Approved by: Vice President & Chief Medical Officer; and Vice President & Chief Operating Officer Death Corporate Policy & Procedures Manual Number: VII-B-410 Date Approved November 24, 2017 Date Effective December 8, 2017 Next Review (3 years from Effective Date) December 2020 NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section. Purpose To provide a consistent direction for health care providers in instances of death. Policy Statement When a patient/resident 1 death occurs, Covenant Health health care providers shall take care to: maintain the dignity of deceased persons during the discharge process; aid in consideration of the wishes of the deceased and significant others; when necessary, to protect evidence regarding cause and manner of death; assist in the orderly and thoughtful discharge of deceased patients; and maintain regulation for the handling of bodies of deceased persons to prevent the spread of infection. Applicability This policy and procedure applies to all Covenant Health facilities, staff, members of the medical staff, volunteers, students and any other persons acting on behalf of Covenant Health. Responsibility Patient care provider roles and responsibilities are outlined in the "Procedure" section of this document. Procedure 1.0 Pronouncement of Death 2.0 Immediate Decisions 2.1 Reporting to Medical Examiner 2.2 Hospital Autopsy 2.3 Organ / Tissue / Anatomical Donation 3.0 Notification of Family and Others 4.0 Signing of Death Certificate 5.0 Duty to Report to Medical Examiner 6.0 Death of a Patient in a Patient Support Area (i.e. not on the Nursing Unit) 7.0 Handling of Bodies 8.0 Preparing the Body for Viewing 9.0 Moving the Body 10.0 Documentation 1 - Hereafter, all references to 'patients' includes residents and clients.
1.0 PRONOUNCEMENT OF DEATH VII-B--410 Page 2 of 10 1.1 The staff member who witnesses the death or finds the deceased, notifies the charge nurse/designate. The most responsible health practitioner is then notified. 1.2 Pronouncement of death may be made by a health care professional working within his/her scope and role. 1.2.1 The health care professional who pronounces death shall document the time of last breath (or an estimate if unwitnessed) in the patient care record 1.2.2 At Covenant Health facilities where there are no health care professionals available or qualified to pronounce death (eg. lodges), staff shall notify their usual community resources (eg. EMS, RCMP, or Medical Examiner). 1.3 The body may NOT be prepared or moved until the pronouncement is made and staff can determine whether the Medical Examiner is to be notified. 2.0 IMMEDIATE DECISIONS 2.1 Reporting to Medical Examiner: Any death that is reportable to the Medical Examiner as described in the Fatality Inquiries Act must be reported to the Medical Examiner. Refer to section 5.0 Duty to Report to Medical Examiner. 2.2 Hospital Autopsy - If a physician has requested an autopsy he/she must obtain a valid consent from the legal next of kin. 2.2.1 The physician requesting the autopsy must also ensure that he/she provides the Pathology Department with the patient's relevant medical history, circumstances of death, reason for requesting the autopsy and any history of infectious disease. 2.2.3 The body must remain the same as it was at the time of death. Do not wash the body or remove dressings, tubes, drains, etc. 2.2.4 Tubes, needles, catheters must be left in place. They may be cut and tied off. External devices (eg. monitors) may be removed. 2.2.5 When a family requests an autopsy, they need to speak to a physician, and then the physician needs to request the autopsy (it then becomes a 'physician requested autopsy). (Per Regional Laboratory Services Anatomical Pathology Bulletin RAPAUX00006MUL, version 1.2, effective date November 9, 2016.)
