There are regional differences but the general principles are the same. Need to assess for at least 2 mins.
| Called to see patient who has died |
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Assuming expected death and not for resuscitation or failed resuscitation
Often family will have attended and left, if not you might ask them to wait outside though their presence shouldn't stop your respectful and peaceful assessment
Record date and time and ward
Record who called you and names of at least one staff member
Circumstances of death and Check for signs of death
- Patient Apnoeic so not breathing for 2 minutes
- Check no carotid or femoral pulse for at least 2 minutes
- Listen for heart sounds which should be absent for 2 minutes
- Pupils are typically fixed and dilated ( test to a bright light)
- These assessments can often be done simultaneously over 5 minutes
Check for a pacemaker and record if one noted by palpation or by recent CXR
Sign the record, contact details
State at what time the patient was declared deceased
Check that family have been informed
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About
- Death is a process involving the cessation of physiological functions. The determination of death is the final event in that process. For most people, death takes occurs with the confirmation of irreversible cessation of cardiorespiratory function.
- For others a more detailed assessment is needed especially in the realms of ITU and ventilators. Being on a Ventilator does not necessarily mean life.
- Although there are different ways to determine death, there is only one way of being dead; thus, the two classic algorithms of brain death and circulatory death initially presented should merge into a single endpoint identified as death and should not imply that brain death and circulatory death are two distinct phenomena
Confirming Death in the normal manner
- Wash your hands, identify the patient. Pull the ward screens around. Take your time. Be sensitive as a family may be present at the time of death. You may wish them to leave but that is your decision. As long as they are quiet and do not interrupt so you can perform the assessment.
- Check over a 5 minute period (observation of breathing and auscultation can happen together)
- (1) Palpate absence of a carotid or femoral pulse on palpation and
- (2) Listen for the absence of heart sound on auscultation
- (3) Observe the absence of breathing and respiratory effort
- (4) Look for the absence of pupillary responses to light. Pupils usually fixed and dilated
- The time of death is recorded as the time at which these
criteria are fulfilled. Document your findings. Date, time and GMC number. Speak to the family as appropriate. Offer condolences. Answer any queries. Most issues will be managed by the bereavement office.
The algorithm should then state that one or more of the following instrumental tests should be performed if indicated:
- (1) asystole or pulseless electrical activity on a continuous ECG display; and/or
- (2) absence of pulsatile flow during intraarterial pressure monitoring; and/or
- (3) absence of contractile activity using echocardiography.
Instrumental tests are not mandatory since diagnosis can be made without them. The instrumental tests would, however, be indicated for patients on advanced life support therapies or for whom life-sustaining treatment is withdrawn in a critical care setting.
Brain Death: Coma + absent brainstem reflexes + apnoea
- Brain death: brainstem function lost (no spontaneous ventilation)
- Death: Irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brainstem.
- Aetiology of coma known from clinical assessment or neuroimaging or catastrophic structural damage to the CNS
Diagnostic criteria of brain death
- Confirm clearance of depressant drugs: Exclude toxic levels of sedatives, aminoglycosides, tricyclic antidepressants, anticholinergics, antiepileptic drugs, chemotherapeutic agents, neuromuscular blockade
- Absence of hypothermia: (defined as temperature <32 C)
- No gross electrolyte/acid-base/metabolic issues e.g. hypothyroid, liver failure
- Apnoea: absence of relaxants, opioids or other depressants. Raised PaCO2, normal PaO2
- Irreversible structure brain damage
Procedure
- No Pupillary response to light
- Corneal reflex absent
- Vestibulo-ocular reflexes absent
- Caloric tests 20 ml ice-cold water in ear canals, no eye movement
- Facial motor response to trigeminal distribution pain absent
- Gag and cough reflexes absent
- Apnoea in the presence of PaCO2 >60 mmHg, pH < 7.30
- Two examinations at least 2 h apart by separate qualified doctors usually registrar grade or above
- Angiography required if no diagnosis or tests incomplete (e.g. eye injury)
- Modified criteria <1 year of age due to greater recovery potential
References
Revisions