Death Confirmation Summary

Cardiorespiratory Death

  • Simultaneous irreversible apnoea and unconsciousness
  • Minimum 5-minute observation period
  • Absence of central pulse and heart sounds

Brainstem Death

  • Irreversible brain damage with known cause
  • Exclusion of reversible causes
  • No evidence of depressant drugs

Brainstem Reflex Tests

  • No pupillary light reflex
  • No corneal reflex
  • No oculovestibular reflexes
  • No pain response
  • No cough or gag reflex
  • Apnoea test

Testing Requirements

  • Two registered doctors (>5 years experience)
  • One must be a consultant
  • No transplant team involvement
  • Two complete sets of tests

Legal Considerations

  • Any competent adult may verify death
  • MCCD must be completed by GMC-registered doctor
  • Time of death recorded when criteria fulfilled

Diagnosing and Confirming Death

Medical guidelines for determining and verifying death

Introduction

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.

Obvious Signs of Death

Death may be obvious with clear signs pathognomonic of death such as hypostasis (settling of blood) and rigor mortis (stiffening of muscles).

Verification vs Certification

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 death.

Legal Framework

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.

Diagnosing Death After Cardiorespiratory Arrest

Definition of Death

In the absence of obvious signs of death, we recommend that the point after cardiorespiratory arrest at which death of a living human being occurs is identified by specific conditions.

Essential 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  • Treatment aimed at sustaining life has been withdrawn because it has been decided to be of no further benefit to the patient

Observation and Confirmation

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:
  • Absence of a central pulse on palpation
  • Absence of heart sounds on auscultation
These criteria will normally suffice in the primary care setting. In hospital settings, they can be supplemented by:
  • 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 observation should prompt a further five minutes observation from the next point of cardiorespiratory arrest.
After five minutes of continued cardiorespiratory arrest, confirm absence of:
  • Pupillary responses to light
  • Corneal reflexes
  • Motor response to supra-orbital pressure
The time of death is recorded as the time at which these criteria are fulfilled.

Certification After Death Verification

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.

Who Can Complete MCCD

The certificate must be completed by a doctor who is registered (including temporary registration) and licensed to practice with the GMC.

Purpose of MCCD

The MCCD provides the legal authority for the disposal of the body and is necessary for the death to be formally registered.

Information Required

The MCCD must include accurate information about the cause of death, which should be based on medical knowledge and evidence.

Diagnosing Death Following Irreversible Cessation of Brainstem Function

Prerequisites for Brainstem Death Testing

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 must be established.
Potentially reversible causes of coma must be excluded.
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.
Potentially reversible causes of apnoea must be excluded.

Testing for 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 50ml 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.
No pain response - No motor responses within the cranial nerve distribution can be elicited by adequate stimulation of any somatic area.
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 should be the last brainstem reflex to be tested. 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 and Legal Requirements

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.

Qualification Requirements

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.

Transplant Team Exclusion

Neither doctor should be a member of the transplant team to avoid any potential conflict of interest.

Testing Protocol

Testing should be undertaken by the nominated doctors acting together and must always be performed on two occasions with a complete set of tests performed each time.

Testing Procedure

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.