VII-B--410 Page 3 of 10 2.2.6 Specific questions regarding autopsies can be directed to Laboratory Medicine staff. 2.3 Organ / Tissue / Anatomical Donation: If the patient / family has consented to organ/tissue/anatomical donation, refer to corporate policy #VII-B-415, Organ and Tissue Donation. NOTE: A medical examiner may remove or allow the removal of tissue or organs in accordance with the Human Tissue and Organ Donation Act, if the removal of the tissue or organs does not interfere with any investigation or proceeding under any law in force in Alberta. If the patient has bequeathed his/her body to research or education, contact the appropriate organization. 2.3.1 If the deceased is registered with the Alzheimer Society, the UAH Anatomical Pathology Laboratory will collect brain tissue for the Alzheimer Brain Tissue Bank. The contact number for the UAH Anatomical Pathology Laboratory is 780-407-7444. 3.0 NOTIFICATION OF FAMILY / OTHERS 3.1 The charge nurse/designate shall notify the most responsible health practitioner. The most responsible health practitioner is responsible to notify the family and other medical staff; eg. consultants. 3.1.1 The family is asked if: they wish to come to view the body on the unit before transportation to the funeral home. there are any religious or cultural practices the family wishes to be followed. Spiritual Care may be contacted if staff have questions regarding religious customs related to dying and respectful care of the body. Contact information for Spiritual Care is on compassionnet @ http://www.compassionnet.ca/page637.aspx they would like Spiritual Care (where available) to be called to attend to the family. 3.2. Post signs reading "Please Report to Nursing Desk Before Entering" on the door to a private room or pin it to the curtains around the patient's bed. This notice prevents alarming visitors and other hospital staff (dietary, lab, etc.) who are not aware of patient's death. 4. SIGNING OF DEATH CERTIFICATE 4.1 A physician must complete and sign the Medical Certificate of Death if the case does not become a medical examiners case. 4.2 An effort should be made to complete the Medical Certificate of Death prior to the patient care record being sent to Admitting/Health Information.
VII-B--410 Page 4 of 10 4.3 If a physician is not immediately available (eg. in continuing care facilities), the death certificate may be completed prior to or following transport of the body to the funeral home. 4.4 Refer to Neonatal / Child Health policies regarding stillbirths or infants who die in the first 28 days of life available @ http://www.compassionnet.ca/page1278.aspx 5.0 DUTY TO REPORT TO MEDICAL EXAMINER 5.1 Any person having knowledge or reason to believe that a person has died under any of the circumstances referred to below shall immediately notify a medical examiner (per the Alberta Fatality Inquiries Act). Unexplained deaths. Unexpected deaths when the deceased was not under the care of a physician or death when in apparent good health. Deaths as a result of violence, accident, suicide or poisoning. (If the suicide occurred in-hospital, also refer to corporate policy #VII-B-210, Inpatient Death by Suicide.) Maternal deaths that occur during or following pregnancy. Deaths that occur during an operative procedure; within ten days after an operative procedure; while under anaesthesia; or anytime after anesthesia and that may reasonable be attributed to that anesthesia. Deaths that may have occurred as a result of improper or negligent treatment by any person Deaths while in custody of any person. Deaths resulting from any disease, ill health, injury or toxic substances arising from a person's occupation at any time. Death of a formal patient of any mental health facility or any other institution defined in regulations under this Act. Death of a young person under Child Welfare custody. 5.2 Although consent is not required for Medical Examiner cases, the responsible physician/designate should discuss the possibility of the need for an autopsy with the family. 5.3 The most responsible physician will notify the Medical Examiner. The Medical Examiner may or may not accept the case. (It only becomes a Medical Examiner case once accepted.)
VII-B--410 Page 5 of 10 5.4 The charge nurse/delegate will notify the Admitting department if the Medical Examiner has been notified and of the decision of the Medical Examiner. 5.5 The body is to remain on the nursing unit until the Medical Examiner s decision has been received. 5.6 If the Medical Examiner declines the case, have the most responsible physician sign the Death Certificate. Prepare the body (eg. remove dressings, tubes, drains, etc.) and transport the body to the morgue (if available). 5.7 If the Medical Examiner accepts the case, parts of the patient care record are faxed to the Medical Examiner's office and the body transported to the Medical Examiner's office. (In most cases the Medical Examiner is not required to come to the hospital.) 5.7.1 The body must remain the same as it was at the time of death. Do not wash the body or remove dressings, tubes, drains, etc. 5.7.2 Tubes, needles, catheters must be left in place. They may be cut and tied off. External devices (eg. monitors) may be removed. 5.7.3 The Patient Record is sent to Admitting/Health Information. 5.7.4 All queries concerning the case shall be referred to the Medical Examiner's office. 5.7.5 The Medical Examiner signs the death certificate (not the responsible physician) in medical examiner cases. 6.0 DEATH OF A PATIENT IN A PATIENT SUPPORT AREA (I.E. NOT ON THE NURSING UNIT) 6.1 Inpatients - Call the inpatient unit and have them make arrangements for the body to be returned to the unit. 6.2 Outpatients Any physician responding may pronounce death and will contact the family and the physician responsible for the patient attending the Outpatient Clinic. As appropriate, the body will be placed in an area where family can visit and then moved to the morgue.
