EXPECTED DEATH AT HOME PLANNING TOOL Patients Name

EXPECTED DEATH AT HOME PLANNING TOOL Patient’s Name_______________ MD / RN (EC) / Medical Group Will attend home 24/7 to pronounce and certify HCN ___________________ MD / RN (EC) / Medical Group will certify as soon as possible (within 24 hours of death) Name: __________ Phone: _________ Will not attend home to pronounce or not available 24/7 Following discussion with family and MRP* indicate / circle which process they wish to follow Rev: Nov 2017 Nurse pronounces Funeral Home will accept nurse pronouncement and certification within 24 hours of death Funeral Home will not accept nurse pronouncement and certification within 24 hours of death Determine how to get death certificate to Funeral Home after completion Explore local options: Alternate MD / RN (EC) / Medical Group to attend home to pronounce and certify 24/7 MD / RN (EC) / Medical Group will not certify within 24 hours of death Explore local options: Alternate MD / RN (EC) / Medical Group to certify within 24 hours of death *MRP = Most Responsible Practitioner

EXPECTED DEATH AT HOME PLANNING TOOL Purpose This too was developed to facilitate planning for pronouncement and certification when an expected death occurs at home. Nurses are permitted to pronounce death, but a Physician or Nurse Practitioner must complete the certification of death. Some Physicians/Nurse Practitioners choose to manage their patient throughout the course of a final illness and will attend when death occurs, pronounce, and certify death. If the Physician/Nurse Practitioner does not plan to attend there must be a process in place to ensure that families are not distressed by a lack of a plan at the time of death. Funeral Homes are not obliged to remove a body until after certification has taken place. In the case of an expected death, arrangements may be made at the discretion of the Funeral Director. If any person expresses any concern regarding a death that can not be satisfied by the care team present at the time of death, a coroner should be called. The coroner can be contacted through the hospital switchboard or the police. Instructions The algorithm, kept in the yellow Palliative Care Plan for Expected Death at Home folder, offers a step-by-step process for planning and should be initiated at the time the decision is made for a home death. Once it is decided who will pronounce and certify death, sign and date the planning tool. Record the information on Guidelines for Family/Caregiver at the Time of Death also contained in the aforementioned yellow folder.