As a junior doctor, you will often be called to the ward to confirm death in a patient. It is first important to recognise that dying is a process leading to death. Where a delay to the confirmation of death exists, such as in the pre-hospital or primary care setting, there is often no doubt that the patient has died.
However, in a hospital setting, where such a delay should not exist, the distinction is less clear. We therefore use the guidelines as suggested by the Academy of Medical Royal Colleges, stating that death has occurred when:
- There has been a simultaneous onset of apnoea and unconsciousness in the absence of circulation that is irreversible…
- … following extensive attempts to treat any contributing factors that may have led to cardiorespiratory arrest.
The second point described here is not necessary where a valid ‘Do Not Attempt Resuscitation’ order is in place. It is also not valid in a situation where treatment aimed at sustaining life has been withdrawn because it had been decided to inappropriate (i.e. of no further benefit to the patient and not in their best interests) or at the patient’s request.
Note: As a senior doctor, you may be required to confirm ‘brainstem death’ in a patient (whereby cardiorespiratory function is maintained by artificial means but where the irreversible cessation of their brainstem function has occurred) but this is beyond the scope of this article.
The Final Examination
When you have been asked to confirm the death of a patient, you should observe the patient for a minimum of 5 minutes. To ensure that you perform all necessary steps, you can use a systematic A to E approach:
- Airway / Breathing – Auscultate the lungs for >1min
- There will be no respiratory effort and no audible breath sounds.
- Circulation – Palpate for a pulse for >1min and auscultate the heart for >1min
- There will be no palpable central pulse and no audible heart sounds*
- Make sure you check for any palpable cardiac pacemaker
- Disability – Check for a pupillary response and check for a motor response to pain
- Following 5 minutes of continued cardio-respiratory arrest the patient’s pupils will be fixed, dilated and unresponsive to light.
- There will be no response to a painful stimulus. This can be tested by applying supra-orbital pressure and looking for any motor response.
- Exposure – The patient may be peripherally cold (depending on the timing of your assessment)
*In a patient who had been monitored, you may also notice continuous asystole on the cardiac monitor. In a patient who has an arterial line you can observe an absence of pulsatile flow.
The above examination will often be documented in the notes as below:
DATE 02/12, TIME: 2310: DEATH CERTIFICATION
No audible breath or heart sounds for greater than 1 minute.
No palpable pulse for greater than 1 minute. No palpable cardiac pacemaker.
Pupils are fixed, dilated and unreactive to light.
There is no response to painful stimulus.
The patient has died.
During the process of confirmation of death, you will need to make yourself available to discuss any issues around the circumstances of death or hospital admission with the patient’s next of kin. If the family are not present at the time of death, it is your duty to ensure that they are informed immediately.