the controlled substances ourselves by taking them to a designated depository. It was all simple and dignified.
ReplyDeleteWe were eating dinner at local restaurant when my niece was about 5 years old. The paramedics were called to attend a man having chest pain. Ad they took him out on a stretcher, my niece unprompted stood up and started singing "Swing low Sweet Chariot" the entire way through. I'm pretty sure that poor guy thought the angels were singing him home. Or else that was God'd way of "calling it"
ReplyDeleteYears ago I was sitting and charting when I got a call from ICU asking if there was a doctor on our floor because they needed someone to pronounce a pt. I handed the phone to the Dr sitting next to me ( a podiatrist ). When he hung up he said " I've never done this before". I gave him some advise and told it would be fine, if the RN in the ICU said he was dead, he was. The pt had been a coded but for some reason the family didn't want chest compressions done. Well, the Dr. pronounced him and left the building. The CNA started to clean the dead pt and apparently with the rolling around the drugs that had been injected started to work and the pt came back ! Next day I'm sitting charting, hear a code called in the ICU and a while later the phone rings, they need a Dr to pronounce the pt from the day before. I look over at the podiatrist who's back again...
ReplyDeleteIf there was any kind of money in this The Authorities at Goofmart Pharmacy would be training us pharmacists on how to do this procedure.
ReplyDeleteI can see the printed coupon now, "10% off your next grocery purchase with every pronouncement of death."
I arrived at the hospital after my friend had passed but before the doctor had come to pronounce him. I actually felt sorry for the extremely youthful intern or resident who had to come in to to do it - he looked absolutely terrified. (This was not an unexpected death so we were all sad but calm.)
ReplyDeleteRecently a relative passed, her doctors had indicated 4 to 6 weeks and she was placed in hospice. The hospice nurse told us to be ready as she thought 72 hours. Relative was conscious and communicative, but she was gone in 74 hours. The hospice nurse told me they pick up signs through their experience. Frankly , I was stunned as I was up early on the Sunday morning getting ready to go over to see her and spend the day, when I got the call. I had seen her the day before and nothing seemed out of order.
ReplyDelete@Donna, my daughter a BC nursing school grad works cardiac ICU in major hospital and she says multiple death nights cause some of her colleagues to try and get transferred to the maternity ward, where the patients are going to live. A form of burn out or PTSD, because some of their patients have been there awhile, waiting on transplant or such.
I'm not in the medical field but a frequent patient. I'm in awe of the attention to detail, perseverance, & intelligence required to become & remain a doctor. I could actually feel your apprehension as I read this entry. Thank you for sharing your very human experiences with us.
ReplyDeleteI am from a rural county. I have a friend who is a Paramedic. A few years ago he was elected County Coroner.
ReplyDeleteNow when you call the ambulance, he can handles the paperwork for any outcome
@Bobbie: At least you didn't say "By the power vested in me, I now pronounce you dead."
ReplyDeleteI was thinking "By the power vested in me by the holy stethoscope I now pronounce you dead."
I had the exact same experience as a brand-new intern on night float. The family was still in the room, though. I awkwardly asked if they would like to remain in the room while I performed the formality of checking for a pulse. They were very gracious, but clearly, I had no idea what I was doing.
ReplyDeleteI had the exact same fear that you describe about accidentally pronouncing someone dead who was not actually dead. I'm glad to know that I wasn't alone!
As a nurse, I was famous for accommodating the residents with "drive by" pronouncements. The young MDs would be exhausted and fast asleep in their beds and I felt sorry for calling them in the middle of the night. I tried to minimize the disruption by loading the body up on a carriage and swinging right past their call room for the pronouncement. What the heck, it was right on the way to the morgue
ReplyDeleteAs a state registrar, without personal experience in this area, I did wonder how one "pronounces". At least now with technology they aren't dates/times in the future anymore.
ReplyDeleteMy dad died at home. I remember leaving my parents' house after my visit that Sunday afternoon, knowing that it was the last time.
ReplyDeleteSo my mom gets up the next morning and my dad has passed away, on the couch that was his sick bed in the living room. It was not unexpected, and she was a stoic Italian. She wasn't sure what to do, but my sister, a nurse, had come to help out. So mom did what she always did in the morning, made her coffee and got her grapefruit to eat, and sat down at the kitchen table with the newspaper.
That's where the neighbor, Debbie, came in a bit later, to find my mom and sister still at the breakfast table. Debbie walked in (no locked doors in that neighborhood), came through the living room, passing my dad's body still lying on the couch, poured a cup of coffee, sat down, and only then asked "So how's Mac this morning?".
I'm told that the look on her face with my mom and sister started laughing almost uncontrollably was quite the sight to behold.
there's a Harvard definition of death so no problem :(
ReplyDelete