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Complex Situations (SLO7)
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A 75 year old man, with a history of dementia, is brought to ED in cardiac arrest after being found collapsed at home. CPR has been ongoing for 30 minutes but there has been no change in the patient's condition. The resus team leader makes the call to stop resuscitation and asks you to confirm the patient's death. How should you confirm death in this patient?
Answer:
- The individual should be observed by the person responsible for confirming death for a minimum of five minutes to establish that irreversible cardiorespiratory arrest has occurred. The absence of mechanical cardiac function is normally confirmed using a combination of the following:
- absence of a central pulse on palpation
- absence of heart sounds on auscultation
- After five minutes of continued cardiorespiratory arrest the absence of the pupillary responses to light, of the corneal reflexes, and of any motor response to supra-orbital pressure should be confirmed
- The time of death is recorded as the time at which these criteria are fulfilled
Diagnosis and Confirmation of Death
Complex Situations (SLO7)
Last Updated: 20th January 2023
Diagnosing and confirming death after cardiorespiratory arrest
Whilst dying is a process rather than an event, a definition of when the process reaches the point (death) at which a living human being ceases to exist is necessary to allow the confirmation of death without an unnecessary and potentially distressing delay. Death may be obvious with clear signs pathognomonic of death (hypostasis, rigor mortis). However, in the absence of such signs, we recommend that the point after cardiorespiratory arrest at which death of a living human being occurs is identified by the following conditions:
- The simultaneous and irreversible onset of apnoea and unconsciousness in the absence of the circulation
- Full and extensive attempts at reversal of any contributing cause to the cardiorespiratory arrest have been made
- One of the following is fulfilled:
- the individual meets the criteria for not attempting cardiopulmonary resuscitation
- attempts at cardiopulmonary resuscitation have failed
- treatment aimed at sustaining life has been withdrawn because it has been decided to be of no further benefit to the patient and not in his/her best interest to continue and/or is in respect of the patient’s wishes via an advance decision to refuse treatment
- The individual should be observed by the person responsible for confirming death for a minimum of five minutes to establish that irreversible cardiorespiratory arrest has occurred. The absence of mechanical cardiac function is normally confirmed using a combination of the following:
- absence of a central pulse on palpation
- absence of heart sounds on auscultation
- These criteria will normally suffice in the primary care setting. However, their use can be supplemented in the hospital setting by one or more of the following:
- asystole on a continuous ECG display
- absence of pulsatile flow using direct intra-arterial pressure monitoring
- absence of contractile activity using echocardiography
- Any spontaneous return of cardiac or respiratory activity during this period of observation should prompt a further five minutes observation from the next point of cardiorespiratory arrest
- After five minutes of continued cardiorespiratory arrest the absence of the pupillary responses to light, of the corneal reflexes, and of any motor response to supra-orbital pressure should be confirmed
- The time of death is recorded as the time at which these criteria are fulfilled
Verification of death is the process of identifying that a person has died. It has nothing to do with providing a death certificate or identifying the cause of the death. English Law allows that any competent adult may verify that someone has died, but it does not place them under a legal obligation to do so.
After a death has been verified, a certificate (Medical Certificate of Cause of Death – MCCD) must be completed and submitted to the local registrar of births, marriages and deaths. The certificate must be completed by a doctor who is registered (including temporary registration) and licensed to practice with the GMC.
Diagnosing and confirming death following irreversible cessation of brainstem function
All of the following conditions must be fulfilled to allow the diagnosis of death following irreversible cessation of brainstem function to be undertaken:
- Aetiology of irreversible brain damage
- Exclusion of potentially reversible causes of coma
- There should be no evidence that this state is due to depressant drugs
- Primary hypothermia as the cause of unconsciousness must have been excluded
- Potentially reversible circulatory, metabolic and endocrine disturbances must have been excluded as the cause of the continuation of unconsciousness
- Exclusion of potentially reversible causes of apnoea
Testing for the absence of brainstem reflexes:
- No pupillary light reflex
- The pupils are fixed and do not respond to sharp changes in the intensity of incident light.
- No corneal reflex
- There is an absence of blinking when the cornea is brushed lightly with e.g. cotton wool (care should be taken to avoid damage to the cornea).
- No oculovestibular reflexes
- No eye movements are seen during or following the slow injection of at least 50mls of ice cold water over one minute into each external auditory meatus in turn. Clear access to the tympanic membrane must be established by direct inspection and the head should be at 30o to the horizontal plane, unless this positioning is contraindicated by the presence of an unstable spinal injury.
- No pain response
- No motor responses within the cranial nerve distribution can be elicited by adequate stimulation of any somatic area. No motor response can be elicited within the cranial nerve or somatic distribution in response to supraorbital pressure.
- No cough or gag reflex
- There is no cough reflex response to bronchial stimulation by a suction catheter placed down the trachea to the carina, or gag response to stimulation of the posterior pharynx with a spatula.
- Apnoea test
- The process for testing the respiratory response to hypercarbia (apnoea test) should be the last brainstem reflex to be tested and should not be performed if any of the preceding tests confirm the presence of brainstem reflexes. The test aims to demonstrate brainstem death by producing an acidaemic respiratory stimulus (pH < 7.4) without inducing hypoxia or cardiovascular instability.
Repetition of testing:
The diagnosis of death by brainstem testing should be made by at least two medical practitioners who have been registered for more than five years and are competent in the conduct and interpretation of brainstem testing. At least one of the doctors must be a consultant. Those carrying out the tests must not have, or be perceived to have, any clinical conflict of interest and neither doctor should be a member of the transplant team. Testing should be undertaken by the nominated doctors acting together and must always be performed on two occasions. A complete set of tests should be performed on each occasion, i.e., a total of two sets of tests will be performed. Doctor A may perform the tests while Doctor B observes; this would constitute the first set. Roles may be reversed for the second set. The tests, in particular the apnoea test, are therefore performed only twice in total. If the first set of tests shows no evidence of brainstem function there need not be a lengthy delay prior to performing the second set. Although death is not confirmed until the second test has been completed the legal time of death is when the first test indicates death due to the absence of brainstem reflexes.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
