Autopsy and After Death Services at UWMC and HMC

1. What to Do When a Patient Dies UWMC and HMC Corinne L. Fligner, MD Corinne L. Fligner, MD Director, UW Pathology Director, UW Pathology Autopsy and Autopsy and After Death Services (AADS) After Death Services (AADS) For UWMC, HMC, SCCA and UW Medicine For UWMC, HMC, SCCA and UW Medicine

2. Who can help you or the family with questions about autopsy, death certificate completion, disposition of remains? Who can help you or the family with questions about autopsy, death certificate completion, disposition of remains? Harborview Medical Center Harborview Medical Center University of Washington Medical Center University of Washington Medical Center Autopsy and After Death Services: 744-3078 Voice mail for non-emergent messages After hoursPaging operator Autopsy coordinator: Mike Hobbs Director: Corinne Fligner, MD fligner@uw.edu , 598-6403, or paging Autopsy and After Death Services: 598-4205 Voice mail for non-emergent messages After hoursPaging operator Program Manager: Jessica Malmberg Director: Corinne Fligner, MD fligner@uw.edu , 598-6403, or paging

3. Case #1 The Medicine floor calls to tell you that Mr. G has just died. Your sign-out reads: Your sign-out reads: 65 yo male with metastatic lung cancer. Comfort care. DNAR. 65 yo male with metastatic lung cancer. Comfort care. DNAR. What do you do?

4. Physician (select PA/ARNP) Tasks Physician (select PA/ARNP) Tasks Checklist, instructions, and consents are in the Expiration packet sent by AdmittingAsk Nursing to help you find the papers which you need Checklist, instructions, and consents are in the Expiration packet sent by AdmittingAsk Nursing to help you find the papers which you need Pronounce DeathNote date and time Pronounce DeathNote date and time Notify Family/NOK (next of kin) Notify Family/NOK (next of kin) Notify Attending Notify Attending NO: Organ Donation (HCPs do not request) NO: Organ Donation (HCPs do not request) Determine if the death is a Medical Examiners CaseReport the death if indicated Determine if the death is a Medical Examiners CaseReport the death if indicated Request Autopsy and obtain consent Request Autopsy and obtain consent Complete ORCA Physician Death Noteforward to attending Complete ORCA Physician Death Noteforward to attending Complete Death/Discharge Summary Complete Death/Discharge Summary Review and sign death certificate Review and sign death certificate

8. REQUIRED: ORCA POWERNOTE: PHYSICIAN DEATH NOTE ALSO REQUIRED IS A DEATH/DISCHARGE SUMMARY

9. Physician (select PA/ARNP) Tasks Physician (select PA/ARNP) Tasks Checklist, instructions, and consents are in the Expiration packet sent by AdmittingAsk Nursing to help you find the papers which you need Checklist, instructions, and consents are in the Expiration packet sent by AdmittingAsk Nursing to help you find the papers which you need Pronounce DeathNote date and time (for DC) Pronounce DeathNote date and time (for DC) Notify Family/NOK (next of kin) Notify Family/NOK (next of kin) Notify Attending Notify Attending NO: Organ Donation (HCPs do not request) NO: Organ Donation (HCPs do not request) Determine if the death is a Medical Examiners CaseReport the death if indicated Determine if the death is a Medical Examiners CaseReport the death if indicated Request Autopsy and obtain consent Request Autopsy and obtain consent Complete ORCA Physician Death Noteforward to attending Complete ORCA Physician Death Noteforward to attending Complete Death/Discharge Summary Complete Death/Discharge Summary Review and sign death certificate Review and sign death certificate

10. Pronouncing Death (Pronouncing a Patient) Pronouncing Death (Pronouncing a Patient) When you are called, find out what happened. When you are called, find out what happened. If you do not know the patient, briefly review chart before you see patient/family If you do not know the patient, briefly review chart before you see patient/family Talk with the nursing staff--they may have information about the patient and the family that will be helpful to you. Talk with the nursing staff--they may have information about the patient and the family that will be helpful to you. The Red expiration packet sent to the floor by Admitting contains consents and other paper work The Red expiration packet sent to the floor by Admitting contains consents and other paper work Consider calling the attending before you talk with family Consider calling the attending before you talk with family Do contact the attending at some point based on attending requests, service guidelines, or other discussions Do contact the attending at some point based on attending requests, service guidelines, or other discussions Call the attending if the death was unexpected Call the attending if the death was unexpected If family is present, introduce yourself, explain your role, and express sympathy If family is present, introduce yourself, explain your role, and express sympathy Identify patient by hospital armband Identify patient by hospital armband

