Best Practice Guideline #5. Management of Deaths Occurring Outside of Health Care Facilities

Transcription

1 Best Practice Guideline #5 Management of Deaths Occurring Outside of Health Care Facilities Introduction Emergency Medical Services (EMS) personnel and police officers are most often the first to respond to a death that occurs outside of a health care facility (e.g. private residence). In many of these cases, the practice is for the emergency first responders to contact a coroner, via the Office of Chief Coroner/Ontario Forensic Pathology Service Provincial Dispatch, to ascertain if the death meets criteria set out in Section 10 of the Coroners Act. While many deaths occurring outside of health care facilities are perceived as sudden and unexpected from the perspective of family members or emergency first responders, discussion with a coroner may determine that the circumstances of the individual death do not meet Section 10 criteria and therefore a coroner s investigation is not required. An illustrative case example is of a 62-year-old man who was observed by his spouse to collapse in the kitchen. He had a pacemaker and was being treated for congestive heart failure. The five year mortality for congestive heart failure in men is 50%. 1 Information indicated that his death appeared clearly arrhythmogenic on a background of known cardiac disease and therefore his death was not unexpected to the coroner. However, it is unlikely that a plan for a health care professional to attend at the home to certify death would have been discussed and/or arranged given the decedent had been apparently well prior to collapse. Cases that are not accepted as coroner s investigations have, at times, resulted in prolonged scene attendance for EMS personnel and police officers, particularly where there is no identified primary care practitioner, or where he/she cannot be reached to complete the Medical Certificate of Death (MCOD). Prolonged scene attendance not only restricts the availability of EMS personnel and police officers to respond to subsequent calls, but also may cause additional anxiety to the family of the deceased, as the transfer of the deceased from the death scene may also be delayed. This update of this Best Practice Guideline builds on the original version, Interaction of Investigating Coroners with Emergency Medical Services, Police, Body Removal Services, and Funeral Services Arising from Death Investigations released in 2010 by incorporating the collective experience of coroners and emergency first responders with 1 Best Practice Guideline #5: 1 of 15

2 these types of deaths over the intervening years, and reflects the lessons learned to enhance this process. The name of this Best Practice Guideline has also been updated to succinctly reflect the central purpose of the Guideline. Scope This Best Practice Guideline provides coroners, police services, EMS and other emergency first responders with an approach to circumstances in which an unexpected or expected death occurs outside of a health care facility, and timely certification of the death at the scene by a primary care practitioner is not feasible. The Guideline should be viewed as a decision-making tool or framework, rather than a rigid and prescriptive protocol. In all cases, compassion for family members of the decedent must be a prime consideration. Purpose To create a uniform provincial policy for management of deaths occurring outside of health care facilities where coroners interact with EMS personnel, police officers and other emergency first responders. To provide coroners with a tool to assist in timely disposition of decedents, particularly where the deaths are expected and/or reasonably anticipated and therefore outside of the coroner s jurisdiction. To streamline EMS and police services approaches at death scenes following the direction of the coroner and therefore, reduce the time commitment at death scenes by emergency first responders. Guiding Principles 1. Consideration must be given to the needs of family members of the decedent, and compassion informed decision-making should occur. 2. Except in circumstances requiring a coroner s investigation as defined in the Coroners Act, the primary responsibility for certification of the death rests with the attending physician or Registered Nurse-Extended Class (RN-EC). Best efforts should be made to arrange for certification by the appropriate health care professional. 3. Notwithstanding #2 above, when a coroner is notified of a death in the community and an attending physician or RN-EC is not immediately available to attend the scene to certify the death; the coroner s involvement may be required to assist with facilitation of certification of the death. Best Practice Guideline #5: 2 of 15

