Patient Death in the Primary Care Setting

[00:00] Hello, my name is Jessica Erickson and I'm a primary care physician and assistant clinical professor in the department of medicine at UCSF. This video series is focused on patient death in the primary care setting and providing a review of the resources

[00:20] available for UCSF clinicians and staff when processing an ambulatory patient death. This series is part of a larger project aimed to improve the logistical and emotional processing of patient death for primary care clinicians and is funded by a Mount Zion Health Fund grant. In this four-part video,

[00:40] series, we will start by focusing on the logistics following a patient death, including appropriate death documentation and notification best practices. Next, we will review how to complete death certificate paperwork in the outpatient setting. We will then review available resources to best support your patient's

[01:00] families and loved ones, as well as opportunities for honoring your deceased patients within our department. Lastly, we will review various real-time support resources available to UCSF clinicians to debrief after a patient loss. In this first section,

[01:20] We will begin with the logistics following a patient death, including documentation and notification. Documentation after a patient death is optional, but can be a helpful practice which allows you to alert your clinic admin team, as well as other specialists involved in the patient's care. It also allows you to alert your clinic admin team as well as other specialists involved in the patient's care.

[01:40] allows you the opportunity to review the patient's chart, better understand what happened, and communicate with the patient families in real time. To document a patient's death, you can create a new telephone encounter in their chart. Useful information to include in your telephone note is the patient's date and time of death.

[02:00] the manner in which you or your clinic was notified of the patient's death, the cause of death if known, and if there were any communication on your part with any of the patient's family members or loved ones. To help facilitate this documentation, there is a smart phrase available for you on APACS, which contains all the suggestions.

[02:20] information. If you type in.PCDeathDoc into the telephone encounter, note the following template will appear for you to complete. You can simply F2-click through the template and fill in the relevant portions. You can of course change or add any additional relevant information

[02:40] you choose. Following a primary care patient's death, you should ideally notify your clinic administrative team as soon as possible so that they can change the patient's status to deceased. This will then cancel future appointments and stop the patient's myChart access. To notify your specific clinic's administrative team,

[03:00] You can simply route the encounter to the appropriate pool, P. G. Mosh Admin, with the floor number of your clinic. If you prefer, you can instead route the encounter to Mai Zhang, who is the template teen supervisor for the Department of General Internal Medicine, and can change the patient's status and cancel future appointments herself.

[03:20] Additionally, although optional, a good and appreciated practice is to alert other clinicians involved in the patient's care as APEX does not automatically alert specialists, and therefore long-term providers may not be notified about their patient's death in a timely manner. You may already be well acquainted with some of the specialists involved in the patient's care.

[03:40] involved in your patient's care and know exactly who you would like to notify. However, if you need a reminder of who was involved in their care, you can simply click on your name under PCP on the left-hand panel in the patient's chart and the patient's care team members will pop up. I encourage you to route your death documentation.

[04:00] note to these providers so that they can be alerted of their patient's passing. In the second section, we will review best practices for death certificate completion in the outpatient setting. Because completion of a death certificate is hopefully not a

[04:20] daily or even weekly occurrence in the outpatient setting, it is easy to forget the logistics involved with this type of documentation. Unlike the medical record, the death certificate is a public document that serves as the primary source of information for a variety of purposes. Death certificates are the legal proof of death.

[04:40] for a patient and are often necessary for family to receive social security, health insurance, and other death benefits. They serve as closure for family members and loved ones with the physician's documented final diagnosis. They also provide useful information of national death statistics which are used by policy makers.

[05:00] to set public health goals and determine priorities in healthcare funding. Delays in death certificate completion can lead to delays in patient burial or cremation. It is appropriate for you as the PCP to complete a patient's death certificate if you were the last physician to see the patient alone.

[05:20] alive, and there were no concerns that the patient died of unnatural causes. Even if you were not physically present when your patient passed, it is sometimes reasonable for you to certify the cause of death based on your best guess and witness reports because of your longstanding relationship with the patient.

[05:40] If you have concerns about how or even whether to complete a death certificate, you can always reach out to the medical examiner's office and discuss the situation with them in greater detail. Deaths which require you to reach out to the medical examiner include any deaths involving unclear or suspicious circumstances.

[06:00] chances, or a death from anything other than natural causes. These include, but are not limited to, homicides, suicides, accidents, traumas, and occupational causes. There should be a medical examiner available 24-7, and I recommend saving this number in your phone to use as needed.

[06:20] General rules for completing a death certificate are to try and avoid using medical abbreviations and ensure your entry is clearly legible. The physician portion of the death certificate is made up of two parts. Part 1 asks you to report the chain of events leading directly to a patient's death.

[06:40] Only one cause should be entered on each line, and line A must always have an entry, so make sure not to leave this line blank.

[07:00] online B, and so on until the full sequence is reported. For each cause, you'll be asked to estimate the interval between the presumed onset and the date of death. You can use the terms unknown or approximately if you are unsure of exact timing. More general terms such as minutes, hours,

[07:20] days are also acceptable. Make sure not to leave the section blank, otherwise you may get the form returned to you for corrections. Terminal events such as cardiac arrest or respiratory arrest should generally not be used as ultimately all deaths are caused by a cessation of heart or lung function and are therefore

[07:40] not necessarily unique to your patient's cause of death. If cardiac or respiratory arrest seem most appropriate for line A, however, then just be sure to list the cause below, such as cardiac arrest due to coronary artery disease or chest impact. Additionally, if you're reporting a death

[08:00] from organ failure such as congestive heart failure or hepatic failure, be sure to report the etiology on the lines below. For example, renal failure due to type 1 diabetes mellitus. For deaths due to cancer, you'll want to be sure to include the primary site of the cancer or clarinol-based treatment.

