Deceased Patient Care and Documentation

Introduction to Deceased Patient Care

• A comprehensive deceased patient note should include immediate after-death care documentation, family notification details, and completion of necessary medical and legal documentation, as recommended by the National Comprehensive Cancer Network 1, 2, 3

Patient Identification and Death Information

• Patient identification, including name, medical record number, and date of birth, should be documented, according to the American Heart Association, as seen in Circulation 4
• Date and time of death, as well as location of death, should be recorded, following the guidelines outlined in Circulation 4

Death Certification and Medical Details

• The cause of death should be officially recorded, as stated in Circulation 5
• Resuscitation attempts or DNAR/NFR orders should be documented, as recommended by the American Heart Association, in Circulation 5
• Removal of medical devices, such as tubes and lines, should be documented, unless an autopsy is planned, as suggested by the National Comprehensive Cancer Network 1, 2

Family Notification and Support

• Family notification details, including who was notified, when, and by whom, should be documented, according to the National Comprehensive Cancer Network 1, 2
• Time provided to the family to be with the body should be recorded, as recommended by the National Comprehensive Cancer Network 1, 2
• Culturally sensitive and respectful treatment of the body should be documented, following the guidelines outlined by the National Comprehensive Cancer Network 1, 2

Administrative and Legal Documentation

• Confirmation that the death certificate was filed should be documented, as stated by the National Comprehensive Cancer Network 1, 2
• Forms completed for the funeral director should be recorded, according to the National Comprehensive Cancer Network 1, 2
• Other healthcare providers notified of the patient's death should be documented, as recommended by the National Comprehensive Cancer Network 1, 2

Bereavement Support

• A plan for formal condolences, such as a card or call, should be documented, according to the National Comprehensive Cancer Network 1, 2
• Referral to bereavement services should be recorded, as recommended by the National Comprehensive Cancer Network 1, 2
• Family members at risk for complicated bereavement should be identified, following the guidelines outlined by the National Comprehensive Cancer Network 1, 2

Common Pitfalls to Avoid

• Incomplete documentation of time and cause of death should be avoided, as stated in Circulation 5
• Failure to document family notification details should be avoided, according to the National Comprehensive Cancer Network 1, 2
• Omission of cultural or religious considerations in after-death care should be avoided, as recommended by the National Comprehensive Cancer Network and the Journal of Clinical Oncology 3, 6
• Inadequate documentation of organ donation discussions should be avoided, according to the National Comprehensive Cancer Network 1, 2

Guidelines for Finalizing Nursing Notes After a Patient's Death

Documentation Requirements Following Patient Death

• The National Comprehensive Cancer Network recommends documenting the removal of medical devices, tubes, and lines, unless an autopsy is planned, as part of post-mortem care 7

End-of-Life Care Documentation

• The International Journal of Nursing Studies suggests documenting any rituals or practices that were performed to facilitate a peaceful death, as well as the presence of family members at the time of death or if they were absent 8
• The International Journal of Nursing Studies also recommends documenting any meaningful last words or gestures of the patient that may help family members in their grieving process 9
• The National Comprehensive Cancer Network guidelines include noting any cultural or religious considerations that were addressed in after-death care 7

Family Support Documentation

• The Critical Care Medicine journal recommends recording any emotional support provided to family members, such as time provided to be with the body or information shared with family about the dying process if they were not present 10
• The International Journal of Nursing Studies suggests documenting any dignified photographs shared with bereaved family, with permission, as a way to provide emotional support 9

Bereavement Support

• The National Comprehensive Cancer Network guidelines recommend documenting plans for formal condolences, such as cards or calls, as well as referrals to bereavement services 7
• The International Journal of Nursing Studies suggests identifying and documenting family members at risk for complicated grief, and providing bereavement resources to the family 9
• The Intensive Care Medicine journal recommends noting any bereavement resources provided to the family, such as counseling or support groups 11

Team Communication and Support

• The Intensive Care Medicine journal suggests documenting communication between physicians and nurses regarding the patient's death, as well as any debriefing sessions held following difficult cases 11
• The National Comprehensive Cancer Network guidelines recommend documenting any support provided to staff members experiencing grief, such as counseling or peer support 7
• The Intensive Care Medicine journal also recommends recording any follow-up plans with family members to assess coping, and noting any feedback received from family members about the end-of-life care 11
• The Critical Care Medicine journal suggests documenting any feedback received from family members about the end-of-life care, as a way to improve quality of care 10

End-of-Life Care Documentation

Essential Components

• The National Comprehensive Cancer Network recommends documenting any end-of-life care provided, including pain management and symptom control, as part of comprehensive nursing documentation for deceased patients 12
• Cultural or religious considerations should be addressed in after-death care, as noted by the American Society of Clinical Oncology 13

Administrative and Legal Documentation

• The National Comprehensive Cancer Network suggests noting any organ donation discussions or decisions as part of administrative and legal documentation 12

Important Considerations for Quality Documentation

• The National Comprehensive Cancer Network recommends documenting how the body was prepared with dignity and respect, as part of ensuring dignity and respect in end-of-life care 12
• Cultural and spiritual preferences should be honored, as noted by the American Society of Clinical Oncology, to facilitate a peaceful death 13