3 Note: Bodies may be transported from death scenes to a funeral service provider s facility of the family s choice in such circumstances pending completion of the certification process, i.e. awaiting availability of the primary care practitioner. It is therefore neither necessary nor an expectation that coroners attempt to contact primary care practitioners in the middle of the night for this purpose. 4. Best practice is for the coroner to contact the primary care practitioner directly (when the coroner is notified of the death, or the following day). This allows for further clarification of the decedent s history to ensure that investigation by the coroner is not necessary, and also provides an opportunity for the coroner to provide guidance, if required, to the primary care practitioner with respect to completion of the MCOD (Many primary care practitioners have limited experience in completing MCODs). Note: If it is not possible or practical for the coroner to speak directly with the primary care practitioner, the coroner may ask the police officer and/or the family to make contact with the primary care practitioner. In such circumstances, the coroner must provide his/her name, contact information and contact method to the funeral service provider in the event that the primary care practitioner is unable to certify the death. 5. Certification of the death must occur in a timely manner. A plan for completion of the MCOD that is agreeable to the funeral service provider must be made before the end of the next business day after the death is pronounced. 6. If an attending physician or RN-EC is not able to ensure certification or develop a plan for certification that is agreeable to the funeral service provider within the timeframe outlined in #5, it is the responsibility of the coroner who has been notified to certify the death (or arrange for another coroner to do so). Legislative Authority The relevant sections of the Coroners Act, the Vital Statistics Act and Regulation 1094 of the Vital Statistics Act are reproduced in Appendix A. Management of Deaths Initially Perceived to be Unexpected [see Diagram 1] For the purposes of this Guideline, Unexpected Death refers to a death that was not imminently anticipated (e.g., traumatic deaths, deaths related to the environment, accidental deaths, and apparently natural deaths that are sudden and unexpected). As noted in the Introduction section, although the death may be viewed as unexpected from the perspective of the person reporting the death (emergency first responders; family members), this does not necessarily imply that the death requires investigation by a coroner under the Coroners Act. These cases will generally result in the coroner being contacted via the Office of the Chief Coroner/Ontario Forensic Pathology Service Provincial Dispatch by the police or, Best Practice Guideline #5: 3 of 15

4 at times, EMS personnel (refer to section: Decisions When Order for Termination of Resuscitation Occurs) pursuant to Section 10 of the Coroners Act. Possible outcomes are: A. Circumstances meet criteria for investigation by a coroner 1. The police service will be asked to remain and EMS personnel will generally be released from the scene. 2. If a police service is not present, the EMS personnel will remain on the scene until it has been secured by a police service, or alternatively, until the Investigating coroner is satisfied that EMS personnel may depart from the scene. 3. Patient care information/documentation will be provided to the Investigating coroner by EMS personnel, pursuant to Section 16 of the Coroners Act, upon request. Completion of a Coroner s Authority (or Delegated Authority) to Seize During an Investigation is unnecessary. 4. EMS personnel will communicate with the Investigating coroner regarding the disposition of any records. Documentation that may be left (with the coroner, his/her delegate or the responsible caregiver at the scene) by EMS personnel will be the Ambulance Call Report (ACR), or Patient Care Record. Where the ACR is left with a responsible caregiver, it will be placed in a sealed envelope, wherever possible. Ambulance service specific provision of the ACR may include electronic or faxed reports to the Investigating coroner, via the office of the Regional Supervising Coroner (RSC). 5. The Investigating coroner will attend the scene, examine the body, and provide further direction regarding disposition of the decedent. B. Circumstances do not meet criteria for investigation by a coroner 1. The coroner, EMS personnel and/or police officers will discuss the circumstances following pronouncement of death. Note: There is no legal requirement for a physician to pronounce death. Pronouncement may be completed by paramedics, registered nurses or other emergency first responders, according to the policies of their professional college and/or employer. 2. If a police service is not present, the EMS personnel will remain on the scene until the police service arrives or may depart after initial discussion with the coroner if a responsible person is present. 3. There are important early considerations to determine the next steps and information should be obtained from the family through the emergency first responder at the scene including: 3.1. Is there a primary care practitioner regularly and recently involved in the care of the decedent? Best Practice Guideline #5: 4 of 15

