Pronouncement and certification of death: Changes to practice in Ireland

Dr Mary McCaffrey explains the updated national policy contained in the ‘Pronouncement of Death by Registered Nurses’ document

The recent HSE National Policy on the Pronouncement of Death by Registered Nurses (PDRN) has been in effect since early September. This policy provides a framework for the timely and safe pronouncement of expected death in adults (over 18 years old) by registered nurses in the HSE and Section 38 services:  Designated centres for older persons, nurse-led intellectual disability services registered by HIQA, and specialist palliative care services.

This change in policy will allow for families to be notified in a timely manner and allow the attendance of the funeral undertaker without waiting for the attendance of a medical practitioner.

Nurses who will be undertaking the pronouncement of death are required to participate in training and complete an online assessment as outlined in the policy document.

Recent legislative changes in the UK have removed the need for the medical practitioner to have seen the deceased within the last 28 days. However, the 28-day requirement for a treating doctor to have seen the deceased remains in place in Ireland for cases of unexpected deaths. In any case the coroner must be notified of the deceased’s passing. Following the discussion of the circumstances of death a decision may be made to waive this requirement, at the discretion of the coroner.

Pronouncement of death

Pronouncement of death is the determination, based on physical assessment, that life has ceased, and the person is actually deceased (See Table 1.1 in the HSE policy).

In the HSE national policy on the PDRN, nurses are required to complete a specific form and a notification check list, as set out in Appendix 2. In cases of expected death, the form must also be signed by the treating doctor.

Apart from expected deaths, pronouncement of death in all other cases that occur are the responsibility of the attending medical practitioner.

Expected death vs unexpected death

An expected death is defined when an underlying medical condition is expected to lead to death in the foreseeable future. A medical note must be documented in the patient’s healthcare record, within the previous 14 days, to state that the patient’s condition is terminal. The doctor completing this note should then be the person completing the certificate of death. If the person has not died within the 14 days, the nursing staff would contact the doctor to update the documentation for a further 14 days.

In advance of an expected death, it would be appropriate that the treating doctor would have a ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decision signed in the person’s notes and that it is communicated to the entire team of healthcare providers. This is in line with the Assisted Decision Making Capacity Act (2015).

An unexpected death is defined as:

▶ Deaths where the doctor has not attended to the deceased in the last month;

▶ A sudden, unnatural, violent, or unexplained death;

▶ Deaths which must be reported to the coroner, Coroners (Amendment) Act 2019.

In such unexpected deaths, the treating doctor should be communicated with as soon as possible. Healthcare professionals should be mindful of adhering to the person’s DNACPR and advanced healthcare directive.

An extensive list of deaths are reportable to the coroner and all healthcare professionals should familiarise themselves with this list.

It is also good practice for healthcare professionals to be aware of which coroner district they work within. In rural areas, there may be a number of coroner districts within the catchment area. As practices may vary slightly in how notifications are carried out, it is important to be aware of coronial practices in your own area.

Having pronounced death in an unexpected death, the medical practitioner liaises with the coroner to discuss the need for either (a) autopsy or (b) to confirm certification of death. In many instances the attending doctor may not be familiar with the deceased. Being familiar with the medical records and medications is important prior to contacting the coroner.

Medical certification of the cause of death

This refers to the completion of the death notification form by a registered medical practitioner where the doctor certifies to the cause of death “to the best of their knowledge and belief”.

This change in policy will allow for families to be notified in a timely manner and allow the attendance of the funeral undertaker without waiting for the attendance of a medical practitioner

On receipt of the documentation, the Civil Registration Office will issue a death certificate. Where the coroner has requested an autopsy and/or inquest, interim death certificates may be issued to allow families to proceed with legal and financial business.

Planned cremation

The process of planned cremation is referred to in the HSE policy document. It suggests that if cremation of the deceased is intended, the medical practitioner who will be completing the cremation form is required to view the body after death prior to completion of the documentation and that the body must not be removed from the place of death without the medical practitioner’s consent. While this would be good practice it should be noted that there is no Irish legal regulation relating to cremation that covers all coronial districts. Therefore, it is advisable to seek advice from the undertaker and coroner.

Key messages

▶ A new HSE policy allows registered nurses to pronounce on expected deaths in specific circumstances.

▶ Forward planning by the treating doctor involves completion of Section 1 of the PDRN form as outlined in the HSE policy document.

▶ In all other cases death should only be pronounced by the treating doctor.

▶ In cases where cremation is planned, there is an additional requirement of the treating doctor to complete the cremation form after viewing the body.

The national policy on the PDRN objective is to allow nurses in identified services to provide end-of-life care as an integral part of the complete spectrum of nursing care. The ability for nurses to pronounce the death of a person provides continuity of care at the final stage of a person’s life. The certification of death is and remains the legal responsibility of the dying persons treating doctor.

Author: Dr Mary McCaffrey, Senior Medical Advisor, Medical Protection