Death and brain death

Revisores de contenido

Jennifer Fagel, DO (Internal Medicine),Stefan Stoisavljevic, PhD

Colaboradores/as

Dolores Gonthier, MD,Mariyan Montaque, DNP, FNP-BC, RN,James Rhoads,Alaina Mueller,Jung Hee Lee, MScBMC

The death of a patient is one of the most difficult situations for clinicians, especially if the patient is well known to them or has been their patient for a long time. It is an important clinical responsibility that requires strong communication, clinical accuracy, and an understanding of medical and legal standards. In healthcare, death is diagnosed using either circulatory criteria or neurologic criteria, also known as brain death. Physicians are most commonly responsible for pronouncing the death of a patient.

Okay, let’s start with circulatory death which is defined as an irreversible cessation of circulatory and respiratory function.

When a patient is thought to be deceased, a clinician is contacted by the healthcare team. Keep in mind that even though it is physicians who are typically called to pronounce death, other clinicians like physician assistants, nurse practitioners, nurses, paramedics, or coroners may diagnose death depending on state and institutional laws and policies.

Before entering the patient’s room, the clinician should review the medical chart, identify family members and the health care proxy, and determine whether organ donation or autopsy discussions have already occurred. Nurses may also provide information regarding the patient’s condition and circumstances of death, as well as family needs such as pastoral care.

Upon entering the room, clinicians introduce themselves to the family and explain that an examination will be done to pronounce their loved one. The family may stay or leave the room during the examination.

The exam begins by confirming the patient’s identity on their identification bracelet.

The next step is to assess the lack of movement and absence of response to verbal or tactile stimulation, such as nail bed pressure.

Using more aggressive tactile stimulation, such as a sternal rub, may cause unnecessary distress to the family.

Then, pupils are checked, which are fixed and nonreactive.

Lastly, the absence of respirations is confirmed by observing no chest movement or breath sounds, while absence of circulation is confirmed with no carotid pulse or heart sounds.

For ventilated patients, first confirm that no paralytic drugs were given in the last 6 to 8 hours. The patient should have no pulse, no measurable blood pressure, or no electrical activity on electrocardiogram tracing before the ventilator is disconnected. The remainder of the death examination is then performed as usual.

Transcript

Okay, let’s start with circulatory death which is defined as an irreversible cessation of circulatory and respiratory function.

The exam begins by confirming the patient’s identity on their identification bracelet.

The next step is to assess the lack of movement and absence of response to verbal or tactile stimulation, such as nail bed pressure.

Using more aggressive tactile stimulation, such as a sternal rub, may cause unnecessary distress to the family.

Then, pupils are checked, which are fixed and nonreactive.

Lastly, the absence of respirations is confirmed by observing no chest movement or breath sounds, while absence of circulation is confirmed with no carotid pulse or heart sounds.

DEATH AND BRAIN DEATH
Key Term	Definition	Example
Circulatory Death	The irreversible cessation of circulatory and respiratory function.	A patient is found not breathing and without a pulse, with no respirations, no carotid pulse, and no heart sounds on exam.
Pronouncement of Death	The clinical act of examining the patient, confirming death, communicating with family, and documenting the findings.	A nurse practitioner performs the death exam, informs the healthcare proxy, and documents the date and time of death.
Health Care Proxy	The person identified to help with communication and decision-making after a patient's death or when the patient cannot decide for themselves.	After confirming death, the clinician calls the patient's health care proxy and discusses organ donation and autopsy.
Clinical Signs of Death	Findings used to diagnose circulatory death, including no movement, no response to stimulation, fixed nonreactive pupils, no respirations, and no circulation.	The patient is not moving, does not respond to voice or nail bed pressure, has fixed dilated pupils, no chest movement, and no carotid pulse.
SPIKES	A framework for delivering bad news that includes Setting, Perception, Invitation, Knowledge, Empathy, and Strategy.	The clinician says, “I'm sorry, the patient has died,” avoids jargon, responds with empathy, and discusses next steps.
Coroner Referral	The legal requirement to report certain deaths, depending on state law and circumstances.	A death associated with trauma, sudden death, or death shortly after admission may need to be referred to a coroner.
Brain Death	The complete, irreversible loss of all brain function in a patient who still has cardiac activity.	A patient with a ruptured aneurysm is in a coma, has absent brainstem reflexes, and no spontaneous breathing on apnea testing.
Reversible Conditions that Mimic Brain Death	Conditions that must be excluded or treated before brain death testing because they can mimic or interfere with the examination.	Hypothermia, severe hypotension, drug intoxication, and Guillain-Barre syndrome must be ruled out first.
Coma	An unconscious state where the patient is unresponsive to noxious, visual, auditory, and tactile stimulation.	The patient does not respond to loud voice or to nail bed pressure.
Brainstem Reflexes	Reflexes tested during brain death evaluation to assess brainstem function.	Pupillary, corneal, oculocephalic, oculovestibular, gag, and cough reflexes are absent bilaterally.
Apnea Test	The part of the brain death exam that checks for spontaneous breathing when carbon dioxide levels rise.
Spinal Reflexes	Automatic movements that can remain after brain death and do not indicate consciousness or recovery.	When family members notice leg movements, the physician explains these are spinal reflexes and do not involve the brain.

Death and brain death

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