We all die eventually, although most of us try not to ruminate on the subject. The certification of a patient’s death is one of the legal responsibilities of a doctor. The experience can be distressing for the doctor as well as the patient’s relatives. Students should be given the opportunity to observe senior colleagues performing these tasks and to learn what is required technically and emotionally. Clearly, the declaration that a patient has died must be correct, as well as sympathetically performed.
Death is not easy to define in absolute terms but generally means brain death—an irreversible loss of consciousness, usually but not always linked to an irreversible loss of spontaneous respiration.
If you are called to assess an unresponsive patient, do not assume that the patient has died: start cardiopulmonary resuscitation (CPR) immediately (page 565) and call for help, unless there is a confirmed and current do-not-resuscitate (DNR) order (not for resuscitation: NFR).
Most hospitals have specific policies in place about resuscitation. Patients have the right to make a living will or advanced directive outlining their wishes concerning resuscitation; for example, a patient with a terminal condition can elect to refuse CPR or life support if cardiac arrest occurs. The directive, if known, should be honoured. Remember, however, that if the patient had changed his or her mind before collapsing and notified staff verbally, the current verbal decision rather than the written directive must be honoured (i.e. you should provide CPR or life support). Sometimes, directives may be more specific. For example, a directive may forbid intubation. It would be wrong in this case to deny the patient an attempt at cardioversion from ventricular fibrillation, but it may be reasonable not to proceed to more invasive resuscitation. If the patient is not known to you, it is important to err on the side of caution and begin resuscitation.
The dead patient is unresponsive, has no spontaneous respiratory movements, has no pulse or heart sounds, is very pale and usually the eyes are open and blankly staring. Red–purple discolouration in gravity-dependent areas occurs about half an hour after death, while rigor mortis (muscle stiffening) occurs hours later.
Note that death can be and has been diagnosed in error most often in patients on a ventilator. Important conditions to exclude before declaring a person is dead include:
In these cases, some cardiac and respiratory activity will be present.
List 44.1 summarises the physical examination to confirm death. After brain death there may still be spontaneous movements from the denervated spinal cord or peripheral nerves—examples include flexion of the neck, elbows and trunk (when dramatic, known as the ‘Lazarus sign’) or finger flexor movements.
Remember, certifying death has medico-legal consequences. As a doctor you will be required to examine the patient and record your findings in the medical record, including the date and time that life became extinct. Where possible, you should include the likely cause of death, and sign your name (legibly). You are required to notify the authorities of any unexpected or suspect death.
Patients on a mechanical ventilator require additional testing to confirm they are truly dead.
Potentially reversible causes must always be excluded (especially drugs; see above). There have been cases where brain death has been pronounced and the patient has later woken up.
Do not miss the rare locked-in syndrome. This can occur following an embolus blocking the basilar artery or some other local injury to the base of the pons. The unfortunate patient is not unconscious at all, but cannot move any face, limb or trunk muscles. You can identify the syndrome by asking the patient to blink once for ‘yes’ and two for ‘no’; voluntary blinking as well as vertical eye movements are not affected.
Testing protocols are based on the law, which vary by country and state (check the requirements in your state). Traditionally, testing is carried out by two different doctors on two separate occasions, typically 24 hours apart, to ensure that the state is irreversible (but the timing of repeat testing is dependent on the patient’s age and likely cause of death). Testing typically includes a physical examination (as per List 44.1), an obvious lack of any response to suctioning the tracheal tube, plus an ice-water (oculovestibular reflex) test: no eye response to irrigation of ice-cold water into the ears. If the examination indicates brain death, a medullary brainstem hypercapnia test is performed, whereby the ventilator is ceased while giving 100% oxygen and the arterial CO2 is permitted to rise above a pre-set threshold (>6.7 kPa). Seeing no respiratory effort after 8–10 minutes indicates that there is no medullary function.
Informing relatives is always difficult but is the responsibility of the certifying doctor. It is one of the hardest things doctors have to do. Give the news in person—this will usually be deeply appreciated. Break the bad news professionally and compassionately. Seek a private and quiet environment, speak clearly and concisely, be supportive, respect cultural and religious beliefs and engage the help of the team (e.g. nurse, social worker, cleric). Relatives often want to know what happened, particularly if the death is unexpected. If the patient is well known to you, you may be able to provide that explanation; if not, you should suggest the relatives arrange to meet the consultant responsible for the patient to discuss things.
The death certificate is a legal document. If the death was expected (and not suspect), you should complete the certificate as soon as possible. The World Health Organization (WHO) provides a certificate format that is applied internationally. Certify the disease that led directly to death (in part I of the form), as well as any other diseases that contributed (in part II of the form).
The relatives must agree to a postmortem (PM) before it can be undertaken. There has been a major decline in the undertaking of postmortems in recent decades because of a reluctance to ask relatives and a community reluctance to agree. If the reasons for the request are communicated clearly and compassionately, many will sign the consent.
Remember, the information gleaned from a postmortem not uncommonly leads to significant surprises about the causes of death, and potentially can inform the profession, helping to prevent future diagnostic and treatment mistakes.
If the cause of death is uncertain, a postmortem becomes even more important, and certain events such as recent surgery or trauma mean the case should be referred to the coroner, who will usually insist on a postmortem examination.
In settings where there is brain death but mechanical ventilation can be continued, consent to organ donation should be explored and is ethical. The patient’s wishes may be known (e.g. on the driver’s licence or an organ donation register, or as a result of previous discussion between the patient and relatives). Organ donation may provide some comfort to grieving relatives.