Death Pronouncement Note

Patient: [Patient name, MRN]

Location: [Unit/room/bed or ED bay]

Date/Time of Note: [Auto-populated timestamp]

Pronouncing Clinician: [Name, credentials, role/service]

Circumstances & Timeline

[Brief narrative of circumstances] (State who requested the pronouncement and describe the circumstances: expected death, post-code, withdrawal of life support, or death on arrival. Document code status at time of death. If resuscitation was attempted, include CPR initiation and termination times and reference the code record. If withdrawal of life-sustaining therapy occurred, include the time of withdrawal.)

• Last known alive: [Time, or "unknown" with brief explanation; label approximations as "approx."]
• Found unresponsive: [Time, or "N/A" if witnessed arrest or expected death]
• Pronouncement time: [Time assessment completed]

Pronouncement Examination

(Document each finding explicitly based on direct bedside assessment. Do not omit any required element.)

• Identity confirmed: [Method, e.g., wristband and chart review]
• Responsiveness: No response to verbal or tactile stimulation
• Respirations: Absent x [duration] seconds
• Pulse: No central pulse palpated at [site]
• Heart sounds: Absent on auscultation x [duration] seconds
• Pupils: Fixed and nonreactive to light

(If telemetry available, note rhythm as supportive information only. If special circumstances apply—profound hypothermia, suspected overdose, pacemaker/ICD—document escalation per institutional policy.)

Preliminary Cause of Death

[Clinical cause of death in plain language] (State the underlying condition and proximate cause, not solely the terminal mechanism. If uncertain, document "cause unclear—pending further evaluation" or "referred to ME/coroner.")

Notifications & Referrals

• Family/NOK: [Name, relationship] notified [in person / by phone] at [time]. Family present at death: [yes / no]. Condolences offered. Chaplain/spiritual care offered: [accepted / declined / unavailable]. (If notification pending or unsuccessful, document attempt details and follow-up plan.)

• Attending physician: Notified [yes / no] at [time]. (If pending, document plan.)

• OPO referral: [yes / no] at [time], case number [if provided], disposition [screening in progress / accepted / declined / pending]. (Family approach handled by OPO per protocol.)

• Medical examiner/coroner: Case reportable [yes / no / uncertain]. If yes: contacted [yes / no], disposition [accepted / declined / pending], case number [if available]. Lines/tubes left in place due to ME hold: [yes / no]. (If reportability uncertain, document rationale and next steps.)

• Hospital autopsy (if ME declines): Offered [yes / no], decision [accepted / declined / pending].

Attestation

"I personally examined the patient and determined death based on the findings documented above."

[Electronic signature with credentials]