So Now Families Can Verify Death by Video Consultation
Dealing with Death in the Climate of Covid-19
In the UK, back in April of 2020 as Covid-19 began to make it’s presence felt, a flurry of advisory documentation was produced. Concentrating on worst case scenarios, it was assumed that in the event of the healthcare system becoming overwhelmed, many of the carefully engineered systems and regulations would become invalidated.
There has already been a lot of negative publicity regarding DNAR (do not attempt to resuscitate ) forms. Some GP practices approached nursing and care homes under their remit and advised the staff, wrongly, that they should issue these forms on a blanket policy format relating to all their very elderly and frail patients. This was done in many cases without consultation with their families which is totally against national policy. Many of the elderly were told that they would not be eligible for hospital care in the event that their local secondary care facilities were filling up with Covid-19 patients. As you can imagine, this caused immense distress to families who were not even allowed to visit their loved ones. To be blatantly told that due to their complex medical needs and advanced age, their relative would not be able to access appropriate healthcare, was like a kick in the teeth.
This error of judgement set the scene for growing mistrust in the community. Most were aware that their own access to primary care had changed. Consultations now take place by telephone or video. Very few face to face visits happen. A need to have Internet access and a mobile phone has made it extremely difficult for the disadvantaged to have any contact with normal health care. Some practices require an on-line form to be filled in before the doctor will even call the patient. Then there is the thorny problem of language barriers and confirmation of identity. All the progress that had been made in giving better access to health care for those who were homeless, asylum seekers, mental health sufferers, addicts and those affected by cognitive impairment has been blown away by Covid-19.
Taking this one step further, death in the community becomes another difficult situation. Home visits are to be limited as much as possible. The reasoning behind this is sound. It is vitally important that the health of essential nurses and doctors is protected. So how can the family manage the not unexpected death of their elderly relative? In the past, their GP would visit, confirm death and offer sympathy and advice. This important role has been eroded by Covid-19.
If a qualified health care worker, emergency care technician or nurse is present at the death, then the doctor on the phone can guide them through the requirements to verify death. In a care home or nursing home, there is usually someone who can fulfill this role.
They will be asked, in the first instance, to confirm the identity of the deceased and whether he or she has seen a doctor either in person or by video within the last 28 days ( this information is required for completion of the death certificate). They must then show the deceased to the doctor, using their phone, observing the chest over a period of 3 minutes for any evidence of respiratory activity and ensuring that the face has been viewed. Following this, a pen torch light must be shone in both eyes to demonstrate bilateral dilated pupils. If available, a pulse oximeter should be attached to a finger to show absence of pulse, and a BP cuff may be used to prove lack of systolic blood pressure. Death can now be satisfactorily verified.
The process becomes more difficult in the deceased’s own home. Family members are distressed, as might be expected. The chance that one or more of them may have healthcare experience or qualifications is small. The doctor is required to ask them if there is anyone present who would be prepared to verify the death, with guidance by video.
I would expect most families to be absolutely horrified by this request. They are likely to feel that the doctor is abrogating his or her duty and treating their loved one with considerable disrespect. If they say no, as many must do, they are given two options. Firstly, they can call the undertaker and on arrival he or she can be talked through the verification process with the doctor. Alternatively, as a last resort, the doctor will visit in full PPE, requiring the entire family, including the deceased, to wear masks.
If a relative agrees to the video process, he or she must first confirm the identity of the patient who may be unknown to the doctor. How this is to be done is unclear. Some have advised that a passport or photo documentation should be shown next to the deceased’s face. For the relative, who must first search in the deceased’s belongings in order to comply, this seems very intrusive and insensitive in view of the recent death. They must then show the chest, preferably unclothed, for 3 minutes. Ideally, under the doctor’s guidance they should feel for the carotid pulse for 2 minutes and shine a light in the eyes to demonstrate dilated pupils. To be absolutely certain, the entire process should be repeated in ten minutes before verification of death is confirmed.
The take home message here is clear. Relatives of frail and elderly patients who are expected to die within a short time frame, should be prepared. They should ensure that photographic identity of their relative is available if required. They should have a small torch at hand. They should familiarize themselves with the video function on their mobile telephones.
If all this seems a little far-fetched, do not be deceived. This is happening across the nation.
There is detailed advice in the General Medical Council’s document here. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life.
The British Medical Association has specific guidance here https://www.bma.org.uk/media/2323/bma-guidelines-for-remote-voed-april-2020.pdf
NHS policy on use of ‘Do Not Attempt to Resuscitate Forms’ https://network.healthwatch.co.uk/network-news/2020-04-09/nhs-policy-use-%E2%80%98do-not-attempt-to-resuscitate-forms%E2%80%99
Department of Health
Previously published in Medium October 2020