11. Pronouncing Death Pronouncing Death Examine the patient Examine the patient You may try to arouse by gently calling name, rubbing face or chest, etc You may try to arouse by gently calling name, rubbing face or chest, etc Listen and feel for heart sounds/respirations Listen and feel for heart sounds/respirations Listen and feel for a pulseusually carotid arteries Listen and feel for a pulseusually carotid arteries Check response of pupils to light: Mid-position and fixed in death Check response of pupils to light: Mid-position and fixed in death If all are absent, the patient is dead If all are absent, the patient is dead Time of death = time of your exam, for the most part Time of death = time of your exam, for the most part Note time of death for your note, and also for the death certificate Note time of death for your note, and also for the death certificate

12. Calling Next of Kin (NOK) Calling Next of Kin (NOK) If family is not present, you will need to call the legal next of kin (usually), or other person identified as medical contact If family is not present, you will need to call the legal next of kin (usually), or other person identified as medical contact If the death is anticipated, let your colleagues know who should be called If the death is anticipated, let your colleagues know who should be called Introduce yourself (use your title) Introduce yourself (use your title) Deliver the message Deliver the message Ms. Smith, your husband died at 8:30 this evening. I am sorry for your loss. Ms. Smith, your husband died at 8:30 this evening. I am sorry for your loss. If possible, tell family that patient died comfortably If possible, tell family that patient died comfortably If family wishes to see the patient, communicate with the nursing staffthere are systems in place to allow this, but they must be arranged If family wishes to see the patient, communicate with the nursing staffthere are systems in place to allow this, but they must be arranged

13. Organ Donation: Dont Ask! Organ Donation: Dont Ask!

14. Organ Donation Organ Donation Health care providers are not to request organ/tissue donation, or counsel patients about this Health care providers are not to request organ/tissue donation, or counsel patients about this At both UWMC and HMC, Admitting or Nursing Supervisor, respectively, notify the Organ and Tissue Donation Agencies, who will handle requests for organ and tissue donation At both UWMC and HMC, Admitting or Nursing Supervisor, respectively, notify the Organ and Tissue Donation Agencies, who will handle requests for organ and tissue donation

15. Organ Donation Organ Donation Timely notification of Admitting is importantdeaths must be reported to the Organ and Tissue Procurement Agency within 1 hour of death Timely notification of Admitting is importantdeaths must be reported to the Organ and Tissue Procurement Agency within 1 hour of death Required for maintenance of accreditation as a transplantation center Required for maintenance of accreditation as a transplantation center

16. Physician (select PA/ARNP) Tasks Physician (select PA/ARNP) Tasks Checklist, instructions, and consents are in the Expiration packet sent by AdmittingAsk Nursing to help you find the papers which you need Checklist, instructions, and consents are in the Expiration packet sent by AdmittingAsk Nursing to help you find the papers which you need Pronounce DeathNote date and time Pronounce DeathNote date and time Notify Family/NOK (next of kin) Notify Family/NOK (next of kin) Notify Attending Notify Attending NO: Organ Donation (HCPs do not request) NO: Organ Donation (HCPs do not request) Determine if the death is a Medical Examiners CaseReport the death if indicated Determine if the death is a Medical Examiners CaseReport the death if indicated Request Autopsy and obtain consent Request Autopsy and obtain consent Complete ORCA Physician Death Noteforward to attending Complete ORCA Physician Death Noteforward to attending Complete Death/Discharge Summary Complete Death/Discharge Summary Review and sign death certificate Review and sign death certificate

17. AUTOPSY: KING COUNTY MEDICAL EXAMINER OR HOSPITAL (UWMC / HMC)

18. Medical Examiners Case Medical Examiners Case Determine if death should be reported to the Medical Examiner before requesting an autopsy Determine if death should be reported to the Medical Examiner before requesting an autopsy ME does not require autopsy consent ME does not require autopsy consent The providers obligation is to report cases to the King County Medical Examiner (KCME) The providers obligation is to report cases to the King County Medical Examiner (KCME) Report only those deaths which fall under the jurisdiction of the Medical Examinerdont report all deaths Report only those deaths which fall under the jurisdiction of the Medical Examinerdont report all deaths

