Sunday, July 1, 2007

How to declare people dead.

First step:

Examine the person who may be dead.

Their pupils should be fixed and dilated--that is, showing no responsiveness to light and remaining fully open. They should not have a blink reflex when something brushes against the cornea of the eye. They should have no heart sounds for one minute of listening. They should have no breath sounds, and no other evidence of breathing. They should be unresponsive to deep painful stimuli (e.g., pushing down sharply and rubbing the sternum--the middle of the chest). Especially if they have been brought from somewhere else rather than dying in the hospital, they are "not dead until they are warm and dead", because hypothermia can mimic death by slowing down and dampening down all bodily functions.


Write a note in the chart. Like all other notes in the chart, sign it with your name followed by "MD".

Declare the person to be dead by filling out a form for the hospital admitting office. Call the office and let them know the patient is dead. If need be, they can tell you your medical license number which you are supposed to put on the form; you've only recently become a doctor, and you can be forgiven for forgetting it.

If the death meets any of the criteria listed on the admitting office's form, call the medical examiner's office, who has the right to require an autopsy. You were told in intern orientation to make sure to get the name of which doctor at the medical examiner's office refused the autopsy, or at least which staff person you talked to. You might forget this part. Thankfully you can call back and the ME's office can remind you.

You're required to ask the family if they want the autopsy. The pathology residents require a certain number to graduate from their program, and they've asked you to please try to get autopsies. In theory, autopsies improve healthcare by showing what we might have done wrong, and showing whether our ideas about a person's medical problems were correct. Still, your own inner compass demands that you be gentle about this, and fortunately the vulture-like quality that might surround the request has been taken out of your hands, so that if the autopsy is obviously a dumb idea, you might simply say, "We are required to tell the next-of-kin for everyone who dies that you have a right to an autopsy, at no cost to you."

If the family wants the autopsy there is a consent form. Walk them through it. Once they've consented, sign your name, with "MD" after it.

Based on your earlier phone call, the hospital admitting office fills out the death certificate and pages you when it's time to come down to sign it. Bring the rest of the paperwork also. If you get caught up in something and lose track of time, they'll page you again.

Fortunately, they're there all night. At 4:30 am, as the morning lab results are just starting to trickle in on your MICU patients; as the x-ray tech wheeling around the portable x-ray machine is calling out "X-ray!" as he presses the button to take the morning chest x-ray from outside your patient's room; as he goes and pulls the x-ray plate out from under your sedated and ventilated patient's back, and moves to the next room to repeat the process; and before the sun begins to illuminate the glassed-in walkway between one part of the hospital and another, you can take the elevator down to the little no-windows office with cubicles and dull flourescent lights.

The admitting office workers are sitting in one of the back cubicles with stacks of paper around them. At that time of night one of the admitting office staff members might be doing a crossword puzzle when you arrive. But they know right where the death certificate is; your arrival is a key item on their to-do list, because it has to be done before they can release the body to the funeral home. Don't fill out any of the information on the form--they do that, and anyway, you'll just mess it up. If you start filling out the address and time and date information, they'll have to start a new death certificate. So just sign it with your name, followed by "MD".

Then, when you have a moment:

Recognize that the structure of modern society is to make life and death themselves medical and then legal matters, and to subject the most basic elements of our existence to professional authority. The birth certificate and the death certificate are signed by doctors, and then registered by the civil authorities. The "MD" proves the certificate's legitimacy as a reflection of an actual biological fact.

The birth certificate is not simply an extra voter created by a political machine, but an actual person with a beating heart. The death certificate is not a way for someone to escape their creditors or start anew in another city or make an insurance claim; it reflects one body's stopped heart. The doctor declares a biological process to have definitely begun, or to have irrevocably finished; the declaration of biology is necessary for the legal and political legitimacy of the state. A modern state must be able to keep track of who is born and who dies. This is an important distinction between wealthy nations and impoverished failing ones.

A person who was born without a birth certificate is a person without a legal identity. And a person who is dead but does not have a death certificate is a body in limbo, kept in a hospital morgue until the form is signed with "MD". Without this the body can not be buried; our funeral rituals of helping the person to pass from this life into whatever follows can not take place until a doctor signs the form that verifies that the person has indeed left this life.

Taking the elevator, back up to the ICU, you might think how strange it is to hold a doctor's power. The fact that declaring death requires your presence, your examination of the body, your ritualized declaration, your signature on the forms, are all part of how we wrap death in our own forms of modern technical expert solemnity. You understand why it's a good idea to be sure that someone is dead before you declare them dead, and why a doctor is called on to make sure. Still, to find yourself called to verify the death of a human body that everyone knows is dead is a strange task. You understood that the power of prescription, and the knowledge you hold, and the social role you play, all give you power in the hospital and in the world. But you might now realize for the first time that you are also an official of biological fact, called on by your state to be the neutral observer, to translate the natural world into civil forms and statistics.

As I was taking pre-med classes, one of my dearest friends was going to get married to his then-girlfriend, who had also become a dear friend. They asked me to officiate at their wedding. Of course I was deeply honored, and went immediately to the internet to get myself ordained as a minister--because for the state, sealing the bonds of love requires other distinct forms of authority.

But I also asked them, "Why did you think of me?" Among the things they said was, "Well, you're, like, a doctor." And I said, "No I'm not!" (I still hadn't got through organic chemistry. The outcome was still deeply uncertain.) And they said, "Well, almost." And I said, "Anyway, what does that have to do with anything?"

They tried to explain, and I think what they meant was that by virtue of simply aiming to become a doctor, I had acquired a kind of gravity, a seriousness that was different than their other friends. Or perhaps even more likely, by announcing my intent of becoming a doctor, I had begun to publicly acknowledge the part of myself that wanted to play that kind of role within my community and my society.

That was a long time ago. The daughter they had well after their wedding now has opinions about tacos, burritos, and their relative merits. After all that time, I finally have actually become a doctor, and I have taken on that ceremonial gravity in other ways.

"...I examined him and found his pupils to be fixed and dilated; he had no corneal reflex; he had no heart sounds for one minute; he had no breath sounds, no air movement apparent at his mouth, and no chest excursions; he did not respond to sternal rub or firm pinching. Time of death: 4:45 pm.

Joe Wright, MD. Pager #81987."



Anonymous said...

"warm and dead"? OMG that so funny and yet so disgusting. are we shooting for room temperature? Will cool to the touch do? Do you actually have to pop them in the oven (as I understand David Sedaris's mother did to puppys) so see if you toast them to revival?

Joe Wright said...

No oven--but warming blankets and heat lamps, yes.

For someone who was very certainly not out in the cold--which is most people--this is clearly not necessary.