Discharge as Deceased Navigator
A unique patient navigation workflow is needed when a patient dies in a healthcare facility, including when they are declared dead on arrival at the facility. This "patient movement" is a form of discharge, with death bringing the healthcare encounter to an end. The workflow is supported with a navigator.
Discharge as Deceased Navigator
A link to the "Discharge as Deceased" navigator is found within the Discharge Transfer Gateway activity. There are slight variations in how the navigator is initiated for emergency department encounters.
Emergency department
With a patient chart open and the "Dispo" activity selected, find the "Disposition" section and enter a disposition fitting the death circumstance (e.g., died in ED).
This will reveal a new section in the Dispo activity called "Death Documentation". Select the section link to open the "Discharge as Deceased" navigator.
Inpatient departments
With a patient chart open and the "Discharge Transfer Gateway" navigator selected, look for and select the link labelled "Discharge as Deceased Navigator".
The following information relates to tasks that prescribers must complete, guided by the navigator.
Essential Steps for Prescribers
The Discharge as Deceased navigator is available to all clinicians. The version presented for signed-on prescribers highlights just the tasks with physician accountabilities, and so differs from what is shown to nursing and non-prescribers.
Prescribers must use the Discharge as Deceased navigator to review key information, take actions and complete all required documentation:
Review eligibility criteria for organ or tissue donation, medical examiner notification and autopsy requests.
Reconcile problems by indicating which hospital problems are resolved and which were active at the time of death; plus confirming a principal problem that was the focus of the inpatient encounter.
Clear orders needing co-signs.
Declare the Date, Time and Preliminary Cause of death where the date and time correspond to the instant when a bedside assessment to pronounce death is completed.
Contact and notify the attending provider as well as the patient's designated decision-maker(s), noting who was contacted.
Complete a pronouncement of death progress note.
Complete a discharge-as-deceased discharge summary.
Ensure attending physician completion of a digital Medical Certificate of Death (MCoD).
Confirm completion of all required tasks using the provided Discharge Checklist.
Donation Criteria
The Discharge as Deceased Navigator has an interactive "Review Eligibility Criteria" section that helps clinicians review criteria that must be met in order for a deceased patient to become a tissue or organ donor. Answers to basic questions may expose more detailed questions or instructions for appropriate actions. The section summarizes the status of review tasks, while providing links to pop-up displays of the state of all questions that relate to a task. Instructions are embedded within the section, including a prompt to click on a link(s) to open an editor for reviewing and updating eligibility data.
Medical Examiner Notification
The same "Eligibility Criteria" section helps clinicians review criteria that must be considered to determine whether the Office of the Medical Examiner (ME) must be contacted in compliance with the Alberta Fatalities Act.
Calgary (southern Alberta)
Phone 403-297-8123; fax 403-297-3429; email ocme_admin@gov.ab.ca
Edmonton (northern Alberta)
Phone 780-427-4987; fax 780-422-1265; email ocme_admin@gov.ab.ca
Autopsy Consent and Request for Autopsy Order
Prescribers and/or a deceased patient's legal next of kin may request an autopsy. An offer or request should be documented in the "Eligibility Criteria" section of the Discharge as Deceased navigator. As long as the death does not meet criteria for medical examiner notification (as above), then autopsy consent can be obtained and an autopsy request order entered. Both consent and ordering steps are highlighted in the Eligibility Criteria section of the Discharge as Deceased navigator, and both must be completed for an autopsy to proceed.
Autopsy Consent
Consent for an autopsy should be obtained from an agreeable legal next of kin, specifically defined for this purpose as, in order of authority:
spouse or independent partner (if not estranged);
executor named in will of the deceased;
adult children of the deceased;
parents or guardians of deceased;
adult brothers or sisters of the deceased; or
other next of kin of the deceased.
If a legal next of kin is available, then a digital autopsy consent is obtained using the same eSignature forms and workflows pertaining to other consents. For convenience, a link to this consent form is provided within the Eligibility Criteria section of the Discharge as Deceased navigator. The form requires confirmation or entry of the responsible (attending) prescriber, documentation of any considerations or limits to autopsy specified by the requestor, and e-signature of the prescriber. The legal-next-of-kin signature is obtained with usual involvement of other clinical team members.
NOTE: A copy of the completed autopsy consent will be printed (usually by non-prescriber clinical team members) to send with the deceased body to the hospital morgue. This is a temporary requirement that will be removed when Connect Care workflows are well established and legacy (paper) forms are retired.
