<---Sunrise, Mt Sinai, Egypt. June 2009
Diagnosing Death - from the BMJ Podcast (16/04/10)
Dealing with death is probably one of the hardest things to cope with as a junior doctor, particularly if you are being faced with it for the first time. Here are a few tips on how to manage the situation:
Verify the death - check patient identity, observe patient appearance and note absence of any respiratory movements (over a 5 minute period). Auscultate over the chest and listen for heart/breath sounds. If any activity at all, reassess for a further 5 minutes. Check corneal reflexes, pupil response (reflexes) - pupils will be dilated and non-responsive. Check motor response (apply supra-orbital pressure) Check for pulses - carotid (both sides), radial and femoral. Wash hands. Make an entry in the patient's notes - date and time of death, findings on examination.
Breaking Bad News - Step back, take a deep breath, don't rush into the situation, think about your management plan. Communicate with family members, next of kin, what has happened. Do this in a private, quiet place eg. relatives room (clean and representable). Don't keep people waiting, turn off phone, pager etc and ensure NO interruptions. Use lines eg. "I'm sorry to say we have some very bad news". Use terms dead / died, as opposed to 'passed away', 'deceased' etc. Avoid common euphemisms. Discuss practical issues eg what will be done with the body, how the body is laid out. Inform the GP of the death.
Consider need for a post-mortem / referral to the procurator fiscal eg cause of death is uncertain, suspicious, accidental, violent, due to surgery/anaesthesia. If there is any cause for concern / suspicion, do not complete the death certificate - instead, discuss with a senior colleage.
Complete a death certificate. Ask yourself, am I the best person to complete this certificate? Legally someone can only complete a death certificate if they have seen the patient in the past 14 days. You MUST see the body after death. Once it is completed, it should be taken to the registrar of births and deaths (usually by the patient's next of kin). If there is any doubt, discuss with senior colleagues before proceeding.
Some OnExamination question corrections:
Differential Diagnosis - Thyroid Disease:
deQuervain's Thyroiditis - most frequently seen in young females. Often follows a flu-like illness. The patient commonly reports pain and a tender thyroid gland. It is usually a self-limiting illness.
Follicular Carcinoma - spreads haematogenously to the lungs. Treatment is with a total thyroidectomy. It presents with a firm neck nodule.
Anaplastic Carcinoma - rapid onset growth of a hard, woody thyroid lump which eventually progresses to acute dyspnoea. Abysmal prognosis.
Hashimotos's Disease - the commonest cause of primary hypothyroidism. Usually presents with signs of myxoedema. On examination there is a diffusely enlared non-tender thyroid gland.
Multinodular Goitre - may be asymptomatic or may present with pressure symptoms eg. dysphagia, dyspnoea or hoarseness. Particularly endemic in areas with iodine deficiency.
Medical Eponyms:
Rovsing's Sign - RIF pain exacerbated by pressing in the left iliac fossa (bowel is pushed onto the inflamed appendix) - classic in appendicitis.
Courvoisier's Sign - Law that states that in the presence of painless obstructive jaundice if there is a palpable bladder then the cause is unlikely to be gallstones.
Grey-Turner's Sign - Bruising of the flanks seen in retro-peritoneal haemorrhage.
Tumour Markers:
Carcinoembryonic antigen (CEA) is a commonly used tumour marker in colon cancer.
alpha FP and bHCG are markers raised in testicular cancer.
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