Health Articles

When death is expected, families should be prepared for it, and health care professionals should try to ensure that the following issues are addressed:
1.The family should be thoroughly informed about what will happen
when the patient dies. If the patient is expected to die at home, the
family should be told whom to call (eg, the doctor) and whom not to call
(eg, an ambulance service). The family should also be informed about
obtaining legal advice and burial services.
2.A physician should make the official determination of death as
quickly as possible to reduce the family’s anxiety and uncertainty.
Families or funeral directors should be provided with a properly completed death certificate as quickly as possible. Physicians should be aware that on rare occasions, death may be difficult to determine; eg, when severe hypothermia mimics death.
3.Physicians, nurses, and other health care providers should ad
dress the family’s psychologic needs, providing appropriate counsel
ing, a comfortable environment where family members can grieve to
gether, and adequate time for them to be with the body. Friends,
neighbors, and clergy may be available to provide psychologic support
to the family. Health care providers should be aware of cultural differ
ences in behavior at the time of death.
4.The health care system should ensure that death did not result
from wrongdoing. Even when death was expected, physicians may
have a responsibility to report the death to the coroner or police; thus,
physicians should know their local laws.
5.A discussion about autopsy can occur either before death or just
after. Often, the physician chooses not to raise this issue, but families
may have strong feelings, either for or against it. In any case, the discus
sion of autopsy should not be left to a covering physician or house of
ficer who has not had previous contact with the family. Discussions
about organ donation, if appropriate, should take place before death or
as soon as possible after death.
6.The body should not present a risk to the public health, which
usually means that it must be attended to quickly by persons licensed to
do so.
Often, management of death consists of making sure that someone (eg, a nurse or volunteer) is with the body when the family visits after death, offering to help notify clergy or funeral directors, providing reassurance that the patient was comfortable and that family and caregivers did all that could be done, and making follow-up contact a few weeks later with the most closely affected survivor to answer questions and note whether appropriate adjustment is taking place.

A dying patient should be given appropriate support and symptom relief and vigorous treatment for any reversible aspects of depression and cognitive dysfunction. When the patient or a surrogate proposes an action that seems contrary to the patient’s interests, referral to consultants should be available within the institution or agency to ensure that the physician’s response is defensible even though it differs from the patient’s or surrogate’s request.
In some cases, the care of a dying patient may seem to be directed more toward hastening the patient’s death than toward prolonging life. Whether such an approach should be construed as good medical care or as the criminal taking of life (homicide or assisting with suicide) is an increasingly debated issue. This problem arises, for example, with patients who request a discontinuance of parenteral hydration and nutrition; with those who choose to forgo treatment expected to yield long, disease-free remissions; and with those who develop suffocating dyspnea that can be relieved only with strong sedation, a treatment that can accelerate death.
Most medical actions that accelerate death are intended to relieve pain or other suffering. In these cases, the forgone life would have been so brief and so anguished that little question remains about whether treatment should have been carried out to prolong life. Once the question is raised, however, the issue of what constitutes wrongful death can be quite difficult.
Criminal law does not differentiate between intentional and unintentional crime, although motivation may extenuate the penalty. Thus, even the patient whose pain is relieved only by doses of narcotics that cause deep sedation and who expectedly dies from the effects of treatment could be construed to be the victim of wrongful death.
There are several reasons why these cases are virtually never brought to court: (1) Most people, including prosecutors, judges, and jurors, do in fact consider motivation in their assessments and usually find no willful destruction, only the pathos of a situation that could have had no better outcome. (2) The means used to bring about the death are those ordinarily used in treatment (analgesics, sedatives, and anesthetics), not those associated with crime (poisons, guns, and knives). (3) The means of death are not as certain to result in death as are those in clearly criminal cases.
Assisting with suicide remains a criminal act in most states, but the laws vary substantially and are rarely invoked. Directly providing a dying patient with lethal drugs and instructions for using them might be grounds for prosecution in some states but not in others. Physicians confronted with such situations should seek legal guidance before acting. Physicians and nurses should recognize that very few cases have been prosecuted. The considerations involved are largely conjectural and are changing rapidly with cultural change.
Charges of homicide rather than of assisting with suicide are more likely to be filed if the patient’s interests are not carefully advocated, if the patient lacks capacity or is severely functionally impaired just before death, if documentation is sparse, and if the prosecutor’s electoral base is expected to approve. Physicians engaged in vigorous symptom management and forgoing life-sustaining treatment need to document decision making carefully, provide care in a reputable setting, and be willing to discuss these issues honestly and sensitively with patients, other providers, and the public.
Finally, the physician should not use any treatment that is conventionally thought of as a means of homicide (eg, lethal injection), even though the physician may maintain that the treatment was intended to relieve suffering.

Financial coverage for the care of dying persons is problematic. Medicare regulations exclude supportive care except in a hospice setting. However, not all patients qualify for hospice care, and physicians are often reluctant to certify the 6-mo prognosis required for coverage. Even a certified need for a skilled nursing level of care may not gain admission to a nursing home for a short-term, terminally ill patient. Physicians should know the financing options and the financial effects of choices.