19. Medical Examiners Case: What cases should be reported to the KCME? Medical Examiners Case: What cases should be reported to the KCME? Injury or violence of any type, no matter how long ago injury occurred Injury or violence of any type, no matter how long ago injury occurred Drug overdose or poisoning Drug overdose or poisoning Unexpected death in an apparently healthy person Unexpected death in an apparently healthy person Complication of procedure Complication of procedure Death suspicious in any way Death suspicious in any way Person transferred from an institution (e.g., jail, detox, etc) Person transferred from an institution (e.g., jail, detox, etc) There is NO 24 hour" rule in Washington There is NO 24 hour" rule in Washington

20. What is a ME case What is a ME case Every death reported to the medical examiner gets a number Every death reported to the medical examiner gets a number NJA number: This means No jurisdiction assumed the KCME will not investigate. You can request autopsy consent from the family NJA number: This means No jurisdiction assumed the KCME will not investigate. You can request autopsy consent from the family Case number: The ME will investigate, and at least review the circumstances. Case number: The ME will investigate, and at least review the circumstances. The KCME will not always perform an autopsy even if they take jurisdiction of a case. The KCME will not always perform an autopsy even if they take jurisdiction of a case. Let them know if the family or you / team would like an autopsy AND PUT THIS IN THE ORCA DEATH NOTE OR CALL THE HOSPITAL AUTOPSY / AFTER DEATH SERVICES!! Let them know if the family or you / team would like an autopsy AND PUT THIS IN THE ORCA DEATH NOTE OR CALL THE HOSPITAL AUTOPSY / AFTER DEATH SERVICES!!

21. Medical Examiner Case?That is, Should I report? Medical Examiner Case?That is, Should I report? 45 yo gentleman hit by carYes 45 yo gentleman hit by carYes 67 yo man in MVAfound to have no significant injuries, but to have a large acute MIYes 67 yo man in MVAfound to have no significant injuries, but to have a large acute MIYes 38 yo woman with intentional acetaminophen overdoseYes 38 yo woman with intentional acetaminophen overdoseYes 66 yo woman with metastatic ovarian cancer and respiratory arrest 2 hrs after thoracentesisYes 66 yo woman with metastatic ovarian cancer and respiratory arrest 2 hrs after thoracentesisYes 89 yo woman with dementia whose family is being investigation by APSYes 89 yo woman with dementia whose family is being investigation by APSYes 72 yo gentleman who died of MI within 24 hrs of admissionNo 72 yo gentleman who died of MI within 24 hrs of admissionNo 83 yo woman, suspected PE after hip fracture--Yes 83 yo woman, suspected PE after hip fracture--Yes

22. Questions about the King County Medical Examiner Questions about the King County Medical Examiner Page the UWMC or HMC Autopsy coordinator through hospital paging Page the UWMC or HMC Autopsy coordinator through hospital paging Call the King County Medical Examiner and speak to an investigator (206-744-3232) OR TO THE DUTY PATHOLOGIST Call the King County Medical Examiner and speak to an investigator (206-744-3232) OR TO THE DUTY PATHOLOGIST General information Website: General information Website: http://www.kingcounty.gov/healthservices/healt h/examiner.aspx http://www.kingcounty.gov/healthservices/healt h/examiner.aspx

23. AUTOPSY: KING COUNTY MEDICAL EXAMINER OR HOSPITAL (UWMC / HMC)

24. Autopsy--UW Medicine Autopsy--UW Medicine All families should be offered autopsy for in hospital deaths at UWMC and HMC (and VA, SCH)in house autopsy rate is approximately 25% at UWMC All families should be offered autopsy for in hospital deaths at UWMC and HMC (and VA, SCH)in house autopsy rate is approximately 25% at UWMC Medical Staff Bylaws require this Medical Staff Bylaws require this Families expect this Families expect this Autopsies are provided at no charge to families Autopsies are provided at no charge to families In our experience, and in the medical literature, in around 20-40% of deaths, unexpected and potentially important information will be identified at autopsy for the family, for physicians, and for the institution In our experience, and in the medical literature, in around 20-40% of deaths, unexpected and potentially important information will be identified at autopsy for the family, for physicians, and for the institution Autopsies provide objective, scientific information Autopsies provide objective, scientific information Autopsies are important for pathology resident training and for clinical training Autopsies are important for pathology resident training and for clinical training

