Cold and Dead

Part of the duty of a medical resident in a teaching hospital is to formally pronounce a patient dead. When a patient dies, the nurse would call the resident-on-call to assess and examine the patient and confirm that he or she is indeed dead. Normally this is done in a timely fashion, within several minutes after the patient breathes his/her last breath, and the resident would chart the time the patient was pronounced dead. This would be the official time of death.

I understand that in a non-teaching hospital the attending doctor would be the one to call. If the doctor is not available, a nursing supervisor or a charge nurse can declare the patient dead. 

You may argue that it does not really take a lot of training to determine if a person is dead. Any reasonable person can discern this. Though there are some people you probably know who look like dead, but I’m not talking about that. So why do we need a doctor or an experienced nurse to pronounce a person dead? I think it is more for a medico-legal purpose.

Of course sometimes your judgement that a person is dead can be challenged  by somebody. The following is an actual exchange of questions and answers as recorded in a court documents:

A lawyer was cross-examining a witness, who was a pathologist.

Q: Doctor, before you performed the autopsy, did you check for a pulse?

A: No.

Q: Did you check for blood pressure?

A: No.

Q: Did you check for breathing?

A: No.

Q: So, then it is possible that the patient was alive when you began the autopsy?

A: No.

Q: How can you be so sure, Doctor?

A: Because his brain was sitting on my desk in a jar.

Q: But could the patient have still been alive, nevertheless?

A: Yes, it is possible that he could have been alive, practicing law somewhere.

Several nights ago, we had a very busy night in the ICU. I believe we had 7 admissions to the ICU in a short span of time. This is in addition to the 20 or more critically-ill patients that we already had in our unit. So “busy” may even be an understatement.

One patient that we had that night had been in the hospital for almost 2 months and had been in and out of the ICU a few times. This time around the family had decided that they would transition to comfort cares and the patient would be taken off life support. So death was imminent and expected.

For some reason, whether the medical resident was not called, or he was so busy at that time, or he was called but forgot to do it promptly, but the patient who was taken off life support was not officially pronounced dead right away. Of course everybody knew that the patient expired – the ICU nurses knew, the family members who were gathered in the room knew, and even the morgue and funeral personnel knew.

Perhaps it was assumed the he was already pronounced dead, so the body was taken down to the morgue within an hour or so after the patient died.

It was not after a few hours later that our medical resident learned that the body of our deceased patient was taken to the morgue without him officially examining the patient and pronouncing him dead.

So what would a diligent medical resident do? 

Our conscientious resident went down to the morgue in the wee hours of the morning to search for the body. He pulled out the body from the freezer. He opened the body bag. He identified the deceased patient. Then he examined the body and pronounced it dead. I know, it sounds like a plot of a horror movie. At least he had an interesting story to tell his co-residents the next morning.

A couple of days ago, I received a notice from a funeral parlor to complete and sign a death certificate. Part of the certificate is to write down the official cause of death. Since I had 3 death certificates to complete that day I checked each of the patient’s hospital electronic medical record to be accurate on what I would write. That was when I read our resident’s note on the chart and I could not help but smile: 

Patient examined in morgue. On exam patient did not respond to verbal or physical stimuli. No heart or lung sounds were heard and patient has no response to painful stimuli. Pupils were fixed and dilated. Patient pronounced dead at 0336.

Since the patient was only officially pronounced dead after a few hours in the morgue’s freezer, should I write “froze to death” as the cause of death?

Of course I did not.

(I meant no disrespect to the dead, nor do I make fun of a rather serious situation. I am just relating a light moment in the otherwise morbid world of ICU I lived in.)