5 3.2. Is the practice location of the primary care practitioner in reasonable proximity of the scene (residence), or if not immediately available to attend the scene, the funeral service provider s facility of the family s choosing? 3.3. If not, there should be consideration for immediate involvement of the coroner. 4. As outlined in the Guiding Principles, best practice is for the coroner to contact the primary care practitioner. Note: If it is not possible or practical (i.e. office closed) for the coroner to speak directly with the primary care practitioner, the body may be transported to a funeral facility of the family s choosing (and cost) (see #6 below) and the contact with the primary care practitioner may occur the next morning. Alternatively, the coroner may ask a police officer or a family member to make contact with the primary care practitioner to discuss the need for certification to take place at the funeral facility. It is imperative that the coroner provide his/her name, contact information and contact method in the event that the primary care practitioner is not able to certify the death. 5. The coroner will maintain written record of the case management. The Case Selection Data Form for Natural Deaths provides guidance with the case selection decision 2. All completed forms and accompanying invoices are to be submitted within one business day to the RSC. 6. If the primary care practitioner cannot be located in a reasonable period of time, or is unwilling or unable to attend the scene in a timely manner acceptable to the family and emergency first responders at the scene, the body may be transferred by a funeral service provider to a funeral facility of the family s choice. The family will incur the expense of the transport as part of the funeral costs. 7. The coroner must ensure that the funeral service provider has his/her name, contact information and contact method or an alternative plan defined by the coroner in the event that the primary care practitioner is unable to certify the death (or make a plan for completion that is agreeable to the funeral service provider) by the end of the next business day. Alternatively, if the coroner is not going to be available, he or she will provide the case data to the next scheduled coroner and will ensure that the funeral service provider is aware of the contact method. 8. The primary care practitioner can then attend at the funeral facility to complete the MCOD in a timely manner and definitely by the end of the following business day, or alternatively make a plan for completion of the MCOD that is agreeable to the funeral service provider.the coroner will NOT accept the case for investigation. 9. If the primary care practitioner does not complete the MCOD by the end of the next business day or make a plan for completion that is agreeable to the funeral service provider, the funeral service provider will contact the coroner, who will then accept 2 See Investigating Coroners Best Practice Guideline #4 Investigating Coroners Acceptance of Natural Deaths for Investigation. Best Practice Guideline #5: 5 of 15

6 the case for investigation and complete the MCOD. If the funeral process is to be expedited to accommodate religious or conscience-based beliefs, the coroner may be contacted earlier. Best Practice Guideline #5: 6 of 15

7 Diagram 1 Perceived Unexpected Death Coroner Contacted NO Coroner Investigation Coroner Investigation Coroner Attempts to Contact Primary MD EMS Clears if Body Remains in Custody of Police until Coroner Attends Primary MD WILL ATTEND in Timely Fashion Primary MD CANNOT be Contacted or WILL NOT ATTEND or WILL BE DELAYED EMS Clears if Body Remains in Custody of Police or Family Funeral Service Provider of Family s Choosing Contacted Primary MD Completes Medical Certificate of Death EMS Clears if Body Remains in Custody of Police or Family Funeral Service Provider Called by Family Funeral Service Provider Transfers the Body Coroner Completes Medical Certificate of Death if Primary MD NOT AVAILABLE by the end of next business day or an agreed upon earlier time Best Practice Guideline #5: 7 of 15

