What are the guidelines for confirming death in a clinical setting?

Guidelines for Confirming Death in a Clinical Setting

Death must be declared by either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all brain functions, including the brainstem, with specific clinical criteria and observation periods required for each determination method. 1

Circulatory Death Determination

Clinical Criteria

• Absence of circulation (no pulse, no heart sounds)
• Absence of respiratory effort
• Unresponsiveness to all stimuli
• Minimum 2-5 minutes observation period after cardiorespiratory arrest 1
• Any return of cardiac or respiratory activity during this period requires restarting the observation period 1

Documentation Requirements

• Time of cardiorespiratory arrest
• Confirmation of absence of pulse and heart sounds
• Confirmation of absence of respiratory effort
• Confirmation of unresponsiveness to stimuli
• Duration of observation period
• Time of death declaration

Brain Death Determination

Prerequisites

• Known cause of coma that is irreversible
• Core temperature >35°C
• Normal blood pressure
• Corrected metabolic disturbances
• Discontinued sedatives, analgesics, and neuromuscular blockers with adequate clearance time 1
• Neuromuscular blocking agents must be discontinued with Train of Four (TOF) of 4/4 confirmed 1
• Defer assessment for 24-48 hours after cardiopulmonary resuscitation or severe acute brain injuries 1

Clinical Examination

• Complete unresponsiveness to all stimuli, including painful stimuli
• Absence of all brainstem reflexes:
  • Pupillary light reflex
  • Corneal reflex
  • Oculocephalic reflex (doll's eyes)
  • Oculovestibular reflex (cold caloric)
  • Gag reflex
  • Cough reflex 1

Apnea Testing

• Preoxygenation with 100% oxygen
• Continuous monitoring during test
• PaCO₂ must reach ≥60 mmHg AND ≥20 mmHg above baseline
• Absence of respiratory effort with adequate CO₂ stimulus 1

Observation Periods

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

Ancillary Testing (when needed)

• Required if apnea testing cannot be completed due to medical contraindications or hemodynamic instability 1
• Options include:
  • Cerebral blood flow studies (four-vessel cerebral angiography - gold standard)
  • Radionuclide cerebral blood flow studies (sensitivity ~76%)
  • Electroencephalography (EEG) (sensitivity ~86% on first test, increasing to 89% with multiple EEGs) 1

Special Considerations for Pediatric Patients

Age-Specific Requirements

• Two separate examinations by qualified physicians are mandatory for infants and children 2, 1
• For term newborns (37 weeks to 30 days):
  • First exam may be performed 24 hours after birth or following cardiopulmonary resuscitation/severe brain injury
  • At least 24 hours between examinations 2
• For children (31 days to 18 years):
  • First exam may be performed 24 hours following cardiopulmonary resuscitation/severe brain injury
  • At least 12 hours between examinations 2

Qualified Examiners

• Pediatric intensivists and neonatologists
• Pediatric neurologists and neurosurgeons
• Pediatric trauma surgeons
• Pediatric anesthesiologists with critical care training 2
• Adult specialists with appropriate neurologic and critical care training 2

Common Pitfalls to Avoid

• Misinterpreting spinal reflexes as signs of brain function 1
• Inadequate observation time 1
• False detection of respiratory effort 1
• Performing testing too early after injury 1
• Failing to correct reversible conditions 1
• Failing to recognize that ancillary studies in newborns are less sensitive than in older children 2
• Rushing the death determination process, which should never take priority over the needs of the patient or family 2

Family Communication

• Communication with families must be clear and concise using simple terminology 2
• Consider permitting families to be present during the brain death examination to assist in understanding 2
• Clearly explain that once brain death has been declared, the patient meets legal criteria for death 2
• Make clear that continuation of medical therapies, including ventilator support, is no longer an option unless organ donation is planned 2
• Provide appropriate emotional support and adequate time for the family to grieve 2

Documentation Requirements

• Clinical examination criteria
• Results of apnea testing
• Results of ancillary testing (if performed)
• Determination of irreversibility
• Confirmation by a second physician (when required) 1
• Use of a standardized checklist is recommended to ensure all components are completed and documented appropriately 2