OMG! *I* cannot pronounce death but a paramedic can????

[nervousnurse]

Oh wowwww....forgive me for FREAKING OUT, but I know some (or ALL??) of my fellow nurses will understand my stress, shock and amazement!!! I experienced my FIRST death of a resident withOUT a DNR tonight and I still can NOT believe this!!! First, I have to explain, his death was SOOO unexpected, NO warning signs, etc!!!!!!!!

To make a long story short (I'll TRY....LOL!!!)......I knew he was definitely DEAD, and as I called my DON to report it, she said we HAD to begin CPR since there was no DNR. Trust me, I did already (kind of) know this, and I've talked to SOOOO many experienced LTC nurses about this, and many explained the term "slow code", etc.....Co-workers (I wasn't there!) recently had a HORRIBLE experience with an emaciated, cancer-riddled resident who refused to sign a DNR, and a new grad was absolutely traumatized when she heard ribs cracking during the CPR, when the resident was CLEARLY already dead. She said the paramedics wanted to cease the CPR, but she yelled at them and said she was NOT losing her license over it, so I'm pretty sure the paramedics took over.....Why didn't they just pronounce the resident dead like the paramedic who did that for us tonitght?? can EMTs also pronounce?

ANyway, as we waited for the paramedics, the other nurse and I totally agreed that starting CPR was LUDICROUS.....but we started placing the board, setting up suction, etc. Thank Goodness the police officer who arrived WAY before the paramedics totally understood why we were NOT actually going to dishonor this sweet person's body by

starting compressions and breaths. I was SO torn on what the RIGHT thing to do was.....I figured legally, in a courtroom, I / we could get in HUGE trouble if we never actually did CPR.????? (could we?)

The paramedics arrive, and they pronounce him. I had NO idea paramedics could do that!?!"!?!???!!! And not the two of us LICENSED NURSES can do that????? (I'm an RN, my coworker an LPN).........

Aside from all the emotions and my stress level---again, this was my FIRST death, so.....it was kiiiiiinda stressful!!!.......It ticks me OFF that a police officer and THREE Paramedics/ EMTs had to waste their time, wear and tear on their vehichle, gas, etc....when if I or my coworker could've just prounouned him, call the doc, call the fam, do post-mortem care, call the funeral home, etc......WHY make the paramedics/ EMTs come out???? What if someone else needed them WAY more than this resident did?

I'm just blown away....and, hate to say it, but the waste of our time with all the PAPERWORK that the Paramedics need?!!???? They're not even taking him with them......also, legally, if WE had to start CPR, why didn't they have to continue?

My other concern and I'm also so curious........**IF** we had actually done CPR, his body would be so bruised, ribs possibly broken, etc. How on earth does the mortician handle all of that for viewings (if that's what the resident wanted?) What if the ambu bag broke some of the bones on his face? I know they do all kinds of makeup and have prosthetic implants to make the cheeks / neck, etc look nice if they;re traumatized by CPR, etc.....? How do they get the hands to look folded and peaceful if CPR was done and the arms are bent out to the side, etc? Rigor Mortis had already begun in this man's jaw when the paramedic pronounced him----can you imagine what damage the ambu bag would've done???

I appreciate stories/ experiences/ thoughts/ etc.......Also curious ( I know things vary by STATE!!!), where you work, does the doctor require you to tell them WHO pronounced them dead? Does it always have to be a paramedic? What if we'd found him even later and there was more rigor mortus? Do they still require us legally to begin CPR since there's no DNR? Seriously????

Can an LPN/ RN pronounce death where you work and avoid the WASTE of time having the paramedics and poilce come out? Does a police officer always have to be at a death? Thanks! ***oh em gee, wonder if I'll EVER get to sleep!!!****

[lindseylpn]

When I was in ltc any full code had to be sent to the er and pronounced by a dr, dnrs could be pronounced by an rn and then sent straight to the mortuary. If there wasn't an rn on duty then the ambulance or heorifice would have to swing by the er to have a Dr pronounce before they went to the mortuary. If we had a patient on hospice their personal hospice nurse on call would come out and pronounce and then take care of all the mortuary arrangements etc.

