Forms – advance directives, death
certificate, autopsy and dictations
ADVANCED DIRECTIVES
All patients should be questioned about advanced directives
preferably before they become critically ill.
If a patient or legal surrogate requests DNR/DNI,
document that discussion in the chart and write a DNR
and/or DNI order via OrderNet
or in the orders if on a non-OrderNet floor. Remind the attending of record to co-sign the
order within 24 hours or the order will expire.
AUTOPSY AND ORGAN
DONATION
The American Medical Association and the College of American
Pathologists continue to stress the importance of the autopsy. Despite this emphasis, American medicine has
seen a decline in autopsy rates that may not be completely explained by the use
of extensive antemortem diagnostic techniques. In fact, falling below minimum autopsy
requirements (16%), is one of the most commonly cited deficiencies in residency
review committees (RRCs). It is Maryland law to offer organ donation to
the family of the deceased. The “death
packet” contains the death certificate and consent forms for autopsy and organ
donation.
It is important to
provide the following information to the family:
·
the
person taking responsibility for the body may give permission for the
examination
·
the
family is not charged for the autopsy
·
the
autopsy may confirm the clinical diagnosis or reveal additional causes
contributing to the patient’s death
·
the
autopsy will not delay the funeral or interfere with the viewing of the body
·
the
autopsy contributes to physician education and improved patient care
·
any findings are entrusted to the care team and the patient’s family. Providing prompt, understandable autopsy findings
may allow the family to reconcile with the patient’s death.
For questions pertaining to the
autopsy in general or to any particular case, the Department of Pathology at
The Johns Hopkins Hospital may be contacted at (410) 955-3765 or (410) 955-3500. A pathologist on call for autopsy or the
charge resident may be reached 24 hours a day through the paging operator. Furthermore, the Department of Pathology has
created wallet-sized, laminated cards summarizing the autopsy. A copy of this card can be obtained by
calling the above numbers.
Verbal consent is not valid for autopsy. If a family member is not available, a telegram consent is required. Contact the Admitting Office for details.
REQUESTING ORGAN
DONATION
Requesting organ donation is Maryland law. If the deceased’s family/health care agent
gives consent for organ donation, or if you are unable to obtain consent, call
the Transplant Resource Center at 410-242-1173 (24 hours/day).
DEATH NOTE
Document
time death pronounced, examination for response to
verbal/tactile stimuli, spontaneous respiration, heart sounds/pulses, pupillary response, and notification of family &
attending.
DEATH CERTIFICATE
How to
fill it out:
1.
The
certificate must be completed by the physician declaring the death. Complete Sections 1, 23-30.
Do NOT fill out anything else. Leave space (as much as you can) between
the deceased’s first and last names. Do not fill out the middle name (which
will be added later).
2.
The
Hopkins resident “License number” is RES-000 (Section
29c).
3.
NO
ABBREVIATIONS. Write out the month (do
not use number).
4.
Complete
in black ink, making sure that all copies are legible. Do NOT write outside of the lines.
5.
All
terms must be commonly accepted medical descriptions of diseases or
pathological conditions.
6.
Symptom
complexes should not be used; instead, they should be broken down into their
component parts to state the immediate cause of death and underlying condition(s).
7.
“Cardiac
arrest” or “respiratory arrest” are NOT acceptable
causes of death. A provisional cause of
death may be provided when the exact cause is uncertain. When findings are available which
significantly alter the stated cause of death, the admitting office must be
notified; a new certificate may be required.
8.
The
deceased patient’s family must call a funeral home (of their choice) to make
arrangements to have the body picked up from the morgue; this is the only
arrangement they have to worry about.
Your address at Hopkins:
Johns
Hopkins Hospital
Tower
110, Doctors Lounge
600
North Wolfe Street
Baltimore,
MD 21287