How to verify the death of a patient
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Free How to verify the death of a patient

Clare Elizabeth Churcher Senior Lecturer Adult Nursing, Faculty of Life Science and Education, University of South Wales, Pontypridd, Wales
Iwan Dowie Senior Lecturer in Healthcare Law, Faculty of Life Science and Education, University of South Wales, Pontypridd, Wales

Why you should read this article:
  • To understand the steps involved in verifying the death of a patient

  • To recognise when nurses are able to verify the death of a patient

  • To be aware of how the role of the nurse in verifying death may change during the coronavirus disease 2019 (COVID-19) pandemic

When a patient dies, it is important that nurses understand their role in the verification of death. This article explains the steps required to verify the death of an adult patient. Verification of death is not a mechanistic task, but one that requires sensitivity and compassion. It is also crucial that nurses understand the legal implications of verifying a patient’s death. With the development of the current coronavirus disease 2019 (COVID-19) pandemic, nurses must also understand any changes in their role when verifying the death of a patient.

Verification or confirmation of death is the process of ascertaining whether a patient is deceased, based on a physical assessment.

Nurses can only verify a death if the patient is expected to die and has a do not attempt cardiopulmonary resuscitation (DNACPR) order in place. A DNACPR order is essential because it allows the nurse to verify the death without being concerned with the need to resuscitate the patient.

Nurses should ensure they act in accordance with local and national guidance regarding the verification of a patient’s death.

Reflective activity

How to articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of:

How this article might inform your practice when verifying a patient’s death.

How you could use this information to educate your colleagues on the appropriate steps required when verifying a patient’s death.

Nursing Standard. doi: 10.7748/ns.2020.e11561

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

clare.churcher@southwales.ac.uk

Conflict of interest

None declared

Churcher CE, Dowie I (2020) How to verify the death of a patient. Nursing Standard. doi: 10.7748/ns.2020.e11561

Disclaimer Please note that information provided by Nursing Standard is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed according to local policy and procedures. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence

Published online: 26 May 2020

Preparation and equipment

  • Verification of a patient’s death can be undertaken by an appropriately trained nurse acting in accordance with local policies and procedures. This procedure can be completed by a nurse in any setting where a patient dies, including hospitals, private residences, hospices, residential care homes, nursing homes and prisons. This article focuses on the procedure for verifying death in adult patients; it is beyond the scope of this article to discuss this procedure in child patients.

  • Nurses are usually asked to verify deaths that are expected and where a do not attempt cardiopulmonary resuscitation (DNACPR) order is in place. A DNACPR order allows the nurse to verify the death without being concerned about the need to resuscitate the patient. Doctors are required to verify unexpected deaths.

  • Verification of death differs from certification of death, which involves signing a death certificate and in the UK, can only be completed by a doctor.

  • Before a patient dies, or if the nurse suspects a patient may be dying, the nurse must check the patient’s DNACPR status to ensure the appropriate documentation is in place and dated. If there is no DNACPR order in place, the nurse would be expected to commence cardiopulmonary resuscitation (CPR) on the patient and, if they died, the death would be regarded as unexpected.

  • If the patient’s death is expected and not linked to any suspicious circumstances, it is important for the nurse to acknowledge this and to communicate it to the person’s family members sensitively. (‘Family’ refers to anyone the patient considers significant, whether they are an actual family member or not.) Family members may not always be aware when a person is approaching the end of life, but the nurse will often be able to recognise common signs, for example delirium and noisy respiratory secretions (National Institute for Health and Care Excellence (NICE) 2015). Therefore, it is important for the nurse to be honest with family members that the person’s death is imminent, which will enable them to prepare for this and assist them in coping with their bereavement and grief. The nurse should also offer family members support and information on what to expect during the dying phase.

  • It is important that the nurse uses clear language when communicating with family members, for example using the words ‘death’ and ‘dying’ in relation to the patient’s condition, rather than euphemisms such as ‘poorly’ or ‘unwell’, which may lead family members to think that the person will recover (NICE 2015, Marie Curie 2020).

  • To maintain the safety of the nurse undertaking the verification of death, Hospice UK (2020) guidance on the use of personal protective equipment (PPE) should be used in conjunction with local policy and applied to all verifications of expected adult death, irrespective of whether the patient’s coronavirus disease 2019 (COVID-19) status is ‘not suspected’, ‘suspected’ or ‘confirmed’.

  • The following equipment is required to verify a patient’s death:

    • PPE, including a surgical face mask, disposable gloves and a disposable apron as a minimum.

    • Pen torch.

    • Stethoscope.

    • Watch with a second hand.

    • Clean disposable sheet.