VII-B--410 Page 6 of 10 7.0 HANDLING OF BODIES ** ALERT ** In all cases, use routine practices when handling or preparing the deceased body for viewing. For patients who had required airborne or droplet precautions, masks may no longer be necessary unless aerosols are expected to be generated. Wear gloves. As soon as practically possible, enclose the body in a plastic morgue bag to prevent contamination by spillage of body fluids. 7.1 Bodies infected with the following communicable diseases, i.e. communicable diseases with a high risk of transmission (per Schedule 2 of the Public Health Act, Bodies of Deceased Persons Regulation): acquired immunodeficiency syndrome (AIDS) hepatitis B hepatitis C human immunodeficiency virus infections (HIV) invasive group A streptococcal infection typhus must be identified with a label/sticker placed over the zipper of the morgue bag (on or near the head). The label/sticker shall read as follows: This body is infected with a communicable disease specified in Schedule 2 of the Bodies of Deceased Persons Regulation and must be handled in accordance with that Regulation. Do not remove this label. 7.2 Bodies infected with the following communicable diseases, i.e. communicable diseases with a very high risk of transmission (per Schedule 1 of the Public Health Act, Bodies of Deceased Persons Regulation): anthrax plague smallpox infectious pulmonary tuberculosis rabies yellow fever suspect, probable and confirmed cases of transmissible spongiform encephalopathies, including classic and variant Creutzfeldt-Jakob disease viral hemmorhagic fevers must be identified with a label/sticker placed over the zipper of the morgue bag (on or near the head). The label/sticker shall read as follows:
VII-B--410 Page 7 of 10 This body is infected with a communicable disease specified in Schedule 1 of the Bodies of Deceased Persons Regulation and must be handled in accordance with that Regulation. Do not remove this label and do not open the hermetically sealed container. DO NOT EMBALM. 7.3 The purpose of the label/sticker is to alert funeral home personnel to NOT embalm the body. 8.0 PREPARING THE BODY FOR VIEWING ** NURSING ALERT ** If medical examiner's case do not carry out steps 8.1.4, 8.1.5, 8.1.6 and 8.1.7. 8.1 On the Nursing Unit 8.1.1 Contact Spiritual Care if there are any questions regarding religious customs related to dying and respectful care of the body. 8.1.2 Close eyes and mouth; one pillow may be used to slightly elevate the head thus keeping the face in a more natural position. 8.1.3 Align the body in the horizontal, recumbent position, arms at sides. 8.1.4 Place dentures in mouth. If unable to do so, place the dentures in a labelled denture cup and send them with the body to the morgue. Any other prosthesis such as eyes, limbs, etc. should also accompany the body. 8.1.5 Sponge bath patient and dress in gown. 8.1.6 Replace soiled dressings. 8.1.7 Remove intravenous, drainage tubes, catheters, etc. 8.1.8 In a Medical Examiner's case, tubes, IV, dressings, etc. MUST be left in place. They may be cut and tied off to prevent drainage of body fluids. External devices (i.e. monitors) may be removed. 8.1.9 Remove unnecessary equipment from the room. 8.2 Morgue Viewing 8.2.1 Arrangements can be made for viewing by contacting the Spiritual Care on-call Chaplain through the Switchboard.
9.0 MOVING THE BODY VII-B--410 Page 8 of 10 9.1 Obtain morgue key and transporter (where such facilities are available). 9.2 Spread the plastic morgue bag on the bed or on the cadaver transporter. (If desired, the body may also be wrapped in a sheet.) Place the body gently on the transporter and close the zipper/tabs. When closed, zipper pull is at the head. 9.3 Identify body with identification tag(s). Tape ID clearly on outside of bag. 9.4 When the patient has died while infected with a known or suspected communicable disease (per section 8.0 of procedure) place sticker labels over the zipper of the morgue bag (on or near the head). When a communicable disease death occurs, Nursing is to ensure that the Admitting department is aware. The Admitting department shall notify the funeral home. Public Health Regulations do not prohibit the cosmetizing or viewing of the body prior to the funeral at the funeral home. 9.5 Unit supervisor / charge nurse shall delegate appropriate / available staff to take the body to the morgue. 9.6 Staff log the deceased into the morgue book. 9.7 In certain circumstances (i.e. religious preferences) the family may request that the funeral home pick the deceased up directly from the nursing station. 9.8 The patient's personal effects are to be listed on the Personal Effects Form. Place the effects in the patient's suitcase or plastic patient garment bag and securely attach a copy of the form. Valuables are listed and placed in a Safekeeping Envelope and co-signed by two health care providers. 9.9 If the family is present, personal effects and valuables are signed for on the appropriate form and sent home with the family. 9.10 When family members/public guardian are not present, valuables are sent to the Discharge Office for safekeeping. Personal effects will be retained in the Protective Services for up to 30 days. Encourage the family to collect belongings as soon as possible. 9.11 Close the doors of other patients' rooms (if applicable) and use the service elevator to transfer the body to the morgue. Notify other departments (eg. Rehab Medicine, Dietary) as appropriate.
