Brainstem death

• Definitions of death

  Use:
  • Criteria for death in patients on a ventilator.
  • Allows for treatment to be withdrawn and/or organs to be donated.
  Criteria:
  • Patient must be apnoeic.
  • Brainstem tests must be performed to confirm death on 2 separate occasions by 2 people each time (they can be the same each time). The gap between should be of sufficient time to reassure next of kin.
  • Other causes of loss consciousness must have been excluded.
  • There must be a known and irreversible cause of death.
  Brainstem reflex tests:
  • Fixed pupils unresponsive to light.
  • No corneal reflex.
  • No vestibulo-ocular reflex: no eye movements in response to 50 ml of cold ice water injected into each ear.
  • No response to supra-orbital pressure.
  • No gag reflex.
  • No cough reflex in response to suction catheter.
  • No respiratory movements upon disconnecting the ventilator.

  Cardiac death

  • Cessation of cardiac function.
  • These patients are rarely able to donate organs as the death is typically in the elderly, out of hospital, and/or unexpected. The only context in which they may donate organs is if they are in hospital and withdrawal of care is predicted to lead to cardiac arrest.

• Confirming death

  Before reaching the patient:
  • Check resuscitation status with nurses and in notes. Ensure they are DNACPR or CPR has been attempted and failed.
  • Review notes on patient background for idea of likely cause of death.
  Initial checks at bedside:
  • Check patient ID with wrist band.
  • Check if responsive to voice then pain.
  Examination:
  • Examine pupils: should be unreactive and fixed in dilation.
  • Check corneal reflex.
  • Feel for central pulse (>1 minute).
  • Auscultate for heart sounds (>1 minute).
  • Auscultate for breath sounds (>1 minute) e.g. 30 seconds each side.
  Documentation and finishing:
  • Start with time, date, name and rank, and note that you were called to confirm the death.
  • Make a note of all the tests done and their results.
  • Write: "{Doctor name} confirmed the death of {patient name} at {time and date}". Sign, print name, and note GMC and bleep number.
  • Inform the nurses, who will arrange for transfer to the mortuary and contact the family if not present.

• Certifying death

  Can be completed by doctor who looked after patient in their last illness, and saw them in the 14 days before dying or any point after dying. To have officially seen them in the last 14 days, you must have an entry in their notes in that period.

  Referral to coroner

  Always refer any death which was:
  • Of unknown cause.
  • Violent, unnatural, suspicious, or accidental. This can include common and low impact injuries such as deaths related to a fractured proximal femur.
  • Of a patient not seen by doctor in last 14 days.
  • Related to surgery or anaesthetic.
  • Within 24 hours of admission to hospital.
  Issue certificate but phone coroner to discuss if:
  • Death from industrial disease or in person receiving industrial pension.
  • Suicide
  • Death by poisoning or drugs (including alcohol).
  • Death from want, neglect, or exposure.

  Death certificate contents

  Basics

  • Patient info: name, age, date and place of death.
  • Write date of month in words (e.g. 'seventeenth'), but OK to write year and age in numbers.
  • Date last seen by doctor issuing certificate.
  • Usually 3 is circled, or 4 if postmortem being planned but coroner said you can complete certificate. Circling 1 or 2 is extremely rare as you would not be completing a death certificate after post-mortem.
  • The job box is basically never ticked, as it would imply an industrial cause requiring referral to the coroner and almost certain post-mortem.

  Cause of death

  Part 1:
  • Start with the most immediate cause and work back through the causal pathway.
  • 1a is the disease or condition directly leading to death, 1b is disease leading to 1a, and 1c is disease leading to 1b.
  • The lowermost listed disease is the 'underlying cause of death', and is what is usually noted in mortality statistics.
  • Sometimes 1a alone can be completed if that is responsible e.g. meningococcal septicaemia, infective exacerbation of chronic obstructive pulmonary disease.
  • 2 joint causes can be on any line if they are equally responsible, noting 'joint causes of death' if they are the underlying cause. Additionally, if more than 3 steps to note, more than one can be written per line, provided the causal sequence is indicated between them.
  • If organ failure listed for 1a, there must be another line with a specific cause e.g. 1a congestive heart failure, 1b essential hypertension.
  • Be specific: name the artery (if known) for haemorrhage, name the tumour type (e.g. squamous cell) if cancer, name the pathogen if sepsis.
  • 'Frailty of old age' can be used if >70 years old and no specific cause can be determined. Avoid if possible.
  Part 2:
  • Conditions contributing to death but not related to the primary cause of death.
  • Does not always have to be completed if there are none present.
  There is room to explain any medical terms in the adjacent space for the benefit of families.

  Completion

  • Sign it, name in capitals, date of issue, and qualification. Note GMC number next to qualification, the latter being what is registered with the GMC e.g. MBBS.
  • Note consultant in charge if death in hospital.
  • Certificate is given to relative to deliver to the Registrar of Births, Deaths, and Marriages.

  Cremation form

  • Must be done by 2 doctors: one involved in care before death – usually but not necessarily the one who did the death certificate – and one who is ≥5 years post-registration.
  • Body must be seen to confirm death. Check for pacemakers.
  • Doctor must be unrelated to the patient and have no financial interest in their death.