    • Waste disposal bag.

  • The nurse also requires access to the patient’s medical and nursing notes to record the verification of death and ensure that the doctor certifying the death is aware of the circumstances.

Key points

  • Verification or confirmation of death is the process of ascertaining whether a patient is deceased, based on a physical assessment

  • Nurses are usually asked to verify patient deaths that are expected, and where a do not attempt cardiopulmonary resuscitation (DNACPR) order is in place

  • Verifying a death is different from certifying a death, which involves signing a death certificate. In the UK, only doctors can certify the death of a patient

  • The procedure for verifying a death involves checking that the patient’s cardiac and respiratory functions are non-existent for five minutes and that there is no cerebral activity

Procedure

  • 1. Be aware of the sensitivity of the situation when a patient has died, including any cultural or religious requirements, and undertake the verification of death procedure with the utmost care and compassion.

  • 2. Adopt standard infection control precautions and undertake hand hygiene, then put on appropriate PPE, including a surgical face mask, disposable gloves and a disposable apron as a minimum.

  • 3. Confirm the identity of the patient by checking their wristband against their nursing and medical notes, and with any family members or carers who may be present.

  • 4. Identify any infectious diseases, radioactive implants and implantable medical devices, because the funeral director will need to be informed of these when the body is removed. Remember that COVID-19 may not have been documented in the patient’s medical or nursing notes.

  • 5. Leave all tubes, catheters, drains, medicine patches and pumps in situ, but terminate the flow of any medicines being administered by intravenous drip or syringe driver. Check whether the patient was taking any high doses of opioids or sedative medicines, because these can suppress the respiratory system and give the impression that the patient has ceased breathing.

  • 6. Open a clean disposable sheet onto a cleaned surface, and place a suitably cleaned stethoscope and pen torch onto the sheet. For home visits, a dressing pack may be used, containing the required gloves, apron, waste disposal bag and sheet.

  • 7. Check that the patient’s cardiac and respiratory function is non-existent for a minimum of five minutes to establish irreversible cardiorespiratory arrest and confirm that death has occurred. For at least one minute within this five-minute examination, timed using a watch with a second hand, check that:

    • There are no heart sounds on auscultation with the stethoscope.

    • There is no femoral or carotid pulse on palpation.

    • The patient does not expend any respiratory effort.

      If any of these functions return during the five-minute examination, undertake the checks again for another five minutes.

  • 8. Check that the patient has no cerebral activity. To do this:

    • Use the pen torch to check whether the patient’s pupils in both eyes are unresponsive to light, and are fixed and dilated.

    • Check the patient’s response to pain. There should be no response to pain stimulus in a patient with no cerebral activity, for example no movement or verbal response to a trapezius squeeze (gripping and twisting a portion of the trapezius muscle in the patient’s shoulder).

  • 9. Once it has been verified that the patient is dead, their body should be laid flat and their arms and legs straightened ahead of rigor mortis. This preserves the patient’s appearance, condition and dignity.

  • 10. Remove PPE in the correct order, undertake hand hygiene and place PPE in the waste disposal bag. Dispose of waste in accordance with local policy for clinical waste management. Undertake hand hygiene after removing and disposing of PPE.

  • 11. Record the death clearly and concisely in the patient’s medical and nursing notes, and on the local approved verification of death form. The patient may also have digital records that need to be completed. The verification of death form must be completed by the nurse or doctor who verified the death. Importantly, the time of death must only be recorded once the verification of death has been completed and not before the physical assessment has been undertaken or reported.

  • 12. Document the names of those present at the time of death and their relationship to the deceased. This includes all staff and family members.

  • 13. Notify the appropriate doctor of the death as soon as possible, including the date and time, according to local policy, and ensuring this information is communicated clearly.

  • 14. Ensure that any bereaved family members and friends are supported. Even when it is expected, a death can have significant emotional effects, so it is important to offer them information about professional bereavement support services, where appropriate.

  • 15. Offer support to any patients and staff in the immediate area who may have witnessed the death. They may or may not wish to discuss what has happened.

Evidence base

Caring for patients who are dying is an important role of the nurse and this care does not end once patients have died. After the death of a patient, the nurse can continue to provide care by verifying the death, providing they are deemed competent to undertake this procedure and local policy allows it.

Verification or confirmation of death simply means determining whether a person is actually deceased based on a physical assessment (Royal College of Nursing (RCN) 2020a). The Hospice UK (2020) Registered Nurse Verification of Expected Adult Death guidance states that nurses are able to verify death as long as they have received appropriate training and been deemed competent, the death is expected and there is a DNACPR order in place.