8 Management of Expected Deaths [see Diagram 2] Paramedics and firefighters are expected to honour a Do Not Resuscitate (DNR) Confirmation Form, and all other emergency first responders are encouraged to do so as well. 1. EMS personnel will request that the family notify the primary care practitioner or palliative care team to request their attendance to complete the MCOD. If the family cannot comply, EMS personnel will discuss with their dispatch and request that a primary care practitioner or palliative team member be contacted to attend. 2. The police service or EMS personnel will notify the coroner via the Office of Chief Coroner/Ontario Forensic Pathology Service Provincial Dispatch if: 2.1. the primary care practitioner or palliative care team member cannot be located or cannot attend, or; 2.2. the decedent had not yet been enrolled in a palliative care program, or; 2.3. there is no family or other responsible person identified who is able to make arrangements with a funeral service provider 3. If a police service is not present, the EMS personnel will remain on the scene until the police service arrives or may depart after initial discussion with the coroner if a responsible person is present. 4. There are important early considerations to determine the next steps and information should be obtained from the family through the emergency first responder at the scene including: 4.1. Is there a primary care practitioner regularly and recently involved in the care of the decedent? 4.2 Is the practice location of the primary care practitioner in reasonable proximity of the scene (residence), or if not immediately available to attend the scene, the funeral service provider s facility of the family s choosing? 4.3. If not, there should be consideration for immediate involvement of the coroner. 5. As outlined in the Guiding Principles, best practice is for the coroner to contact the primary care practitioner. Note: If it is not possible or practical (i.e. office closed) for the coroner to speak directly with the primary care practitioner, the body may be transported to a funeral facility of the family s choosing (and cost) (see #7 below) and the contact with the primary care practitioner may occur the next morning. Alternatively, the coroner may ask a police officer or a family member to make contact with the primary care practitioner to discuss the need for certification to take place at the funeral facility. It Best Practice Guideline #5: 8 of 15

9 is imperative that the coroner provide his/her name, contact information and contact method in the event that the primary care practitioner is not able to certify the death. 6. The coroner will maintain written record of the case management. The Case Selection Data Form for Natural Deaths provides guidance with the case selection decision 3. All completed forms and accompanying invoices are to be submitted within one business day to the RSC. 7. If the primary care practitioner cannot be located in a reasonable period of time, or is unwilling or unable to attend the scene in a timely manner acceptable to the family and emergency first responders at the scene, the body may be transferred by a funeral service provider to a funeral facility of the family s choice. The family will incur the expense of the transport as part of the funeral costs. 8. The coroner must ensure that the funeral service provider has his/her name, contact information and contact method or an alternative plan defined by the coroner in the event that the primary care practitioner is unable to certify the death (or make a plan for completion that is agreeable to the funeral service provider) by the end of the next business day. Alternatively, if the coroner is not going to be available, he or she will provide the case data to the next scheduled coroner and will ensure that the funeral service provider is aware of the contact method. 9 The primary care practitioner can then attend at the funeral facility to complete the MCOD in a timely manner and definitely by the end of the following business day, or alternatively make a plan for completion of the MCOD that is agreeable to the funeral service provider. The coroner will NOT accept the case for investigation. 10. If the primary care practitioner does not complete the MCOD by the end of the next business day or make a plan for completion that is agreeable to the funeral service provider, the funeral service provider will contact the coroner, who will then accept the case for investigation and complete the MCOD. If the funeral process is to be expedited to accommodate religious or conscience-based beliefs, the coroner may be contacted earlier. 3 See Investigating Coroners Best Practice Guideline #4 Investigating Coroners Acceptance of Natural Deaths for Investigation. Best Practice Guideline #5: 9 of 15

10 Diagram 2 - Expected Death Family or EMS Contacts Primary MD or Palliative Care Nurse Primary MD/Nurse WILL ATTEND Primary MD/Nurse CANNOT be contacted or Primary MD/Nurse WILL NOT ATTEND or WILL BE DELAYED EMS Clears if Body Remains in Custody of Police or Family Contact Coroner EMS Clears if Body Remains in Custody of Police or Family Primary MD /Nurse Completes Medical Certificate of Death Coroner calls Primary MD /Nurse or Funeral Service Provider as per Unexpected Death Protocol Coroner Completes Medical Certificate of Death if Primary MD NOT AVAILABLE by the end of next business day or an agreed upon earlier time Best Practice Guideline #5: 10 of 15