[08:20] clarify that the primary site is unknown—the cell type, if known, the grade of cancer, and the organs affected. For example, an appropriately cited cause of death from cancer would be a primary, high-grade squamous cell carcinoma of the left upper lobe. Part 2 asks

[08:40] you to enter all diseases or conditions that could have contributed to the patient's death that were not reported in the chain of events in Part I and that did not result in the underlying cause of death. For example, in this case, our patient's direct cause of death was from a rupture of his myocardium, but various other conditions such as

[09:00] diabetes and chronic obstructive pulmonary disease likely contributed to his death as well. If there are two or more possible sequences that resulted in your patient's death, just choose the one that in your opinion most directly caused the death to report in Part 1. In the second section,

[09:20] You will also be asked to disclose the patient's tobacco use history and if you think their tobacco use contributed to their death in any way, such as a death from COPD, lung cancer, or a head and neck cancer. If the death is pending investigation, the medical examiner will be the one to complete the death certificate at a later point

[09:40] based on the autopsy results.

[10:00] patient you've cared for for a long time. There are a variety of different ways you can reach out to support your patient's loved ones and honor their memory after their death. Calling family members is the most common way to provide support and condolences. Each Mount Zion primary care clinic also has sympathy cards

[10:20] available if you prefer to send a handwritten note. If you're not sure exactly where to find these cards, please check in with your site's clinic director and they can direct you to the resource. You can also share grief support resources with loved ones, which we will review in the next slide. Notifying staff

[10:40] and other clinicians who cared for the patient is a helpful way to allow other care providers to reach out to family members directly. You can also attend patient funerals, donate to causes that were important to your patient, or create your own memorial practice such as journaling or meditation. In each Mount

[11:00] Zion Primary Care Clinic, there are also physical memorial tree murals. You can honor your deceased patients by writing a reflection, memory, poem, or story about your patient and hanging it on your clinic's tree. This is a beautiful way to honor a patient's memory and share your loss more

[11:20] broadly with the other clinic providers who may have also interacted with that patient at different times so that they can check in on both you and the patient's family. You can also use APACS to mail a condolence letter and share grief support resources with a patient's loved ones. An optional test is available at ip.us.gov.

[11:40] template for this is a smart phrase, dot PC, death reef resources. This smart phrase will auto populate a letter of condolence, which you can personalize or edit, as well as a list of individual and group grief support resources in San Francisco and the Greater Bay Area.

[12:00] can help patient families access free or low-cost grief support in an easy and timely manner if needed. To mail out this resource, simply create a new encounter in the patient's chart and open the communications tab. Once here, select new communication, then choose the blank left

[12:20] option and insert the dot PC death grief resources smart phrase into the UCSF letterhead. To mail the letter out to the patient's home address, under the recipients and routing tab, simply click the patient's name and select mail under routing options.

[12:40] If you'd prefer for the letter and support resources to be mailed to a different address than the patient's home address, select Print Locally instead and ask your admin team to mail out the letter to the preferred address. In this last section,

[13:00] we will review support resources that are available for clinicians after a primary care patient dies. Patient death is an inevitable and often challenging part of many physicians' jobs. The loss of a primary care patient can be devastating and isolating, especially in the ambulatory care setting where we

[13:20] practice more independently. Below is a list of resources to support primary care clinicians when navigating the emotional challenges and grief following a patient's death. One option is to debrief in real time with an on-call UCSF DGIM primary care colleague. This is a confidential

[13:40] session that can take the form of a peer-to-peer clinical case review or grief support and can be in person or virtual. The current DGIM on-call support contact is myself, Jessica Erickson. I will often reach out to you proactively via email after a DGIM patient

[14:00] dies to check in. Alternatively, I can also be contacted via the provided email or found on Volt during business hours. I'm a current primary care doctor here at UCSF and completed peer support training through UCSF's Caring for the Caregiver program and additional debrief training through

[14:20] UCSF's Chaplain and Spiritual Services. I'm passionate about supporting my colleagues after challenging patient losses. Another great option is contacting a peer support person through UCSF's Caring for the Caregiver program. This is a confidential session which provides emotional support after a patient loss in person and in person.

[14:40] or virtually, and is staffed by UCSF providers from a diverse array of clinical backgrounds. To be paired with a peer supporter, please email them at the listed address. UCSF's spiritual care services are another option for real-time debriefing and support where clinicians can receive emotional and spiritual

[15:00] support from a UCSF-affiliated Chaplain. While the service is mostly intended for inpatient providers, occasional exceptions can be made to support outpatient providers after particularly challenging losses. The best way to reach the Mount Zion on-call Chaplain is to call them at the number listed.

[15:20] Lastly, as a reminder, UCSF's faculty and staff assistant program is always an option for all UCSF staff to receive free, confidential, individual psychological counseling services for mental health experts, including licensed psychologists and postdoctoral fellows.

[15:40] with them via the provided email or by filling out an appointment form on their website. Thank you so much for your time and interest in this topic. We hope that this has been a helpful review of some of the resources available to you when processing primary care patient death. Please know that you do not have to

[16:00] navigate this loss alone. Please feel free to reach out to me directly if you have any additional questions or concerns. Thank you. ["The

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