1. EXPECTED DEATH AT HOME PLANNING TOOL
Patient’s Name_____________________________ HCN _____________________________________
Will attend home 24/7
to pronounce and certify
MD / RN (EC) /
Medical Group
Name:___________________
Phone: __________________
MD / RN (EC) / Medical Group
will certify as soon as possible
(within 24 hours of death)
Funeral Home will
accept nurse pronouncement
and certification
within 24 hours
of death
Funeral Home will
not accept nurse pronouncement
and certification
within 24 hours
of death
Will not attend
home to pronounce or
not available 24/7
Nurse pronounces
MD / RN (EC) / Medical Group
will not certify within
24 hours of death
Following discussion with family and MRP* indicate / circle which process they wish to follow
Determine how to
get death
certificate to
Funeral Home
after completion
Explore local options:
Alternate MD /
RN (EC) /
Medical Group
to attend home
to pronounce and
certify 24/7
Explore local options:
Alternate MD / RN (EC) /
Medical Group to certify within
24 hours of death
Rev: Nov 2017
*MRP = Most Responsible Practitioner

2. EXPECTED DEATH AT HOME PLANNING TOOL
Purpose
This too was developed to facilitate planning for pronouncement and certification when an expected death occurs at home. Nurses are permitted to pronounce death, but a Physician or Nurse Practitioner must complete the certification of death.
Some Physicians/Nurse Practitioners choose to manage their patient throughout the course of a final illness and will attend when death occurs, pronounce, and certify death. If the Physician/Nurse Practitioner does not plan to attend there must be a process in place to ensure that families are not distressed by a lack of a plan at the time of death.
Funeral Homes are not obliged to remove a body until after certification has taken place. In the case of an expected death, arrangements may be made at the discretion of the Funeral Director.
If any person expresses any concern regarding a death that can not be satisfied by the care team present at the time of death, a coroner should be called. The coroner can be contacted through the hospital switchboard or the police.
Instructions
The algorithm, kept in the yellow Palliative Care Plan for Expected Death at Home folder, offers a step-by-step process for planning and should be initiated at the time the decision is made for a home death. Once it is decided who will pronounce and certify death, sign and date the planning tool. Record the information on Guidelines for Family/Caregiver at the Time of Death also contained in the aforementioned yellow folder.