You may be pretty familiar with the scene: a doctor in a white lab coat stands beside a hospital bed, using a stethoscope to search for a pulse. They look up at a nearby family member and solemnly shake their head, then quietly tell the nurse next to them, “Time of death: 8:07 PM.” Is this really how it happens when you die?
We expect doctors to officially pronounce death and then later list that time on a death certificate, and we all imagine something similar happens when a person dies at a nursing home or assisted living facility. But death can happen anywhere, so how does someone officially die outside of a hospital? What does it mean to be “pronounced dead?” And how does hospice affect this? Well, let’s just talk all this through!
A: Only A Doctor Can Pronounce You Dead
Movies and television have it mostly right: doctors pronounce death, which means officially saying someone has died. These doctors need to comply with federal laws, state and local laws, and the policies of the hospital or facility where they work. But doctors generally work with nurses and other employees who form a care team, and this changes the situation that movies have portrayed.
Usually, it works like this: a nurse is called to your room. They note the time they visit you, check for signs of respiration and a pulse using a stethoscope, and then check your pupils for a response. Then they call the on-call doctor and report what they have found. If the doctor agrees with the nurse’s report, they note the death in your record at the time the nurse quoted. (I’m skipping over an endless pile of forms that the hospital likely requires.)
And there you have it! You’re officially dead.
Afterward, that doctor will be responsible for listing the cause of death on your death certificate, based on your medical history. It is generally listed as the immediate cause of death (like sepsis, a severe bacterial infection), and then the causes that contributed to that (why you got that bacterial infection.)
Oops, You’ve Died Outside A Hospital
Dying is pretty straightforward at a hospital, right? Well, with the advent of nursing homes and in-home hospice care, more people are dying outside hospitals, and this affects how you officially die.
Death at A Nursing Home
This actually looks basically the same as death at a hospital. Nurses report their findings to doctors, and doctors pronounce your death. Then those doctors determine the cause of death listed on your death certificate.
Death Literally Anywhere Else
Doctors are allowed to pronounce death at the places they work, but as you can imagine, they can’t just walk into a random hospital or nursing home and pronounce those people dead. (Imagine the paperwork!) So there’s another doctor whose workplace is the whole county: the medical examiner. A medical examiner (or M.E.) is the doctor responsible for pronouncing death and determining the cause of death for anyone who dies outside of a hospital or nursing home in their county.
So now, instead of picturing that lab coat scene we started with, picture situations that look more like Quincy, M.E. (Google it, millennials) or Law & Order. What happens when someone dies unexpectedly? We call the cops. And then the police and/or first responders arrive and assess the situation, and if someone has died, the M.E. gets involved. Let’s take a closer look at what medical examiners do.
The Role of the Medical Examiner
Medical examiners are trained medical doctors who’ve specialized in forensic pathology. As a forensic pathologist told me in my Mortuary Science program, their job is to speak for the dead. They investigate the death, the body of the person who died, and the circumstances to make their best approximation of the person’s cause of death. This includes performing an autopsy, if necessary, testing blood samples, and many other activities. Just like you can’t tell the police that fingerprinting “goes against your religion,” an M.E. has the authority to perform an autopsy whether the family agrees or not. They will try to be culturally and spiritually sensitive, when possible, but they have to do their job.
M.E. v. Coroner
Many folks have heard of a coroner but are less familiar with the position of a medical examiner. A coroner, unlike an M.E., is an elected official, like a sheriff. It used to be common for morticians to also serve as coroners because, well, we don’t mind being around the dead and we already have that fancy car to chauffeur them in. An M.E., on the other hand, is a bona fide doctor, board-certified in figuring out what happened to the deceased. Morticians and coroners? Well, we ain’t got the schoolin’ for that. So, as you can imagine, an M.E. is much more effective at determining a person’s cause of death.
Pronounced v. Found
So based on what we learned about pronouncing death, how does it work when an M.E. is involved? Well, it depends. If trained medical personnel attempt resuscitation and then determine an absence of pulse, respiration, and pupil dilation (like the nurses in medical facilities), then the time they report to the M.E. will likely be listed as a “pronounced time.”
However, if first responders don’t need any kind of a degree to know without a doubt that you are well and truly dead (use your imagination), the time they report will be listed as a “found time.” So you can be pronounced dead or found dead, depending on how dead you are when first responders arrive.
How Hospice Changes Everything
Okay, fine not everything, but hospice does change some things, and for the better. Registering with hospice is generally a process in which a doctor expects you to live less than six months, and you are no longer trying to cure the illness you have. Hospice care means treating you holistically, paying special attention to your pain management and comfort. Hospice patients may live at their home, at a nursing home or residence especially designed for end-of-life care, or sometimes at hospitals or other medical facilities. If you choose hospice care at home, hospice employees and volunteers will provide care in your home.
But wait! If you die at home, doesn’t that mean that the cops and first responders and everyone will need to come out to the house, and the M.E. will investigate? Nope! That’s one of the many cool things about hospice. Registering with hospice creates a special relationship between the doctor and the M.E. so they know to expect the death and they know that they (likely) don’t need to investigate it. The hospice nurse can check for vital signs, report to your regular doctor, and the process happens as if it occurred in a hospital.
Are There Any Other Exceptions?
Not really. Even if you are really, really, really old but NOT on hospice and you die at home, the police have to be called. Period. Even if it’s really obvious that there is no foul play, it’s the M.E.’s job to determine that. In this circumstance, it would be unlikely that the M.E. would need to bring you back to their office or perform an autopsy. It doesn’t take the cast of CSI to crack the case, you know? But the process of calling the police and reporting the death to the M.E. still has to be followed.
So there you have it: how to become officially dead and who gets the final say-so. I hope you have enjoyed the first installment of this blog! Again, let us know what you are Dying to Know for future installments.
A Note on Language in This Post
Two things you may have noticed in this article: I talk about death a lot, and I talk about you being dead in particular. I’m not trying to be rude, but I think it’s important that we all regularly acknowledge the reality that we are all going to die. Sure, it’s tough to face and potentially scary, but it’s also what we’re built to do–all of us. Our amazing bodies are built to run, and breathe, and laugh, and make babies, and eventually die. So, I hope this doesn’t reach you at a particularly tough time, because I want you to be happy and healthy and fulfilled for as long as you can. Knowing I’m going to die makes every day special for me, and I hope it can do that for you, too.
Second, I made a very conscious choice with pronouns in this article. No one in this article was gendered, and I used the “singular they” throughout. Maybe you noticed. Maybe it bugged you. I hope it didn’t bug you, but if it did, well, too bad? It’s important to me to help normalize the use of the singular “they” to make our world more gender-inclusive. The singular “they” isn’t even new in English, and I used it in a perfectly cromulent way throughout this article. And if you didn’t notice until just now when I pointed it out, I hope you too will make a conscious effort to use gender-inclusive pronouns. I can guarantee it will make a difference to someone in your life.
A special thanks to my mom, Carol Woosley, R.N. (ret.) and colleague, Robert L. Archbold, for their help with the nursing and paramedic perspectives of pronouncing death.