11 Decisions When Order for Termination of Resuscitation Occurs Guiding Principles 1. Coroners prefer that the body of the deceased person remain at the death scene. There have been instances in Ontario where removal of a deceased person has seriously hampered a death investigation. 2. As outlined in Section 11 of the Coroners Act, if there is reason to believe that the death may require involvement of a coroner, interference with the body (i.e. movement or alteration of medical equipment) should not occur unless directed by the coroner. This authority supersedes any standard, policy or regulation in any other Act. 3. A deceased person should generally not be returned to a residence from which he/she has been removed. 4. Effective communication between the coroner, police and paramedics is of the utmost importance. Case specific plans should take into account operational issues for the coroner and EMS, as well as the impact on the family. 5. Management of Perceived Unexpected Deaths and Management of Expected Deaths procedures are applicable in these cases (i.e. termination of resuscitation may occur in a natural death at home, and discussion with the coroner determines that an investigation is not required). Procedure 1. When an order for termination of resuscitation arising from the Deceased Patient Standard is received in the field, and the deceased person has not been removed from the place of death, paramedics should not remove the body. The applicable Management of Perceived Unexpected Deaths and Management of Expected Deaths procedure will be followed. 2. If the deceased has been moved to the ambulance, and the ambulance has not yet departed the scene, EMS dispatch must be notified and contact with the coroner 4 will be made to determine the appropriate next steps prior to departure from the scene. The paramedics should apprise the coroner of any operational concerns regarding ambulance service/coverage issues that may arise by maintaining the body in the ambulance and holding the ambulance at the scene. The coroner should facilitate appropriate next steps to allow a rapid return of the ambulance to service whenever possible. The ultimate decisions regarding disposition of the deceased should be documented on the Ambulance Call Report (ACR). 4 Contact with the Coroner can be made by paramedics or dispatch according to established local protocols. Best Practice Guideline #5: 11 of 15

12 3. If the ambulance is in motion when resuscitation is terminated, paramedics should continue to the nearest hospital emergency department as the family will most likely be en-route concurrently. The body shall be transferred to an appropriate hospital area that will allow family attendance with the decedent in a dignified manner If the death is unexpected (see Management of Perceived Unexpected Deaths) and/or fits any of the other criteria for notification of a coroner under Section 10 of the Coroners Act, paramedics must notify the coroner of the death and location of the decedent. The paramedics should discuss with the coroner where the patient care documentation (ACR) will be left for the coroner. Ambulance service specific provision of the ACR may include electronic or faxed reports to the coroner If the death is expected (see Management of Expected Deaths), paramedics or hospital staff should attempt to contact the decedent s attending physician and/or palliative care provider (alternatively, an attending physician at the hospital may agree to certify the death). If no attending physician/rn-ec can be identified to certify the death, the coroner must be notified and he/she must ensure that certification takes place within a reasonable timeframe, and definitely by the end of the next business day or alternatively make a plan for completion of the MCOD that is agreeable to the funeral service provider. Appropriate documentation of the identity of the decedent should be affixed to the body, where possible, by the paramedics. Bibliography 1. Verbeek R and Sherwood C, End-of-Life care in the home; how a new procedure for Ontario paramedics and fire fighters may affect your patients and your practice, Ontario Medical Review, November The Coroners Act R.S.O Decision-making for the End of Life, Policy Statement #1-06, The College of Physicians and Surgeons of Ontario, July Investigating Coroners Best Practice Guideline #4 Investigating Coroners Acceptance of Natural Deaths for Investigation 5. Basic Life Support Patient Care Standards, Ministry of Health and Long-Term Care. Deceased Patient Standard Best Practice Guideline #5: 12 of 15