[BrandonLPN, LPN]

When I was in ltc any full code had to be sent to the er and pronounced by a dr, dnrs could be pronounced by an rn and then sent straight to the mortuary. If there wasn't an rn on duty then the ambulance or heorifice would have to swing by the er to have a Dr pronounce before they went to the mortuary. If we had a patient on hospice their personal hospice nurse on call would come out and pronounce and then take care of all the mortuary arrangements etc.

Interesting. I have never once been questioned about my credentials, or asked if a RN/Physician "verified" that the resident was dead. They just pick the body up and off they go to the funeral home. And when our doctor comes in the next day, the secretary has the death certificate ready to go and the doctor signs it.

Maybe the rules vary by state?

[lindseylpn]

It probably is a state thing. I remember that the facility got in a little trouble one time by the state because, a dr gave an order over the phone for the RN to pronounce a full code patient instead of sending him to the er for him to pronounce. One of the emts had went to the nursing station and called the dr and then handed the phone to the RN, the Dr told her to not send the patient by ambulance to the er, to pronounce him and call the mortuary. A memo was sent out to never accept an order like that again, to send the patient to the er no matter what the dr or ems said.

[Esme12, ASN, BSN, RN]

Oh wowwww....forgive me for FREAKING OUT, but I know some (or ALL??) of my fellow nurses will understand my stress, shock and amazement!!! I experienced my FIRST death of a resident withOUT a DNR tonight and I still can NOT believe this!!! First, I have to explain, his death was SOOO unexpected, NO warning signs, etc!!!!!!!!

To make a long story short (I'll TRY....LOL!!!)......I knew he was definitely DEAD, and as I called my DON to report it, she said we HAD to begin CPR since there was no DNR. Trust me, I did already (kind of) know this, and I've talked to SOOOO many experienced LTC nurses about this, and many explained the term "slow code", etc.....Co-workers (I wasn't there!) recently had a HORRIBLE experience with an emaciated, cancer-riddled resident who refused to sign a DNR, and a new grad was absolutely traumatized when she heard ribs cracking during the CPR, when the resident was CLEARLY already dead. She said the paramedics wanted to cease the CPR, but she yelled at them and said she was NOT losing her license over it, so I'm pretty sure the paramedics took over.....Why didn't they just pronounce the resident dead like the paramedic who did that for us tonitght?? can EMTs also pronounce?

ANyway, as we waited for the paramedics, the other nurse and I totally agreed that starting CPR was LUDICROUS.....but we started placing the board, setting up suction, etc. Thank Goodness the police officer who arrived WAY before the paramedics totally understood why we were NOT actually going to dishonor this sweet person's body by

starting compressions and breaths. I was SO torn on what the RIGHT thing to do was.....I figured legally, in a courtroom, I / we could get in HUGE trouble if we never actually did CPR.????? (could we?)

The paramedics arrive, and they pronounce him. I had NO idea paramedics could do that!?!"!?!???!!! And not the two of us LICENSED NURSES can do that????? (I'm an RN, my coworker an LPN).........

Aside from all the emotions and my stress level---again, this was my FIRST death, so.....it was kiiiiiinda stressful!!!.......It ticks me OFF that a police officer and THREE Paramedics/ EMTs had to waste their time, wear and tear on their vehichle, gas, etc....when if I or my coworker could've just prounouned him, call the doc, call the fam, do post-mortem care, call the funeral home, etc......WHY make the paramedics/ EMTs come out???? What if someone else needed them WAY more than this resident did?

I'm just blown away....and, hate to say it, but the waste of our time with all the PAPERWORK that the Paramedics need?!!???? They're not even taking him with them......also, legally, if WE had to start CPR, why didn't they have to continue?

My other concern and I'm also so curious........**IF** we had actually done CPR, his body would be so bruised, ribs possibly broken, etc. How on earth does the mortician handle all of that for viewings (if that's what the resident wanted?) What if the ambu bag broke some of the bones on his face? I know they do all kinds of makeup and have prosthetic implants to make the cheeks / neck, etc look nice if they;re traumatized by CPR, etc.....? How do they get the hands to look folded and peaceful if CPR was done and the arms are bent out to the side, etc? Rigor Mortis had already begun in this man's jaw when the paramedic pronounced him----can you imagine what damage the ambu bag would've done???