Autopsy Request Order
An order requesting an autopsy needs to be placed to inform and initiate laboratory processes. An autopsy request order can be placed if:
the death does not meet criteria for medical examiner notification;
a legal next of kin is available and consents to autopsy.
The Eligibility Criteria section of the Discharge as Deceased navigator provides a link that can be used to initiate the request for autopsy order. The order itself includes links for pop-up information that can help answer questions appearing within the order.
A legacy (paper) autopsy consent and request (combined) form can be used by healthcare teams that have not yet adopted the digital workflow. A link to this printable form is provided within the Eligibility Criteria questionnaire (as above).
Additional information about these workflows can be found in:
Tip: Deceased Navigator Autopsy Consent and Request Order (prescribers)
Legacy Form: Autopsy Consent and Consultation Request (paper analogue)
Date, Time and Preliminary Cause of Death
The Discharge as Deceased navigator has an important section that facilitates capture of the prescrsiber (physician or nurse practitioner) declared date and time of death. This must correspond to the instant when a direct assessment for signs confirming death has been completed. A preliminary cause of death must also be entered. This can be as general or specific as the completing physician feels appropriate. It may be revised later when or if additional information becomes available.
Entering the structured information in the form provided is mandatory. That information then flows into other required documentation.
Death Pronouncement Progress Note
Pronouncement of a patient's death must be documented in the legal record of care. This is done in Connect Care by entering a progress note recording the findings of the prescriber assessing the patient for signs of death.
The Discharge as Deceased navigator has a section that provides interactive links for reviewing and/or updating key structured data, such as whether and how a patient's designated decision-maker was contacted. Another clearly labelled link will initiate a progress note using a standardized format. This includes key information that must be in a pronouncement. In most cases, the default values can be accepted.
SmartLink: .PRONOUNCEDEATH
Discharge Summary for a Deceased Patient
Discharge summaries are required documentation for all inpatient encounters. However, there are specific content requirements when discharge is because of death.
Medical Certificate of Death
Digital Certificate of Death
Alberta Health and Vital Statistics have worked with Connect Care to enable a digital workflow for completing Medical Certificates of Death (MCoD). This minimizes double data entry by taking advantage of information abstracted from a patient's chart.
Prescribers (physicians or nurse practitioners) must complete a digital MCoD whenever Connect Care is the record of care at the time of a patient's death. This includes all deaths on arrival to or within health care facilities (inpatient, emergency, outpatient) using Connect Care.
Use the "Certificate of Death" section of the Discharge as Deceased navigator (as above) to initiate a "chart abstraction" that will set up a MCoD using the patient's health data. An interface opens in the chart sidebar where the prescriber validates abstracted data and adds information not already pulled from the deceased patient's chart.
The certificate is digitally signed, requiring the user to re-authenticate with their Connect Care password to confirm their identity. The electronic signature is accepted. Accordingly, death certificates can be completed by authorized prescribers at locations remote from the actual place of death. Once signed, the MCoD is automatically sent to Vital Statistics through a systems interface. Print (paper) forms are not used.
Nursing units continue sending printed death information with a body on dispatch from the ward. Any associated printing is not a prescriber responsibility. The relevant "Death Information Report" is available via the Media tab of the Chart Review activity in a patient chart. From there it can be printed as needed, or routed within Connect Care via In Basket or outside Connect Care via e-fax or mail.
Paper Medical Certificate of Death
Prescribers may wonder about access to paper certificates for specific workflows:
Downtime: If a death occurs during a Connect Care downtime, responsible prescribers are advised to complete a digital death certificate after the downtime finishes.
Unidentified patient: If a death occurs before a patient is identified ("unknown patient"), responsible prescribers are advised to submit a chart correction request and wait for positive patient identification and the associated chart merge before completing a digital death certificate.
Responsible physicians and nurse practitioners can download, complete and print a paper-based certificate of death only if completion within Connect Care is not possible.
Resources
FAQ: How do I edit an already signed Medical Certificate of Death?
FAQ: How do I complete a Medical Certificate of Death for an unidentified patient?
Discharge Checklist
A final section within the Discharge as Deceased navigator displays a copy of the chart "Discharge Checklist". This lists required actions and documentation, indicating whether the tasks have been completed or not. Any deficient task can be clicked (selected) to jump to a tool for resolving the deficiency.