How to Pronounce a Patient's Death Compassionately

The Time-of-Death Ritual

There are many components of care for patients at the end of life, yet the one that makes the most impact is often the pronouncement of death. The act of declaring that a patient has died is a long-held memory of the family, yet previous literature has documented deficiencies in how this important aspect of care is carried out.

A recent randomized study by Mori and colleagues^[1] compared reactions to two video vignettes showing death pronouncements. The vignettes involved a terminally ill man in his 70s with a chronic, incurable illness whose death had been expected, with his wife, son, and daughter at the bedside. One version of the vignette showed a standard, business-like death pronouncement; the other showed the death pronouncement enhanced with five behaviors intended to convey compassion:

Waiting until the family members calm themselves down;
Explaining that the physician has received a sign-out of information about the patient's condition;
Performing an examination of the patient respectfully;
Ascertaining the time of death with a wristwatch (vs a smartphone); and
Reassuring families that the patient did not experience pain.

The outcomes were a physician compassion score, trust in the physician, and viewer emotions (sadness, fear, anger, and disgust). The study found that the video showing a more compassionate pronouncement of the patient's death was associated with positive outcomes in each of these areas.

Viewpoint

The act of pronouncing death is recognized as a profound moment for families. The memories of how the death pronouncement occurred have been recognized as a factor in bereavement and also as a sacred moment.^[2,3,4] Yet, the realities of hospitals often mean that the death pronouncement happens at times when only an on-call physician is present, a person who is often unknown to the family and who has never met the patient. Previous literature and clinical experiences have also reported that many physicians are ill-prepared to perform a death pronouncement.^[5,6]

This study adds to the literature by demonstrating that physician behaviors intended to convey compassion have the capacity to more positively affect the surviving family or friends at the time of a loved one's death. The study authors acknowledged the limitations of this study, including awareness that the hypothetical scenarios shown on video may be different from actual patient death pronouncements. They also recognized that other variables and behaviors could be important in different patient situations, such as with patients or family members of different ages or dying from different diseases or conditions. It would also be very interesting to replicate this study, conducted in Tokyo, in other countries to determine whether the compassion behaviors are generalizable and whether the perceptions of those witnessing the pronouncements are also similar.

This article is an important contribution to the field of palliative care because it brings attention to one of the most significant rituals of medicine, the pronouncement of death. It also demonstrates that clinician behaviors have lasting impact and that the time of death should promote healing and comfort, often not the norm. The compassionate behaviors are simple in some respects yet profound in others.

This study challenges all clinicians caring for patients at life's end to think carefully about the brief moments at the bedside and the memories that will endure.

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