Confirmation of death

Confirmation of death is an important part of healthcare practice.

The confirmation of death is an essential part of practice within both the community and hospital setting. In 2008, the Academy of Royal Medical Colleges issued a generalised code of practice for the confirmation of death.

Death may occur from:

• Irreversible cessation of brain-stem function (i.e. brain-stem death)
• Following cessation of cardiorespiratory function (including failed resuscitation)

The confirmation of brain-stem death (i.e. the heart and lungs can only be maintained by artificial ventilation) is advanced and has to be carried out by at least two medical practitioners (minimum one consultant) who have been registered for >5 years. This is discussed briefly below.

The confirmation of death after cessation of cardiorespiratory function can be completed by a doctor, or appropriately trained healthcare professional (e.g. registered nurse, paramedic). It involves a clinical examination of the patient including auscultation of the heart and lungs. It forms a vital duty of newly qualified doctors.

Here, we describe a practical guide to the process of death confirmation for healthcare professionals involved in this process.

Verification is the process of confirming death and certification is the process of completing the ‘Medical Certificate of Cause of Death’.

Verification and certification are two key terms that are used when patients have died. It is important to understand what each means.

• Verification: the formal clinical assessment to confirm that death has taken place. Known as confirmation of death.
• Certification: the process of completing the ‘Medical Certificate of Cause of Death’ (MCCD). This is a legal requirement for recording a person’s death. It is often referred to as the ‘death certificate’.

DNACPR refers to ‘Do Not Attempt Cardiopulmonary Resuscitation’.

Cardiopulmonary resuscitation (CPR) is the process of performing ‘life support’ to try and restart cardiorespiratory function following a cardiac or respiratory arrest. A DNACPR order is an advanced decision not to attempt CPR in the event that a patient has a cardiac or respiratory arrest.

When confirming death, it is vital to check the patient's ‘resuscitation status’ (i.e. are they for resuscitation or do they have a DNACPR order?). If the patient has a DNACPR, or the resuscitation attempt has failed, confirmation of death can take place. If the patient does not have a DNACPR, or there is uncertainty, cardiopulmonary resuscitation should be commenced immediately.

This outlines the process of death confirmation predominantly from a hospital (i.e. secondary care) perspective.

Before confirmation

Prior to confirmation of death, check the patient's resuscitation status. If there is any uncertainty then call for help and commence CPR whilst this is clarified. It is good practice to briefly review the patient’s notes and events leading up to death. Was it expected or unexpected?

Check whether any family are present and ensure you answer any questions or concerns before proceeding to death confirmation.

Confirmation

We outline the basic steps to confirming death in the hospital.

Equipment: pen torch, stethoscope, watch, personal protective equipment (PPE)

• Step 1: wash hands and don PPE as appropriate
• Step 2: confirm the identity of the patient by checking their wristband and lie the patient flat
• Step 3: inspect for any obvious signs of life (e.g. movement or respiratory effort)
• Step 4: assess the patient’s response to verbal stimuli (e.g. Hello Mrs Mills, can you hear me?)
• Step 5: observe the patient for a min. 5 minutes to establish irreversible cardiorespiratory arrest has occurred
  • Step 5a (absent central pulse): palpate a central pulse (e.g. carotid artery) for a minimum of 1 minute
  • Step 5b (absent heart sounds): auscultate for heart sounds for a minimum of 2 minutes
  • Step 5c (absent respiratory effort): auscultate for breath sounds for a minimum of 1 minute on each side and observe for any signs of respiratory effort during the 5 minutes
• Step 6: check the patient’s pupillary light reflex (after death they are fixed and dilated)
• Step 7: check for the absence of a motor response following painful stimuli (e.g. trapezius squeeze, supraorbital pressure)
• Step 8: record time death once the above criteria have been fulfilled
• Step 9: it’s good practice to note any suspected/confirmed infectious diseases, radioactive implants, or implantable medical devices during your assessment
• Step 10: wash hands and doff PPE as appropriate. Close curtains or doors to maintain dignity.

Importantly, any spontaneous return of cardiac or respiratory activity observed during the clinical assessment should prompt a further five minutes of observation from the next point of cardiorespiratory arrest.

After confirmation

Once death is confirmed, documentation of your clinical assessment is important and discussed below.

Document each of the above steps in the notes including the time and date of death.

Good documentation is a core part of confirming death. Ensure you write or enter the documentation as ‘confirmation of death’ and include the date and time of assessment. This is followed by documenting each of the steps outlined above including the date and time of death and any implantable medical devices. Finally, ensure you sign off the note with your full name, grade, registration number, and contact number.

Example

Note: Confirmation of death

Date: 08/09/2021

Time: 08:00

• Identity confirmed by wristband
• Patient in bed with family at bedside, no signs of life present
• No response to verbal stimuli
• No respiratory effort over 5 minutes of observation
• No palpable carotid pulse
• No heart sounds were noted over 2 minutes of auscultation
• No breath sounds were noted over 2 minutes of auscultation
• Pupils fixed and dilated
• No response to painful stimuli
• Confirmation of death on 08/09/21 at 07:50

No concerns from family or nursing staff

No external pacemaker or implantable device seen

Norton, Benjamin

Foundation year 1

GMC: 0000001

Bleep: 6258

This refers to the irreversible cessation of brain-stem function that equates with the death of the individual.

The diagnosis of brain-stem death is typically made in the intensive care setting with patients being artificially kept alive with a ventilator. In patients with suspected brain-stem death several important criteria need to be met before testing brain-stem function:

• Exclusion of a potentially reversible cause of coma
• No evidence of use of depressant drugs (e.g. opiates, benzodiazepines)
• Exclusion of primary hypothermia (brain-stem reflexes usually lost < 28ºC)
• Potentially reversible circulatory, metabolic and endocrine disturbances have been excluded
• Exclusion of potentially reversible causes of apnoea

The above represent certain prerequisite criteria that need to be established before brain-stem testing can take place, which include haemodynamic status (e.g. blood pressure), oxygenation, temperature, and electrolytes among others. If any of these are abnormal there could be a reversible cause of coma.

If the above considerations have been addressed, then confirmation of brain-stem death can be carried out by two medical professionals (minimum one consultant) who have been registered for > 5 years using neurological criteria. For more information see ‘A code of practice for the diagnosis and confirmation of death’.

Last updated: May 2022