10.0 DOCUMENTATION VII-B--410 Page 9 of 10 10.1 Record the Following on the Patient Record: 10.1.1 Time the responsible physician was notified of the patient's condition. 10.1.2 Time respirations and pulse ceased (if known). 10.1.3 Time and name of responsible physician/designate who pronounced the patient's death. ** ALERT ** The time of death recorded on the Patient Information System must coincide with the time recorded on the patient care record. Patient discharge disposition on the Patient Information System must be Discharged Deceased. 10.1.4 Time responsible physician was notified, if not present to pronounce death. 10.1.5 Time the relatives were notified. 10.1.6 Time of family visit and if personal effects and valuables were taken by the family. 10.1.7 Valuables are sent to the Discharge Office, note on Personal Effects form. 10.2 Ensure all forms are completed and sent to designated areas 10.2.1 Notice of Death - Forward to Admitting as soon as nursing has completed their portion. 10.2.2 The Medical Certificate of Death Should be signed as soon as possible following the patient's demise. Forward the Medical Certificate of Death to Admitting as soon as it has been signed by the responsible physician. The Patient Record is sent to Admitting (GNCH) or Health Records (MCH). 10.3 The patient's demographic label is not to be used on any government form. Definitions For the purpose of this policy, expected death refers to when, in the opinion of the health care team, the patient is irreversibly and irreparably terminally ill; that is, there is no available treatment to restore health or the client refuses the treatment that is available (CNO, 2009). CARNA also goes on to further clarify: Expected death also implies that the death of the client has been
VII-B--410 Page 10 of 10 anticipated by the client, the family, and the health team and anticipated events have been planned for in a written plan. (CARNA Pronouncement of Death guidelines, 2011). Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act [Alberta] or the Health Professions Act [Alberta], and who practices within scope and role. Health care provider means any person who provides goods or services to a patient, inclusive of health care professionals, staff, students, volunteers and other persons acting on behalf of or in conjunction with Covenant Health. Most responsible health practitioner means the health care professional who has responsibility and accountability for the patient and who is authorized by Covenant Health to perform the duties required to fulfill the delivery of such a treatment/procedure(s), within the scope of his/her practice. Physician means (i) with reference to medical services provided in Alberta, a person registered as a regulated member of the College of Physicians and Surgeons of Alberta under the Health Professions Act who holds a practice permit issued under the Act, and (ii) with reference to medical services provided in a place outside Alberta, a person lawfully entitled to practice medicine or osteopathy in that place. [Hospitals Act, Section 1(n)] Related Documents Attachments: Public Health Act, Bodies of Deceased Persons Regulations Labels for Schedule 1 Communicable Diseases Labels for Schedule 2 Communicable Diseases Covenant Health Policies: VII-B-210, Inpatient Death by Suicide VII-B-415, Organ and Tissue Donation VII-B-400, Neurological Determination of Death References Fatality Inquiries Act, Revised Statutes of Alberta 2000, Chapter F-9, current as of December 17, 2014. College of Licensed Practical Nurses of Alberta. Competency Profile for LPNs. Accessed on-line March 3, 2015 @ http://www.clpna.com/members/continuing-competencyprogram/competency-profile-for-lpns/ Bodies of Deceased Persons Regulation 135/2008. College and Association of Registered Nurses of Alberta. Pronouncement of death: guidelines for regulated members. September 2011. Hospitals Act, Revised Statutes of Alberta 2000, Chapter H-12, Current as of December 9, 2016 Vital Statistics Act, Statutes of Alberta, 2007, Chapter V-4.1, current as of February 27, 2015 Operation of Approved Hospital Regulation AR 247/90 2012 Chronological Revision Date(s) December 8, 2015 August 7, 2015