While all nurses should be able to recognise that a patient has died from the clinical signs – such as the absence of cardiac or respiratory function – they require certain clinical competencies to verify death. These competencies are a combination of practical skills, knowledge and understanding (Hospice UK 2020). Box 1 details the competencies required by nurses to verify an expected adult death; the Hospice UK (2020) guidance provides the full criteria for achieving each standard.

Box 1.

Competencies required by nurses to verify an expected adult death

  • Standard 1: the nurse is aware of their role and associated guidance

  • Standard 2: the nurse is aware of several definitions, including: who can recognise a death; who can verify a death; and what constitutes an expected or unexpected death

  • Standard 3: the nurse is aware of the medical and nursing responsibilities

  • Standard 4: the nurse understands the procedure for verification of a patient’s death

  • Standard 5: the nurse is able to follow the procedure and undertake a patient examination to verify death

  • Standard 6: the nurse is able to complete the appropriate documentation in a timely manner

  • Standard 7: the nurse knows how to support and provide appropriate information to bereaved family and friends

(Hospice UK 2020)

If the nurse feels that a death has occurred as a result of an unexpected situation, they can refuse to verify the death and request the presence of a doctor – the nurse can also do this even if the death was expected. One example of such a situation might be where a patient with a life-limiting condition and a DNACPR order in place is found dead, but the nurse suspects that the cause of death may have been suicide.

The role of the nurse in verifying the death of a patient can involve minimising the distress caused to the family, and caring for the patient before and after death (Laverty et al 2018). By verifying death in a timely manner, the nurse can also demonstrate respect for patients and family members’ cultural and religious beliefs; for example, some Christian family members may want the body to be blessed, while some Jewish and Muslim family members may wish the body to be covered. Delays in the verification of death can cause anxiety and stress to the family during the process of bereavement and grief (Hospice UK 2016).

The timing of verification of death will depend on the environment where the death has taken place. For example, in a UK community setting, a death must be verified within four hours, whereas in a hospital setting verification is required within one hour (Hospice UK 2020). It is also important to consider geographical variations. For example, the time required to transfer the body to the morgue is important because refrigeration within 4-6 hours of death is optimal to prevent natural deterioration. Timely verification of death can assist family members with bereavement during the crucial phase of moving the body to the mortuary or funeral directors (Hospice UK 2020).

Verification of death must not be confused with the certification of death. In the UK, the certification of death and the signing of the relevant documents can only be completed by a doctor (RCN 2020a). Family members will need to be made aware that there may be a time difference between the verification of death and the certification or official time of death.

Legal position on verifying death

There is no legal definition of death in the UK. Rather, death is verified by a nurse or a doctor, then the issuing of a death certificate by a doctor provides the legal confirmation of death. In the UK, there is no legal restriction on nurses undertaking verification of death; however, under UK legislation nurses are not able to certify death. In England and Wales, the ability to certify death is conferred on doctors by the Births and Deaths Registration Act 1953. In Scotland and Northern Ireland, similar powers are enshrined in the Registration of Births, Deaths and Marriages (Scotland) Act 1965, and the Births and Deaths Registration (Northern Ireland) Order 1976.

The death certificate is referred to as the medical certificate cause of death (MCCD). In the UK, to certify the death, the doctor must have seen the patient during their most recent illness before death or seen the body soon after death. If practicable, the certifying doctor should be the doctor who provided care during the patient’s last illness and should have seen the patient within 14 days before their death. However, the term ‘practicable’ also allows a doctor to sign an MCCD without having seen the patient, but on seeing the body.

During events such as the COVID-19 pandemic, doctors may be required to certify the death of patients they have not attended to, because of the large number of deaths and risks to themselves. The Coronavirus Act 2020 allows a doctor to issue an MCCD if they have seen the patient within 28 days before their death, rather than 14 days, or if they have seen the body after death. To provide clarity, the position of ‘practicability’ has been further strengthened by schedule 13 of the Coronavirus Act 2020, which allows a doctor who has not attended to the patient or seen the body to sign an MCCD, for example if the patient’s usual doctor is self-isolating or unwell themselves. Even though they may not have seen the patient before, the doctor still needs to state the cause of death to the best of their knowledge and belief. In these circumstances, where the attending doctor has not seen the patient before their death, the nurse and other healthcare professionals can assist the doctor in determining the cause of death by providing a patient history.