25. Requesting autopsy Requesting autopsy I would like to discuss some issues with you that we discuss with the families of all patients who die in the hospital. I would like to discuss some issues with you that we discuss with the families of all patients who die in the hospital. I would like to discuss the possibility of performing an autopsy on your (mother, father, ) I would like to discuss the possibility of performing an autopsy on your (mother, father, ) Even though we have a good idea of what caused your fathers death, an autopsy can give us more information about how to treat others with his disease. Even though we have a good idea of what caused your fathers death, an autopsy can give us more information about how to treat others with his disease. We dont know exactly why your husband died. An autopsy may help us determine cause of death. Would you give permission for an autopsy? We dont know exactly why your husband died. An autopsy may help us determine cause of death. Would you give permission for an autopsy? An autopsy may provide helpful information for other members of your family if hereditary factors are involved. An autopsy may provide helpful information for other members of your family if hereditary factors are involved. Allowing an autopsy is a valued way to contribute to medical education and increased understanding of disease, for students, trainees, and practicing physicians and other health care providers. Allowing an autopsy is a valued way to contribute to medical education and increased understanding of disease, for students, trainees, and practicing physicians and other health care providers.

26. Requesting autopsy Requesting autopsy Families may want more information or may be undecided. Families may want more information or may be undecided. Note this in your death note, and let the family know that someone from Autopsy and After Death Services will call them the next business day. Note this in your death note, and let the family know that someone from Autopsy and After Death Services will call them the next business day. If family members would like to speak to a pathologist, please contact Autopsy and After Death Services, and we can arrange to directly answer their questions If family members would like to speak to a pathologist, please contact Autopsy and After Death Services, and we can arrange to directly answer their questions

27. FOR THE FAMILY: AUTOPSY INFORMATION, ALSO AVAILABLE IN HEALTH ON LINE INFORMATION ALSO FOUND IN THE BLUE BEREAVEMENT PACKET

28. AUTOPSY: KING COUNTY MEDICAL EXAMINER OR HOSPITAL (UWMC / HMC)

29. Just like any procedure on a live patient, a procedure on a dead patient (autopsy, or any limited procedure) requires consent, signed or witnessed phone consent Staff members in Autopsy and After Death Services can assist you in obtaining the Consent from the correct person

30. Autopsy Consent Autopsy Consent Obtain signed consent may be signed in person or use a witnessed phone consent (operator may help): Please read the instructions Obtain signed consent may be signed in person or use a witnessed phone consent (operator may help): Please read the instructions I read the consent to the family on the phone when I am doing the consenting, so that I can ask about restrictions, etc I read the consent to the family on the phone when I am doing the consenting, so that I can ask about restrictions, etc Common restriction: No brain, or No research Common restriction: No brain, or No research The correct LNOK must sign OR give witnessed phone consent or autopsy cannot be performed The correct LNOK must sign OR give witnessed phone consent or autopsy cannot be performed Durable medical power of attorney (DPOA) ends at death! This is confusing and many providers dont realize this is true Durable medical power of attorney (DPOA) ends at death! This is confusing and many providers dont realize this is true If the correct LNOK is not present, you can have the available LNOK or POA sign and provide their contact information, or have them call the Autopsy service with contact information If the correct LNOK is not present, you can have the available LNOK or POA sign and provide their contact information, or have them call the Autopsy service with contact information If the family is is undecided and would like to be contacted, you can put that in the death note and we will follow up the next day (or leave a voice mail / page). If the family is is undecided and would like to be contacted, you can put that in the death note and we will follow up the next day (or leave a voice mail / page).

