Sunsets in San Francisco, when not enveloped in trademark fog, are beautiful. From the vantage of the 14th floor resident workroom, these sunsets have served as a metaphor for my patients who have died. To provide care in the final moments of life is an immense privilege. Yet, despite extensive training in transitions of care, the transition for patients and their loved ones after death has often been shrouded by fog.

The sunset of one patient especially endures. He was a middle-aged man with a toothy optimism that persevered despite a yellow complexion and rejections at multiple liver transplant centers due to substance use and inadequate social support. His designated decision-maker was a longtime friend. Both remained hopeful that he’d receive a transplant.

Unfortunately, all avenues for transplant would be exhausted. The patient’s goals transitioned to reconnecting with his estranged family and meeting his newly born grandson. Through a shared decision to pursue temporary dialysis, he lived to hold his grandson. His friend wasn’t sure if she’d ever be ready to say goodbye, but we agreed to focus on the patient’s comfort.

The next morning, my patient stopped breathing. I was relieved knowing he would no longer suffer, yet familiar questions swirled in my head: How do I notify someone of their loved one’s death? How do I discuss autopsy? Who helps the family?

I found a quiet place to call his friend. She immediately knew something was amiss. I approached the conversation with honesty and disclosed the death directly. His friend, audibly anguished, hung up. Emotionally numb, I moved to responsibilities learned through an unwritten curriculum on death passed down resident-to-resident. Some tasks such as notifying the donor network and medical examiner were relatively straightforward. Others felt more nuanced and skill-based such as debriefing with loved ones and discussing autopsy.

A loud sob alerted me that his friend had entered the ward. I shared with her a few words of condolence and reflection. She was in disbelief. I hoped we could quickly manage the logistics so she could grieve in peace. Gingerly, I introduced autopsy. However, before I could get to my untrained summary of possible benefits, she declined.

She had more pressing concerns including what would happen to the body. My answer felt unhelpful. In a hopeful and guilty fabrication of staff members I would only later learn definitively existed, I explained that others would come to help and that, for now, she should grieve as necessary and be with the patient.

I went to follow up with her a couple hours later, only to find an empty room. Although we achieved so much in my patient’s final days, the emptiness of that room and my final memory of his friend in distress would stay with me. I knew there had to be a better approach to post-death care for survivors and providers alike.

SUNSET ROUNDS

As a resident, heroic accomplishments in end-of-life care have felt tarnished by an ambiguous set of post-death care responsibilities often performed in isolation and without formal training. The discomfort and awkwardness surrounding post-death processes illustrated in the patient vignette are not unique to the plight of a resident though, but rather emblematic of an aspect of patient care that is broadly neglected by the healthcare system. To move post-death care beyond an afterthought, several changes should be implemented.

First, clear institutional guidance on roles, responsibilities, and resources is needed. Limited literature exists to guide best practices in post-death care. Of the most thorough, the American Academy of Pediatrics published a review for pediatric death in the emergency department.1 They provide guidance on several essential aspects of post-death care including organ donation, autopsy, family bereavement, and care for the care provider. To support this need, we propose “Sunset Rounds” as a concise framework to address post-death issues (Table 1).

Table 1 Sunset Rounds: a Framework for Post-death Care in the Hospital
Full size table

Second, structured communication should be employed by a multidisciplinary team. Sunset Rounds can function as an interprofessional timeout, wherein a group consisting of primary physicians and nurses, relevant consultants (e.g., palliative care), spiritual personnel, and decedent affairs team members could gather to address post-death care. Many hospitals have a decedent affairs team to assist family members with navigating post-death logistics. However, in our experience, the primary medical team typically has limited interface and awareness of this important, yet often understaffed, resource, a missed opportunity for a more effective, coordinated approach.

Third, trainees should have formal training and feedback on post-death care. Autopsy is an example of the many educational opportunities in post-death care. My hospital requires us to inquire about autopsy. However, without formal training on the details and value of autopsy, it is unsurprising that many discussions unfold like mine did and that autopsy rates are “vanishing.”4 It is only through my own research on out-of-hospital sudden cardiac death5 that I became familiar with autopsy. I learned that presumed cause of death is often wrong in cases of diagnostic uncertainty; almost half of sudden cardiac deaths by the World Health Organization (WHO) clinical criteria were found to have non-arrhythmic cause on autopsy (e.g., occult overdose, pulmonary embolism, intracranial hemorrhage).5 I also learned that incisions are made to facilitate open casket viewing and that autopsies typically do not delay funeral proceedings. Autopsy is a surgical procedure; as with procedures on the living, trainees should receive formal training on how to appropriately inform consent.

Amidst the coronavirus disease 2019 (COVID-19) pandemic, the fog of death looms particularly large. Unique challenges—limited workforce, racial disparities, lack of patient and family contact, and specialized guidance on safe post-death arrangements in patients with COVID-19 from the WHO3—have compounded the difficulties of post-death transitions. Overcoming these difficulties in post-death care will require a significant, sustained investment in education and resources coordinated across multiple disciplines. Fortunately, as with other neglected areas of the healthcare system brought to light by COVID-19, we are beginning to see long needed recognition of and innovation in post-death care; these range from novel approaches to death disclosure training6 and condolence communication7 to renewed attention to the proper completion of the death certificate.8 Now, more than ever, it is important that we work collectively to care for each other, support our survivors, and honor the sunsets of our patients.