In policy, it is generally accepted that nurses do not verify deaths that are sudden or unexpected and where there is no DNACPR order in place; in such cases, the verification should be undertaken by a doctor, although this is not a legal requirement. However, if a nurse does not perform CPR on a patient who is obviously dying but does not have a DNACPR order in place, by implication they have verified the death, usually against policy. In the UK, there have been several fitness-to-practise cases brought by the Nursing and Midwifery Council (NMC) against nurses for not undertaking CPR in these situations (Jones-Berry 2020). The British Medical Association et al (2016) guidance states that if a patient dies without a DNACPR order in place, and where no explicit decision about CPR has been recorded in advance, there should be an initial presumption in favour of performing CPR.

The British Medical Association et al (2016) guidance also states that ‘there will be cases where healthcare professionals discover patients with features of irreversible death – for example, rigor mortis. In such circumstances, any healthcare professional who makes a carefully considered decision not to start CPR should be supported by their senior colleagues, employers and professional bodies’. In practice, this position remains ambiguous because it is not entirely clear what evidence is required to demonstrate a ‘carefully considered’ decision. Therefore, deciding to verify death without a DNACPR order, while not illegal, still leaves the nurse in a challenging position with regards to their professional accountability. To clarify their position, the NMC and RCN issued a joint statement reiterating that, in such situations, the NMC fully supports nurses ‘to use their professional judgement to decide what action should be taken in the best interests of the person in their care’ (NMC 2020).

In addition, during events such as the COVID-19 pandemic, nurses may be asked to verify the deaths of patients with no DNACPR order in place. In these circumstances, the nurse should also be supported in verifying any deaths by their employers and senior colleagues, as well as local policies and procedures (RCN 2020b).

It is not advisable for the nurse to verify deaths that have occurred under suspicious circumstances or within 24 hours of a suspected accident or incident. A doctor would usually verify the death in these cases because of the potential legal issues involved, including criminality (Laverty et al 2018). According to most NHS trust and health board policies, nurses are not generally involved in verifying death in prisons, or for patients who were under the Mental Health Act 1983, because these deaths are reportable to the coroner and a doctor is usually responsible for verification of death in these circumstances. However, where local policy allows a nurse to verify a death that would be reportable to the coroner, the body still has to be seen by a doctor before the death can be certified.

References

  1. British Medical Association, Resuscitation Council (UK), Royal College of Nursing (2016) Decisions Relating to Cardiopulmonary Resuscitation: Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. Third edition, first revision. http://resus.org.uk/dnacpr/decisions-relating-to-cpr (Last accessed: 18 May 2020.)
  2. Hospice UK (2016) Care After Death Publication Update With New Guidance for Registered Nurses on Verification of Expected Deaths. http://hospiceuk.org/about-hospice-care/media-centre/press-releases/details/2016/12/15/care-after-death-publication-updated-with-new-guidance-for-registered-nurses-on-verification-of-expected-deaths (Last accessed: 18 May 2020.)
  3. Hospice UK (2020) Special Edition of Care After Death: Registered Nurse Verification of Expected Adult Death (RNVoEAD) Guidance. http://hospiceuk.org/what-we-offer/clinical-and-care-support/clinical-resources (Last accessed: 18 May 2020.)
  4. Jones-Berry S (2020) NMC Suspends Nurse for Failing to Give CPR to Care Home Resident. http://rcni.com/nursing-standard/newsroom/news/nmc-suspends-nurse-failing-to-give-cpr-to-care-home-resident-157026 (Last accessed: 18 May 2020.)
  5. Laverty D, Wilson J, Cooper M (2018) Registered nurse verification of expected adult death: new guidance provides direction. International Journal of Palliative Medicine. 24, 4, 178-183. doi: 10.12968/ijpn.2018.24.4.178
  6. Marie Curie (2020) Telling Someone That They’re Dying. http://mariecurie.org.uk/professionals/palliative-care-knowledge-zone/individual-needs/telling-someone-that-they-are-dying (Last accessed: 18 May 2020.)
  7. National Institute for Health and Care Excellence (2015) Care of Dying Adults in the Last Days of Life. NICE guideline No. 31. NICE, London.
  8. Nursing and Midwifery Council (2020) Joint NMC/RCN Statement Regarding Decisions Relating to Cardiopulmonary Resuscitation (CPR). http://nmc.org.uk/news/news-and-updates/joint-nmc-rcn-statement-cpr (Last accessed: 18 May 2020.)
  9. Royal College of Nursing (2020a) Confirmation or Verification of Death by Registered Nurses. http://rcn.org.uk/get-help/rcn-advice/confirmation-of-death (Last accessed: 18 May 2020.)
  10. Royal College of Nursing (2020b) COVID-19 Guidance on DNACPR and Verification of Death. http://rcn.org.uk/clinical-topics/end-of-life-care/covid-19-guidance-on-dnacpr-and-verification-of-death (Last accessed: 18 May 2020.)
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