I appreciate stories/ experiences/ thoughts/ etc.......Also curious ( I know things vary by STATE!!!), where you work, does the doctor require you to tell them WHO pronounced them dead? Does it always have to be a paramedic? What if we'd found him even later and there was more rigor mortus? Do they still require us legally to begin CPR since there's no DNR? Seriously????

Can an LPN/ RN pronounce death where you work and avoid the WASTE of time having the paramedics and poilce come out? Does a police officer always have to be at a death? Thanks! ***oh em gee, wonder if I'll EVER get to sleep!!!****

If there is no DNR...yes you need to begin CPR. even with Rigor....the ambu would not have done any "damage" the effort would just be futile. Medics (EMT-P) can indicate code not indicated and let medical control "pronounce them" the actual death certificate is filed out by "authorized personnel" which medics are not.....there are still some states that do not allow medics to "call the code" or stop resuscitative efforts until they get to the ED but there are very few. Just like at a crime scene the police officer and indicate that the patient is deceased...call for the medics then call the coroner if indicated...or call no one if it is clear that decomposition has occurred.

ANY TIME 911 is called for rescue units......the police are dispatched. when you call 911 for the resident it's like calling them to someone's home and they act accordingly which sets in motion the regulations/protocols of the EMS in your state. These regulations very slightly state to state but for the most part they can "call the code" when it is clear there is an unlikely chance of survival..police are dispatched to file a report and assist the fire department/ambulance if necessary.

The protocols are set up for general safety...it is difficult to write the law...police shall be dispatched to residents for 911 calls except for nursing homes residential nursing homes, assisted living and maybe long term acute care. If the ambulance you are using is fire department based...the police file a report.

Ribs can break any time you perform CPR even if it is "proper" it happens. MANY new nurses, EMT's CNA's are surprised at the visual/actual brutality of resuscitative efforts. It is unnerving....but you will in many ways grow accustom that sometimes efforts to help people are not always without a price or trade.

Morticians have a wide array of prosthetic and makeup at their disposal to assist with the body cosmetics.....if you are really interested....call a local mortician ans ask them if you can see what they do....I warn you it too has it's brutal side and NOT for the faint of heart!

As far as your co-worker.....I'll bet they "called the code" in the rig and transported the patient to the ED knowing they had to do something to stop the insanity and help this poor nurse out.

TYhe moral of the story....look up the laws in your state. Look up you nurse practice act. Look up your policy and procedure manual and know yoru policies. MOST IMPORTANT of all!!!! GET malpractice insurance!! It's cheap....It will protect you and you license. FOr those who say it makes it more likely you will be sued...hogwash. I carried it for 34 years nad was (knock on wood) never sued....or depositioned for what I did.

I hope you got some sleep! ((HUGS))

[CT Pixie, BSN, RN]

In my State an RN in LTC/SNF can pronounce a patient as long as they are a DNR. LPN's cannot.

A DNR patient will/must have CPT initiated and continued until the ambulance arrives, they then take over. Even if it is obvious that the patient is gone (stone cold and stiff) in LTC we *have* to start CPR on full code patients.

EMT's can pronounce dead on scene if the person is decapitated, is in full rigor or is burned beyond recognition, other than those 3 things, the EMT cannot pronounce, they must have med control make the call as well as continue with resusitation efforts until such time they are told to stop by medical control.

I remember years ago when RN's couldn't pronounce. The body would lie there until the doc got there to 'make the call' and sign the death certificate. Then and only then could the body be taken down to the facility holding room for the funeral home to pick up.

[SoldierNurse22, BSN, RN]

I know medics have much different training and school than RNs because of what they have to do..

EMT-Ps (paramedics) have education that is specific to medicine on the street. They are taught how to survive outside a hospital environment with the supplies that they have on hand. Their education, however, does not supercede that of an RN's, and I have also always been of the opinion that if an EMT-P was able and educated enough to pronounce a death, an RN (especially an ER RN) should be able to do the same. The only reason they can't, in my opinion, is because there are docs in the ER that can call the patient. Out on the streets, that authority gets transfered to the EMT-P.

