Station Title & Timing

  • Title: Verification of Death and Breaking Bad News
  • Duration: 10 minutes (2 minutes reading time + 8 minutes performance)

Learning Objectives

  • Communication: Breaking bad news to a grieving relative with empathy and professionalism.
  • Clinical Procedure: Performing a systematic 5-minute examination to verify death.
  • Legal/Ethical: Correctly identifying a “Coronable” death vs. a death suitable for a Medical Certificate of Cause of Death (MCCD).
  • Safety: Identifying the presence of a pacemaker for cremation purposes.

Patient Profile

  • Name: Mr. Harold Thompson (Deceased)
  • Age: 85 years old
  • Ethnicity: Caucasian
  • Occupation: Retired Carpenter
  • Medical History: Advanced Metastatic Lung Cancer, COPD, Chronic Kidney Disease.

Presenting Complaint

The nursing staff at the palliative care hospice have called you to Mr. Thompson’s room. He has just stopped breathing. His wife, Mrs. Thompson, is sitting by the bed.

Contextual Information

  • Medical History: Mr. Thompson was admitted for end-of-life care 4 days ago. He had a “Not for Resuscitation” (NFR) order in place. Death was expected.
  • Social History: Married for 60 years. His wife is his primary support.
  • Medications: Had been on a Syringe Driver (Morphine and Midazolam).

Exam Instructions

Candidate Instructions

You are the Ward Resident. You have been called to verify the death of Mr. Harold Thompson.

  1. Introduce yourself to Mrs. Thompson and break the news sensitively.
  2. Explain the procedure for verification of death.
  3. Perform the verification examination on the mannequin.
  4. Discuss the certification process (MCCD vs. Coroner) and check for any safety hazards (pacemaker).

Standardised Patient (SP) Instructions (Mrs. Thompson)

  • Affect: You are in shock but quiet. You are holding Harold’s hand. You should be weeping softly but able to engage in conversation.
  • Reaction: If the doctor is too “robotic,” become distressed and ask, “Why are you touching his eyes like that?”
  • Key Question: “Did he suffer at the end? What happens now? Do I need to call the police?”

Examiner Checklist Items

  • Acknowledges the relative and offers condolences immediately.
  • Uses the deceased’s name (“Mr. Thompson” or “Harold”) throughout.
  • Verbalizes the 5-minute observation rule.
  • Checks: Pupils (fixed/dilated), Carotid pulse (absent), Heart sounds (2 mins), Breath sounds (2 mins).
  • Crucial Safety Step: Specifically checks for/palpates for a pacemaker.
  • Correctly identifies this as a “natural, expected death” that does not require a Coroner’s report.

Key Clinical Findings

  • General: No respiratory effort; no movement.
  • Neurological: Pupils 6mm, non-reactive to light. No response to painful stimuli (trapezius squeeze).
  • Circulatory: No carotid pulse. No heart sounds audible for 120 seconds.
  • Respiratory: No breath sounds or chest expansion for 120 seconds.
  • Chest Wall: No palpable pacemaker generator in the infraclavicular regions.

Communication Triggers (Murtagh-Aligned)

  • Open-ended questions: “Mrs. Thompson, I am so sorry. How are you holding up at this moment?”
  • Summarizing/Signposting: “I need to perform a formal check now to fulfill the legal requirements. After that, we can talk about the next steps for Harold.”
  • Handling Emotion: Offer a tissue. Use silence as a tool. Avoid euphemisms like “he’s gone” or “passed away” early on; clarify that he has “died” to avoid confusion, but do so gently.

Assessment & Marking Guide

DomainKey Performance Indicators
CommunicationOffered genuine empathy; used patient’s name; offered relative the choice to stay or leave.
VerificationVerified death systematically: 2 mins heart/lungs, fixed pupils, no pulse.
Safety CheckMust check for pacemaker (Essential for cremation).
Legal/EthicsCorrectly determined this is an MCCD case (not Coroner) because the cause is known and natural.
ProfessionalismHandled the mannequin and the situation with dignity.

Sample Answers / Model Performance

The Verification Script:

“I am now going to verify the death. I am observing the patient; there is no respiratory effort or spontaneous movement. I am checking the pupils; they are fixed and dilated. I am palpating the carotid pulse for one minute; it is absent. Now, I will listen to the heart for a full two minutes… [Pause] …there are no heart sounds. I am listening to the lungs for a full two minutes… [Pause] …there are no breath sounds. Finally, I am feeling the chest for a pacemaker. There is no pacemaker present.”

Explaining the Certification (MCCD):

“Mrs. Thompson, because Harold’s death was expected due to his illness, I can sign the Medical Certificate of Cause of Death here at the hospital. This means we don’t need to involve the Coroner or the police. I will list the cause as metastatic lung cancer. We will notify your funeral director of choice, and they will help you with the registration through Births, Deaths, and Marriages.”

When to involve the Coroner (For Candidate Knowledge):

If this were a 19-year-old with no medical history, or if Mr. Thompson had fallen and hit his head (unnatural), the candidate must state: “Because this death was [sudden/unnatural], I have a legal obligation to report this to the Coroner. I cannot sign the death certificate myself.”