31. Autopsy: What happens Autopsy: What happens Performed on next business day (not weekends) Performed on next business day (not weekends) We can work with familys schedules, and are used to working with funeral homes We can work with familys schedules, and are used to working with funeral homes Autopsy resident/attending will call prior to autopsy, and after autopsy (or you can contact them) Autopsy resident/attending will call prior to autopsy, and after autopsy (or you can contact them) Provisional and Final reports are in the Pathology tab in Mindscape and ORCA Provisional and Final reports are in the Pathology tab in Mindscape and ORCA Provisional report 2 days after autopsy Provisional report 2 days after autopsy Final report-within 3 months after autopsy Final report-within 3 months after autopsy You can observe all or part of autopsy, or we will show the pertinent pathology at our regular Wednesday conference or at a mutually convenient time You can observe all or part of autopsy, or we will show the pertinent pathology at our regular Wednesday conference or at a mutually convenient time Some cases are presented at Medicine Autopsy conference Some cases are presented at Medicine Autopsy conference

32. Autopsy for out of hospital deaths of a UW Medicine patient Autopsy for out of hospital deaths of a UW Medicine patient Autopsy is provided at no charge for UW Medicine patients (at the discretion of the pathologist director)death may need to cleared by the medical examiner if it is unexpected Autopsy is provided at no charge for UW Medicine patients (at the discretion of the pathologist director)death may need to cleared by the medical examiner if it is unexpected Transportation costs must be paid by family (or rarely, by a division or department). Costs are modest (less than $200 one way in the greater King County region) and must be paid by the family Transportation costs must be paid by family (or rarely, by a division or department). Costs are modest (less than $200 one way in the greater King County region) and must be paid by the family UWMC Autopsy and After Death Services can help physicians or a patients family by answering questions, obtaining the proper consent forms and/or counseling the family, and facilitating transportation to UWMC UWMC Autopsy and After Death Services can help physicians or a patients family by answering questions, obtaining the proper consent forms and/or counseling the family, and facilitating transportation to UWMC

33. Physician (select PA/ARNP) Tasks Physician (select PA/ARNP) Tasks Checklist, instructions, and consents are in the Expiration packet sent by AdmittingAsk Nursing to help you find the papers which you need Checklist, instructions, and consents are in the Expiration packet sent by AdmittingAsk Nursing to help you find the papers which you need Pronounce DeathNote date and time Pronounce DeathNote date and time Notify Family/NOK (next of kin) Notify Family/NOK (next of kin) Notify Attending Notify Attending NO: Organ Donation (HCPs do not request) NO: Organ Donation (HCPs do not request) Determine if the death is a Medical Examiners CaseReport the death if indicated Determine if the death is a Medical Examiners CaseReport the death if indicated Request Autopsy and obtain consent Request Autopsy and obtain consent Complete ORCA Physician Death Noteforward to attending Complete ORCA Physician Death Noteforward to attending Complete Death/Discharge Summary Complete Death/Discharge Summary Review and sign death certificate Review and sign death certificate

34. Death certificate (DC) Death certificate (DC) Legal document which the family will receive Legal document which the family will receive An important public health document which is the basis for allocation of health and research funding An important public health document which is the basis for allocation of health and research funding Cause of death statement is considered to be more likely than not or probable Cause of death statement is considered to be more likely than not or probable If the DC is incorrect when you are asked to sign, please let us know and we will make a correct document If the DC is incorrect when you are asked to sign, please let us know and we will make a correct document

35. The cause of death statement On the death certificate comes from this section in the Physician Death Note

36. Death Certificate Death Certificate (Insert photo of purple sheet) (Insert photo of purple sheet) Who can sign the Death Certificate? Who can sign the Death Certificate? Certifying and attending physician are different Certifying and attending physician are different Certifying physician must have knowledge of the death, which can be conveyed by information from the attending physician or medical record Certifying physician must have knowledge of the death, which can be conveyed by information from the attending physician or medical record MD, DO, PA-C, ARNP and Nurse midwives can certify death, based on law MD, DO, PA-C, ARNP and Nurse midwives can certify death, based on law At UWMC, selected ARNP and PA-C can certify At UWMC, selected ARNP and PA-C can certify

37. Death certification is backwardsthe underlying cause of death is at the end You dont have to have four lines You dont have to list every contributory factor

38. Cardiorespiratory arrest Mechanisms of death cannot stand alone You dont have to list any mechanisms (like cardio-respiratory arrest, shock, metabolic acidosis There must be an underlying cause of death CAUSE OF DEATH: NOT!!