[BuckyBadgerRN, ASN, RN]

Very good response to the OP. OP sounds very young (basing that on the writing style) and uninformed. (paramedics ARE licensed providers)

A debriefing and a working understanding of her facility's procedures as well as the laws in her state would be hugely beneficial, IMO

[pmdcjg]

I am currently an active Paramedic in Georgia. I am in my last term of nursing school for RN as well. I can shed a little light on some of your questions in your post. In Georgia Paramedics cannot legally pronounce someone dead. When we are called to a scene (be it a residence, business, healthcare facility, etc.) we operate under protocols and standing medical orders that are preapproved by the medical director of the EMS/Ambulance service. We have SMO's in place that address cardiac arrests and also operate under the ACLS guidelines of American Heart Association. It is the discretion of the Paramedic on scene to decide based on clinical condition of the patient as to continue CPR, or even start CPR on a patient. This decision is backed by ACLS and the SMO in place by a licensed physican that is the approving medical director of those SMO's. If CPR has been established then we allow that to continue and call medical control and speak with the doctor and provide current patient clinical findings and our suggestion and then the doctor will give us the approval to stop resusitation efforts or to continue and transport. Generally, the doctor will support the Paramedic's decision/suggestion and that doctor then needs to sign the patient care report for that patient signing that he agrees with termination decision. If we respond to a call of cardiac arrest and no CPR has been established then the Paramedic makes the decision based on current patient clinical findings and no physican contact is usually needed if it is an abvious death such as those findings that are recognized by AHA such as mortal wounds, Asystole, hospice patient. If the death occurs in a healthcare facility the county coroner is notified. If the death occurs outside a healthcare facility then the county coroner must be contacted on all those death suspicious or not. It is the county coroner or medical doctor that pronounces a person dead, not the Paramedic. The Paramedic determines whether or not to start or continue resusitation efforts. If the death is outside a healthcare facility then the coroner comes and investigates the scene and the patient and then will decide to either release the body to funeral home or if autopsy must be done and then they will arrange transportation of the body to the state crime lab. It can be a little confusing at times. This is pretty much how it works in Georgia. I am sure there are some more finer details concerning the coroner and death pronouncement that i am not aware of.

Nurses (RN's) should be allowed the same ability and supported in being able to make that determination of CPR or not. RN's are highly skilled and knowledable of patient care and it is in the best interest of the patient and the family that they be allowed to make that clinical decision.

[Asystole RN]

In the state of Arizona a nurse can pronounce death.

[AngelRN27]

When I used to work LTC NOC shift, I was put into a similar situation as well and we did not run a "slow" code as the patient was not going into rigor mortus and was basically still "warm" but you could tell she had gone a while earlier... she was not a DNR due to the family's decision as she could no longer make decisions for herself, so we also felt very guilty running the code... it's a tough situation but as some posters mentioned, it's not truly for us to decide what, when or how the patient wants their death to be handled. That is up to them and/or their family/HC proxy, etc...

One thing to be clarified in the OP's second (or third?) post about EMTs/Medics versus RN/LPN: I agree with BrandonLPN, I never had to worry about someone being "pronounced", etc. Also, it is incorrect to state that Medics intubate and we don't. At my current job (LTAC, totally different setting) everyone is ACLS certified and therefore either the Respiratory Therapist or the RN will intubate as we do not have docs in-house 24/7. As a matter of fact, the two codes that I saw during daylight hours where docs WERE present, the RT still did the intubation. Just a fun fact, LOL.

[RNsRWe, ASN, RN]

It was only recently that the Massachusetts BON and DPH decided we didn't have to do CPR on someone if they'd been decapitated.

....and this decision was probably only reached because of the recognition that it's impossible to give rescue breaths to a headless body. Bizarre.

[Asystole RN]

....and this decision was probably only reached because of the recognition that it's impossible to give rescue breaths to a headless body. Bizarre.

Don't be a quitter.

You can still ventilate the stump. You just take a firm grasp of the trachea with your thumbs and forefinger, purse your lips, and inflate like an air mattress.