Chapter 7: Caring in the Last Days and Hours 247 When Death Occurs What You Will See At the time of death, the person does not have a pulse and does not breathe. Their pupils are enlarged, their eyes are fixed in one position, either open or closed, and their mouth and jaw relax. If the person dies in their home in the community, a specific care plan may be in place for what to do at the time of death. If the person dies in a facility, it will have a protocol about what to do following a death. In addition to following the protocol, it is important to consider and, if possible, adapt to the needs of the family. Following a loved one’s death, the family may respond in a variety of ways. Each person is unique, and the family’s responses reflect cultural traditions and family and per- sonal styles and ways of being. Watching people express deep emotion can be difficult, and you may be tempted to “shush” the person, pat their back, and tell them to breathe or to be quiet. Instead of doing that, you might consider that crying and sobbing may be how the person needs to express their grief. I have never heard of a person who did not eventually stop crying. Breathe deeply your- self so you can relax and be fully present. Some people respond to death by becoming silent and withdrawn, or get busy with phone calls and organizing the funeral, or reminisce and laugh or cry about old mem- ories. Some people express anger or frustration at the un- fairness of the loss, or their perception of a difficult death or a health care system that did not meet their needs. All of these responses are normal. You do not need to guide, control, or judge people’s responses. It is important for you to be present in a calm and supportive way for all involved. What You Can Do At the time of death, if there is a signed do-not-resuscitate (DNR) form: • Note and record the time of death—when the person’s breathing and pulse stopped. • Breathe. This is not an emergency. Nothing has to hap- pen right away. • Do not call 911, the ambulance, the police, or the fire department. • Notify the attending physician/nurse practitioner. • Notify the family if the family is not present when death occurs. • Ensure that the appropriate HCP pronounces and cer- tifies the death. The HCP confirms that the person’s heart is not beating, the person is not breathing, and the per- son’s pupils are fixed and dilated. • Confirm (if this has not already been done) with the family whether any rituals or special preferences re- garding care of the body need to be observed. If ap- propriate, create a space in which the rituals can take place. • Offer the family nourishment, space, and privacy. • Position the person’s body on their back, place a small pillow under the head, and place the hands either at the person’s sides or across the abdomen. • Declutter and simplify the space around the person to help create space for the family to be with the person. • Check that the care plan has been followed. If death occurs in the community and there is no signed DNR form in the home or on the chart, and the family is not present to refuse cardiopulmonary resuscitation, then be sure to follow agency policies about responding to death. In this situation, you may need to call 911. When an “Expected Death” Form Has Been Signed In some communities in Canada, if the physician has previously signed an “Expected Death” form, the death does not need to be pronounced by an official. The form directs the family to contact the funeral home following the death.