I. Problem/Challenge.

As inpatient physicians, hospitalists must often declare the cardiopulmonary death of a patient. There are several different scenarios in which hospitalist physicians may find themselves: 1) an expected death of a patient with do not resuscitate (DNR) orders; 2) a sudden unexpected death; or 3) death following unsuccessful resuscitative efforts. A hospitalist should be able to adjust the death examination to each specific situation in order to ensure an accurate determination of death.

II. Identify the Goal Behavior

Ideally, when called upon, the physician should be able to determine whether the death of the patient was straightforward and expected, thus requiring a basic examination, or sudden or unexpected, possibly requiring a more thorough examination or adjunctive diagnostic tools to confirm the diagnosis of death. The physician should also make every effort to be sensitive to the presence and concerns of friends and family who may be in the room with the deceased patient.

III. Describe a Step-by-Step approach/method to this problem.

The physician should first assess whether or not there are family members or friends in the room with the patient. These individuals should be allowed some time with their loved one. Some may wish to involve a hospital chaplain or pastor. At an appropriate time, the physician may inform them that he or she must perform the death examination. The physician may ask them whether they would prefer to stay there or leave the room for the few minutes that it will take to perform the exam.

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Death occurs when there is permanent cessation of circulatory and respiratory function. The death exam takes place as follows.

Step 1: The physician should begin by confirming cessation of circulatory and respiratory function. Cessation of function can be determined by a simple bedside exam: palpating for pulses and listening for the absence of heartbeat and respiratory effort. “Mechanical asystole,” or lack of palpated pulse and auscultated heartbeat, is sufficient to determine death. Further testing, such as the use of an electrocardiogram (EKG) or telemetry to demonstrate “electrical asystole,” is not required in most cases.

In circumstances in which the patient had been on cardiac monitoring at the time of death, the presence of asystole or ventricular fibrillation (electrical asystole) would be sufficient to demonstrate cessation of circulatory function.

Step 2: The physician should then ensure that the cessation of function is permanent by observing for an appropriate period of time. Suggestions in the literature vary, but most experts agree that a period of two to five minutes is sufficient.

A few examples here may help elucidate these steps.

Scenario 1: A patient who has a DNR order dies after a gradual progression of their disease, as anticipated.In this case, an appropriate period of examination may be just the few minutes it takes to complete auscultation of heart and lungs and palpation of pulses.

Scenario 2: A patient in a telemetry unit on cardiac monitoring who demonstrates constant asystole on the monitor for over five minutes.In this case, further examination may not be necessary, but many physicians prefer to perform a bedside exam for confirmation.

Scenario 3: A patient has an unexpected or sudden death, and resuscitative efforts are initiated.In this case, death can be determined once the team decides that resuscitative efforts will not succeed. Examples include persistent asystole, pulseless electrical activity (mechanical asystole is sufficient for death), or ventricular fibrillation despite appropriate ACLS measures. As noted above, an appropriate time interval must be observed to demonstrate that cessation of function is permanent.

Hospitalists may be aware of another standard of death, namely “brain death.” This diagnosis was defined by a committee at Harvard Medical School in 1968 and has since been codified in United States’law. It requires “whole brain death,” or permanent cessation of function of the entire brain, including the basic functions of the brainstem such as respiration. Patients for whom this diagnosis is under consideration are typically cared for in ICUs, which are increasingly staffed by intensivists rather than general internists. Therefore the determination of brain death is not discussed in detail in this article, which is intended for hospitalists.

IV. Common Pitfalls.

In general, the determination of death is straightforward. However, there may be a few circumstances in which closer attention is necessary.

In patients for whom the clinical exam, including auscultation and palpation, is difficult, as in morbidly obese patients, further testing to ensure cessation of function, such as an EKG, may be appropriate.

In patients suffering from hypothermia, drug intoxication, or severe metabolic derangements, cardiopulmonary functions may be depressed and more difficult to ascertain. A longer period of examination or adjunctive tests may be needed to determine death.

V. National Standards, Core Indicators and Quality Measures.

Almost all states have adopted the Uniform Determination of Death Act (UDDA), which was developed by a group of medical consultants and is outlined in the 1981 report “Guidelines for the Determination of Death,” published in the Journal of the American Medical Association. It sets forth two major criteria for the determination of death: 1) irreversible cessation of circulatory and respiratory functions, or 2) irreversible cessation of all functions of the entire brain, including the brain stem. The act does not provide specific time intervals or strict criteria, but rather lays down guidelines and relies on the existence of “accepted medical standards.”

Of note, some have criticized the use of the term “irreversible” in the UDDA, recognizing that some patients may appropriately be declared dead whose cessation of cardiopulmonary function may in fact be temporarily reversible using resuscitative measures such as ACLS. For this reason, the term “permanent” (will not reverse) rather than “irreversible” (cannot reverse) has been used preferentially in this article.

VI. What's the evidence?

“Report of the medical consultants on the diagnosis of death to the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research”. JAMA. vol. 246. 1981. pp. 2184-2186.

Bernat, JL. “How the distinction between “irreversible” and “permanent” illuminates circulatory-respiratory death determination”. Journal of Medicine and Philosophy. vol. 35. 2010. pp. 242-255. (This article recounts the history of the UDDA and Harvard Medical School committees and explains the difference between irreversible and permanent cessation of function.)