Nurse May Pronounce

Although pronouncing someones death is a task that's technically the responsibility of a medical doctor, it's commonly delegated to RNs and Paramedics every day. Paramedics and some nurses have the luxury of elaborate standing orders that allow them to perform this delegated task whenever appropriate, I have to open a chart and look for a physicians order. Many orders pack the entire box with text, this one is a simple, minimalist "NMP", a date, and a medical doctor's signature.

The ritual is simple. It begins when you notice that breathing has stopped. Maybe something happened to remind you to check. A sudden change in weather. A premonition.

Next, you listen to the chest cavity for a full minute and verify that the heart has stopped beating.

Then, you watch the person for two full minutes to verify that they aren't breathing. I like to place a hand on the carotid artery (located in the neck) while I'm doing this.

Corneal reflexes are next, lightly brushing the eyelids to detect an autonomic response.

Finally, a sternal rub. I've heard pinching the trapezius muscle in the shoulder is preferred, but I like the symbology of the sternal rub. I'll quietly, gently, say the person's name a couple of times as I do this.

Time speeds up now. The realization that I still have a full census (minus one) to take care of sinks in. Post-Mortum care is delegated to the nurse's aides. If they haven't done it before they might need a little bit of intraprofessional caring to get them through it. The doctor needs to be called, leaving a message with the answering service is generally sufficient. The informant needs to be informed (or woken up), and then asked when I should call the funeral director. The funeral director gets the next phone call, and the estimated time of arrival is relayed to the family. There's one more MD order to obtain, something else delegated to us: "Please release body to funeral home of family's choice". If you write it post-mortum as a telephone order no one will mind. Getting this order ahead of time might be a good idea if the idea of writing telephone orders without a doctor on the phone makes you nervous.

The family might need various things. Food and drink, emotional support, explanations as to what happens next. Children seem to be the most resilient, asking questions out of curiosity and comforting their family better than I could.

Finally, the death certificate. The final bureaucratic nail in the coffin. All the relevant details of the recently concluded life are boiled down into a simple official document. What was their name? Where/when were they born? When/where did they die? What was their most recent address? What were their parent's names? Were they married? Did they have children? What are their names? Were they in the military? What did they die of? Was an autopsy performed? Was a medical examiner contacted?

Nestled in the middle of the document is my signature. This, it feels, is the final stroke. Actually watching the process of death conclude makes me relieved that their suffering is over. Signing that document makes me miss them terribly. It's my final act of care for that person, my final duty to them is discharged. To my process-oriented mind, their life did not actually end until I record all the intimate details of their life into that document and sign it, even though I was the one responsible for verifying that they had passed.

Hugs all around, then it's back to work. The med-pass waits for no one. The thunderstorm had passed and the rest of the residents were waking up. I grabbed my MP3 player with the built-in speakers and queued up a selection of jazz and proto-blues from the 1930s-40s and stuck it on my med-cart.



This is a great interview for Nurses and MDs to listen to. Title is "BBC World Service - Forum 02 May 09: Robert may, Abraham Verghese, Gillian Tett.

I haven't had much time to write lately, my laptop is busted and I rarely write at home.