13 Appendix A Relevant Legislation and Regulations (I) Coroners Act Police assistance 9. (1) The police force having jurisdiction in the locality in which a coroner has jurisdiction shall make available to the coroner the assistance of such police officers as are necessary for the purpose of carrying out the coroner's duties. 2009, c. 15, s. 5 Duty to give information 10. (1) Every person who has reason to believe that a deceased person died, (a) as a result of, (i) violence, (ii) misadventure, (iii) negligence, (iv) misconduct, or (v) malpractice; (b) by unfair means; (c) during pregnancy or following pregnancy in circumstances that might reasonably be attributable thereto; (d) suddenly and unexpectedly; (e) from disease or sickness for which he or she was not treated by a legally qualified medical practitioner; (f) from any cause other than disease; or (g) under such circumstances as may require investigation, shall immediately notify a coroner or a police officer of the facts and circumstances relating to the death, and where a police officer is notified he or she shall in turn immediately notify the coroner of such facts and circumstances. R.S.O. 1990, c. C.37, s. 10 (1). Interference with body 11. No person who has reason to believe that a person died in any of the circumstances mentioned in section 10 shall interfere with or alter the body or its condition in any way until the coroner so directs by a warrant. R.S.O. 1990, c. C.37, s. 11. Investigative powers 16. (1) A coroner may, (a) examine or take possession of any dead body, or both; and (b) enter and inspect any place where a dead body is and any place from which the coroner has reasonable grounds for believing the body was removed. R.S.O. 1990, c. C.37, s. 16 (1); 2009, c. 15, s. 8. Best Practice Guideline #5: 13 of 15

14 Idem (2) A coroner who believes on reasonable and probable grounds that to do so is necessary for the purposes of the investigation may, (a) inspect any place in which the deceased person was, or in which the coroner has reasonable grounds to believe the deceased person was, prior to his or her death; (b) inspect and extract information from any records or writings relating to the deceased or his or her circumstances and reproduce such copies therefrom as the coroner believes necessary; (c) seize anything that the coroner has reasonable grounds to believe is material to the purposes of the investigation. R.S.O. 1990, c. C.37, s. 16 (2). (II) Vital Statistics Act Death except by disease 21. (5) If there is reason to believe that a person has died as a result of any cause other than disease, or has died as a result of negligence, malpractice or misconduct on the part of others or under such circumstances as require investigation, no documentation shall be issued unless, (a) in accordance with the Coroners Act, the body has been examined and an investigation into the circumstances of the death has been made or an inquest has been held; (b) a coroner has signed the documentation if any that is prescribed; and (c) the other provisions of this Act and the regulations regarding registration of death have been complied with. 2001, c. 21, s. 16; 2010, c. 16, Sched. 8, s. 4 (1). (III) Regulation 1094, Vital Statistics Act REGISTRATION OF DEATHS 35. (2) Subject to subsections (3) and (4), any legally qualified medical practitioner who has been in attendance during the last illness of a deceased person or who has sufficient knowledge of the last illness shall immediately after the death complete and sign a medical certificate of death in the form approved by the Registrar General, stating the cause of death according to the classification of diseases adopted by reference in section 70, and shall deliver the medical certificate to the funeral director. O. Reg. 68/09, s. 22. Best Practice Guideline #5: 14 of 15

15 (3) A registered nurse who holds an extended certificate of registration under the Nursing Act, 1991 shall, immediately after the death of a person, complete and sign a medical certificate of death in the form approved by the Registrar General, stating the cause of death according to the classification of diseases adopted by reference in section 70 and shall deliver the medical certificate to the funeral director if, (a) the nurse has had primary responsibility for the care of the deceased during the last illness of the deceased; (b) the death was expected during the last illness of the deceased; (c) there was a documented medical diagnosis of a terminal disease for the deceased made by a legally qualified medical practitioner during the last illness of the deceased; (d) there was a predictable pattern of decline for the deceased during the last illness of the deceased; and (e) there were no unexpected events or unexpected complications during the last illness of the deceased. O. Reg. 68/09, s. 22. (4) In the case of a death of which the coroner is required to be notified under section 10 of the Coroners Act, the coroner notified shall, as soon as the cause of death is known, complete and sign a medical certificate of death in the form approved by the Registrar General, stating the cause of death according to the classification of diseases adopted by reference in section 70, and shall deliver the medical certificate to the funeral director. O. Reg. 68/09, s. 22. Best Practice Guideline #5: 15 of 15