Dealing with a death in the Nuclear Medicine department

Now this may seem like a bit of a morbid subject, but I think it’s an important one.

Unlike many other departments in the hospital, it is unusual to have a patient die while they are in our care. Where I work, there was only one other case some years ago that anyone could remember – until about 18 months ago, when I was the most senior manager on site. When something doesn’t happen very often, it can make it more difficult to know what to do and in Nuclear Medicine, we have some very specific things which need to be considered.

I’ll start with what needs to be done as soon as it is clear there is a problem. Our patient was having a VQ scan, and what alerted our technologist was that they stopped seeing Krypton update on the ventilation scan, as the patient had stopped breathing. They called immediately for a doctor and CPR was commenced. This may seem like the right thing to do, but someone does needs to check whether there is a DNR (Do Not Resuscitate) order in place. If there is, then resuscitation shouldn’t be attempted. Accompanying ward staff should know this, but in this case, a student had been left with the patient who didn’t. When it was checked with the ward, it became clear in this case there was a DNR order in place for this gentleman, and resuscitation was stopped immediately. There had been a couple of instances just before this in Imaging where patients had been resuscitated despite having a DNR and this is viewed very dimly as it goes against the patient’s wishes.

If the patient’s study has started, they are likely to have been injected with radioactivity. In essence, the body is a radioactive source, so care must be taken with handling and transporting the body. In our case, the patient was a Muslim and so his family wanted to hold the burial within 2 days, as is tradition in their religion. Because his body was radioactive, it wasn’t going to be possible to transport it to the funeral home, so careful and sensitive explanation was necessary, mindful that not all members of his family spoke good English. The family agreed that they would wait until after the weekend to arrange the burial.

This happened on a Friday, so we needed to identify somewhere where the body could be kept over the weekend. By the time we were ready to move it from the Nuclear Medicine department, it was after 5pm, so most of the staff in the morgue had gone home. We had to consider proximity of the body to people working in the morgue over the weekend, so arrangements were made for it to be kept separately, to minimise exposure to staff. It is important to get your physicist to provide support for these arrangements. On the day in question, there were no senior physicists available, so I and the junior physicist in attendance decided to proceed on the cautious side.

Another thing to consider is what to do with any cannulas or lines. As these would be radioactive, they were removed and disposed of by the Nuclear Medicine staff.

As well as the practical considerations, is important to remember that this is a person, with a family. In one way, it being a Friday afternoon was advantageous, as the department was relatively quiet. This meant the man’s body could be kept in a separate room. The immediate family came to the department quickly and asked if others could join them. We agreed to this, but quickly the department filled up with a large number of relatives and they stayed quite some time. It did become a bit difficult for the staff and remaining patients. In the end, a senior nurse from the ward politely steered them away. That is something we felt unwilling to do, but the ability to do this comes with experience, so we were very grateful to the nurse for her support.

A key message here is to have good communication links with the ward and ask for their help on all things that don’t relate to the patient having received an administration of radioactivity.

The patient’s culture and religion must be respected. This patient was a Muslim, so there were traditions which the family wanted to observe, such as wrapping the body. We agreed to this, although asked that it wasn’t all carried out by the same family member, so that they weren’t individually spending too much time in close proximity.

it is important to look after everyone in the department who is involved with caring for the patient, including scanning, attempting to resuscitate and providing support to relatives. Asking if they are OK at the time and afterwards is important so they know that if they need to talk about it, then they can. Although no-one felt they needed it, counselling was offered. This is important – I was OK with it then, but if it had happened in those first few months after I lost mammy, I definitely would not have been.

Finally, this has to be logged as an incident and an investigation must be held with an independent investigator. This part of the process was quite hard. It felt like we were in some way being blamed for his death. It is important to release that this is not the case. Any death in the hospital must be taken seriously and it is important to question and learn from it. This man was very poorly and one question was whether, given those circumstances, he should have been moved to Nuclear Medicine for a scan at all. However, having been asked to scan him and believing a diagnosis would be of benefit, it was felt that that the decision made at the time was the right one with the information available.

After this happened, it made me think about what happens if a patient who has had a radioactive injection dies shortly afterwards when the radiation is still within their body. This could happen anywhere, not necessarily in the Nuclear Medicine department. So, guidance on how to manage that situation is needed. This is something we have started looking at in the BNMS UK MRT Consortium, since it is more likely to be a problem if the patient has had therapy.

I can’t apologise for the somewhat serious subject matter this month, as it is something that I think we should think about, even if it’s uncomfortable. On 26^th February it will be a year since I lost my lovely mum, and I feel it is so important that we, as Nuclear Medicine staff entrusted with the care of other people’s loved ones, look after them as well as we can – particularly if we are the people there at the end. Until next time.

Ms Jilly Croasdale

BNMS President