What is the procedure for confirming death in a clinical setting?

Procedure for Confirming Death in a Clinical Setting

Death determination requires a comprehensive clinical examination confirming absence of neurologic function with a known irreversible cause of coma, including absence of all brainstem reflexes and apnea testing, performed by qualified physicians with appropriate observation periods. 1

Clinical Examination for Death Determination

Primary Assessment

• Confirm absence of:
  • Cardiac output (no pulse)
  • Respiratory effort (no breathing)
  • Response to painful stimuli (including supraorbital pressure)
  • Pupillary and corneal reflexes 2

Observation Period

• Minimum 5-minute observation period after cardiorespiratory arrest 2
• Any return of cardiac or respiratory activity during this period requires restarting the observation period 2

Brain Death Determination (for patients on life support)

• Requires clinical confirmation of:
  1. Complete unresponsiveness to all stimuli
  2. Absence of all brainstem reflexes:
     • Pupillary light reflex
     • Corneal reflex
     • Oculocephalic reflex ("doll's eyes")
     • Oculovestibular reflex (caloric testing)
     • Gag and cough reflexes 2, 1
  3. Apnea (confirmed through formal testing)

Apnea Testing Protocol

• Preoxygenate with 100% oxygen
• Disconnect from ventilator
• Observe for respiratory effort
• Measure arterial blood gases until PaCO₂ ≥60 mmHg AND ≥20 mmHg above baseline 1
• Continuously monitor vital signs during testing

Required Observation Periods for Brain Death

• Term newborns (37 weeks to 30 days): 24 hours between examinations 2, 1
• Infants and children (30 days to 18 years): 12 hours between examinations 2, 1
• Adults: Typically 6 hours between examinations 1

Prerequisites Before Testing

• Ensure reversible conditions are corrected:
  • Core temperature >35°C (normothermia)
  • Normal blood pressure
  • Corrected metabolic disturbances
  • Discontinued sedatives, analgesics, and neuromuscular blockers with adequate clearance time 2, 1
• Defer assessment for 24-48 hours after cardiopulmonary resuscitation or severe acute brain injuries 1

Ancillary Testing

Indicated when:

• Components of examination or apnea testing cannot be completed safely
• Uncertainty exists about clinical examination
• Medication effects may be present
• To reduce observation period between examinations 2, 1

Recommended Tests

• Cerebral blood flow studies (sensitivity ~86%)
  • Four-vessel cerebral angiography (gold standard)
  • Radionuclide cerebral blood flow studies
• Electroencephalography (sensitivity ~76% on first EEG) 1

Documentation Requirements

• Clinical examination criteria
• Results of apnea testing
• Results of ancillary testing (if performed)
• Determination of irreversibility
• Confirmation by a second physician (required by law in some jurisdictions) 2, 1

Common Pitfalls to Avoid

• Misinterpreting spinal reflexes as signs of brain function
• Inadequate observation time
• False detection of respiratory effort
• Performing testing too early after injury
• Failing to correct reversible conditions
• Attempting brain death determination while neuromuscular blocking agents are still active 2, 1

Special Considerations

• Neuromuscular blocking agents (NMBAs) must be discontinued prior to death determination 2
• Clinical diagnosis of brain death should not be made unless the patient has a Train of Four (TOF) of 4/4 as measured using peripheral nerve stimulation 2
• For organ donation after circulatory death, standard protocols for death determination must be followed before proceeding with donation 2

By following these evidence-based protocols, clinicians can ensure accurate and consistent determination of death in clinical settings.