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Pronouncing Death and End-of-Life Issues
One of the most unpleasant requirements of on-call responsibilities is pronouncing death. This important task represents a significant medicolegal responsibility. You may not have had much experience evaluating recently deceased persons, and there is some controversy as to what exactly constitutes the legal definition of death. This chapter provides a guide of the steps to follow when declaring a patient dead.
Different states in the United States may have differing criteria for declaring death. However, most states and neighboring countries, including Canada and Mexico, have adopted the concepts of both physiologic death and brain death. Physiologic death refers to absence of any spontaneous cardiac activity, no blood pressure (BP), and no evidence of respiration. Pronouncing brain death is more complicated and is usually managed by neurology or neurosurgery services. There is more variability regionally as to what constitutes brain death.
Remember that declaring death is a serious medicolegal responsibility. Be careful and studious in your evaluation of the person presumed deceased.
When you are paged by the RN to pronounce a patient dead, it is advisable that you come equipped with a stethoscope and a penlight. The most important thing to ascertain is that the patient has no spontaneous circulation or respiratory function. It is also important to perform a brief assessment of the neurologic system. Table 25.1 indicates the key criteria for declaring death. Using these criteria to declare death requires that the person presumed deceased has a body temperature of at least 34˚ C to 35˚ C. If the body is very cold (e.g., after ice water immersion or cold weather exposure), you may have to warm it before legally pronouncing death. Recall that hypothermia slows metabolic rate, heart rate (HR), and respiratory rate (RR). Hypothermic, critically ill patients have been mistaken for dead. Also make sure that there is no history of use of paralytic drugs or sedatives within a reasonable time period. If paralytic drugs were used within the past 6 to 8 hours before the presumed death, a paralytic reversing agent such as neostigmine methylsulfate (Prostigmin) should be administered.
Table 25.1
Key Criteria for Pronouncing Death
| No cardiac activity (asystole) |
| No blood pressure |
| No respiratory activity |
Steps for Pronouncing Physiologic Death
The Non-Ventilated Patient
- 1.
Overview the chart briefly.
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Make sure that in examining the presumed deceased you will incur no infectious risk (e.g., human immunodeficiency virus [HIV] or hepatitis). Wear gloves.
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- 2.
Check the identity of the patient by looking at the identification bracelet worn on the wrist.
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Make sure you know who you are pronouncing dead.
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- 3.
Make sure that the patient does not respond to verbal or tactile stimuli.
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You may want to perform a sternal rub to satisfy yourself that the presumed deceased does not respond to painful stimuli.
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- 4.
Check for radial and carotid pulses.
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The deceased patient will have no pulses anywhere.
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- 5.
Check the BP.
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The deceased patient will have no BP.
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- 6.
Listen for heart sounds; listen carefully over the entire precordium.
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You will not hear heart sounds in a deceased patient. You may also want to listen over the carotid artery in the neck. If the patient is in the intensive care unit (ICU) and is attached to monitoring leads, you may wish to evaluate the rhythm strip.
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- 7.
Listen for spontaneous respirations over both lung fields.
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A deceased patient will have no air movement whatsoever.
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- 8.
Examine the pupils.
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The pupils of a deceased patient will be fixed, and they also may often be dilated, but not always. The pupils will not respond to light.
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The Ventilated Patient
If a mechanically ventilated patient has lost cardiac activity and has no BP, you must alter the procedure by which you declare death. First, contact the attending physician for consent to turn off the ventilator. Once there is agreement to terminate mechanical ventilation, proceed to disconnect the ventilator. Before doing so, make sure that all the electrocardiographic (ECG) leads are properly connected and that the monitoring equipment is functioning. You do not want to disconnect from the ventilator a patient who actually does have cardiac activity. Additionally, make sure that the patient has not been given any paralytic drugs within 6 to 8 hours of the examination.
- 1.
After you have verified that the ECG monitoring equipment is functioning and all the connections are intact, proceed to disconnect the ventilator from the patient; leave the endotracheal (ET) tube in place.
- 2.
Follow the procedure outlined in steps 1 to 8 in the preceding section for declaring death.
- 3.
Observe the patient for a full 3 minutes for evidence of spontaneous respiration.
- 4.
Record in the medical record that mechanical ventilation was terminated after consultation with the attending physician and after all evidence of circulatory function had ceased. Document the rest of your examination. Give a time and a date when you declared death.
After Your Examination
Always remember to document your examination in the chart. Carefully list what your examination found. The time of death is the time you complete your examination. Record the time of death and the date. Sign the note. You also may be required to fill out and sign the death certificate. Some hospitals will also ask that you call the medical examiner’s office to notify them of the death. Some states require contact with the local donor network or tissue bank. The head nurse or unit clerk can be very helpful in obtaining and correctly filling out the required documents and following your hospital-specific protocol.
It is appropriate to contact your supervising resident or the attending physician as soon as you pronounce the patient dead. Ask your superiors if they want you to contact the next of kin. It is appropriate to notify the family as soon as practically possible. Also ascertain from the attending physician whether an autopsy is necessary or appropriate. The attending physician may want to consult the family about this option.
If you are going to notify the family of the deceased and you did not know the patient, take some time to review the medical history and the recent events. Talk to the nursing staff about the family members who have visited the patient. Become aware of any difficult family situations that may be important.
First, contact the family member closest to the patient. Sometimes the RN will know which family member is the spokesperson for the family. You may also see a notation in the chart as to who is the next of kin. Once you have made telephone contact with the family member, identify yourself and the hospital where you work. In an apologetic and conciliatory tone, inform the family member that their loved one has passed away. Frequently, the family member will want to know the time of death and the circumstances. If appropriate, you may wish to offer the reassurance that death was painless and peaceful. Do not be shocked if a family member is not surprised or too upset. Many families have watched a loved one deal with chronic illness, pain, and suffering for many years. They often are relieved when they hear that the loved one’s suffering has ended. Other families may show obvious grief and despair at the notification of the death of their loved one. Try to be supportive, and understand that distinct cultures deal with death in different ways.
Brain Death and Organ Donation
As the on-call physician, it is not your responsibility to pronounce brain death. This is a more complicated task than declaring physiologic death. Consult neurology or neurosurgery for help with this task. The declaration of brain death is important for obtaining legal clearance for organ donation. If you believe that a brain-dead patient may be a good candidate for organ donation and the family is supportive, contact the organ transplant program at your hospital or in your city. There is usually a transplant coordinator on call 24 hours a day to help make arrangements. You should maintain the brain-dead patient on supportive hydration and ventilation until the transplant service takes over the management of the organ donor. Some states require that the local transplant coordinator be contacted with every death.
The concept of brain death has been accepted throughout the United States, Canada, Mexico, and much of the world. The diagnostic criteria followed by most hospitals are shown in Table 25.2 .
Table 25.2
Criteria for Pronouncing Brain Death
| No cerebral or brain stem function |
| Fixed pupils |
| No response (including reflexes) to noxious stimuli |
| Apneic during oxygenation (for 10 min) |
| No oculovestibular responses (50-mL ice-water calorics) |
| Spinal reflexes may be intact |
| Circulatory function may be intact |
| Coma of known cause and duration |
| Known structural damage or disease |
| Known irreversible metabolic disease |
| No hypothermia, sedation, paralytic drugs, or drug intoxication |
| Minimum 6 h observation of no brain function; if drugs or alcohol were involved, a minimum of 24 h of observation of no brain function and a negative toxicology screen is required |
| Optional criteria |
| No cerebral circulation on angiogram |
| Electroencephalogram isoelectric for 30 min at maximal gain |
| Auditory-evoked responses show no brain stem function |
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