39. Completing the death certificate--figuring out the cause of death 52 year old woman who died of massive upper gastrointestinal hemorrhage from esophageal and gastric varices. She is known to have cirrhosis. She has type 2 diabetes and morbid obesity. She is a long time cigarette smoker with a clinical diagnosis of COPD, although this did not directly cause her death She has never drunk alcohol, and her hepatitis viral serologies are negative How should you complete the death certificate?

40. 1. List the underlying cause of death last 2. List the immediate cause of death in 34 A 3. Work through the chain of events in between and add contributory factors 4. IS THIS AN ADEQUATE DEATH CERTIFICATE? NO Upper gastrointestinal hemorrhage Esophageal and gastric varices Cirrhosis of the liver Morbid obesity. Chronic obstructive pulmonary disease

41. IS THIS AN ADEQUATE DEATH CERTIFICATE? YESit states the etiology for the Hepatic cirrhosis You must be specific about the underlying cause of death (etiology) or you will receive an inquiry letter from WA Vital Statistics. List the cause of the cirrhosis like this certificate Upper gastrointestinal hemorrhage Esophageal and gastric varices Hepatic cirrhosis due to probable steatohepatitis Morbid obesity. Chronic obstructive pulmonary disease

42. Heres another way to do it !! Cirrhosis of the liver Upper gastrointestinal hemorrhage Hepatic cirrhosis Probably due to non-alcoholic steatohepatitis Morbid obesity Severe chronic obstructive pulmonary disease.

43. What if you dont know the underlying etiologyie, you dont know the cause of the cirrhosis? Indicate that! This death certificate lists contributory causes, but does not indicate that NASH is the probable cause of the hepatic cirrhosis Same guideline for Metastatic carcinomaindicate the site, or indicate the probable site, or undetermined primary Esophago-gastric hemorrhage Esophageal & gastric varices Cirrhosis of the liver, etiology undetermined Morbid obesity. Severe chronic obstructive pulmonary disease.

44. Natural death is Natural death is Due to disease alone. Injury did not contribute or cause the death You will only certify natural deaths report Un-natural deaths to the KCME

45. Be careful about these check boxes dont check them unless you are sure of the answer, and do proof read them! You will only certify natural deaths, unless instructed by the Medical Examinerusually in the case of an accidental fall

46. PLEASE DONT USE ABBREVIATIONSTHIS IS A LEGAL DOCUMENT! Family members, insurance agents, lawyers, etc, will read this document. Write out the words! UGIB ESLD PROBABLE NASH COPD

47. Complete the death certificate like this instead!! Upper gastrointestinal hemorrhage End stage liver disease (cirrhosis) Probable non-alcoholic steatohepatitis Chronic obstructive pulmonary disease

48. Resources for Death Certification Resources for Death Certification http://www.doh.wa.gov/ehsphl/chs/ch s- data/Public/pubMain.htm#Handouts http://www.doh.wa.gov/ehsphl/chs/ch s- data/Public/pubMain.htm#Handouts for instructions for Washington for instructions for Washington Or Or https://netforum.avectra.com/eweb/Dy namicPage.aspx?Site=NAME&WebC ode=DeathCert https://netforum.avectra.com/eweb/Dy namicPage.aspx?Site=NAME&WebC ode=DeathCert For a tutorial on death certification For a tutorial on death certification

49. Who can help you or the family with questions about autopsy, death certificate completion, disposition of remains? Who can help you or the family with questions about autopsy, death certificate completion, disposition of remains? Harborview Medical Center Harborview Medical Center University of Washington Medical Center University of Washington Medical Center Autopsy and After Death Services: 744-3078 Voice mail for non-emergent messages After hoursPaging operator Autopsy coordinator: Mike Hobbs Director: Corinne Fligner, MD fligner@uw.edu , 598-6403, or paging Autopsy and After Death Services: 598-4205 Voice mail for non-emergent messages After hoursPaging operator Program Manager: Jessica Malmberg Director: Corinne Fligner, MD fligner@uw.edu , 598-6403, or paging

50. Thanks for your attention Thanks for your attention Please contact us at Autopsy and After Death Services if we can help you or the families of deceased patients Please contact us at Autopsy and After Death Services if we can help you or the families of deceased patients