Authors: Charlotte Davies / Editor: Liz Herrieven / Codes: PalC1, PalC7, RC5, SLO12, SLO3, SLO5, SLO7 / Published: 25/07/2023
We’ve talked a lot in RCEMLearning blogs about how to recognise death, why dying matters, talking about dying, palliative care in Emergency Department (ED) and how to break bad news, but we haven’t ever really focused on how to legally “declare” someone as dead, and complete the relevant paperwork. Your trust will almost certainly have a policy on this, and it is through researching updates to my trust’s policy, together with making sure our international medical graduates were aware of the UK rules, that this blog post was born.
Recognising Imminent Death
We talk about this lots, and we all know the signs. We see the patient peri-arrest, or the patient with Cheyne-Stokes respirations, and we know their time is close. When does this dying process obtain permanence?
For us, as doctors, there is no standard approach to defining death although it is generally considered to be cardiovascular, neurological (ie brain stem death) or somatic. Because of the processes involved in defining neurological death we will not be covering that here.
Confirmation or verification of death can be performed by nurses or doctors, dependent on local protocols. As only doctors can certify death, it is generally best in ED for a doctor to verify the death as well.
This is when there are features visible externally on the corpse compatible with death – so this will be a death that is verified by coroner processes.
This generally occurs after a resuscitation attempt has been terminated, and there are no standard methods of diagnosing it. Current practice varies from confirming death as soon as the heart stops of its own accord, or when attempts at cardiopulmonary resuscitation are abandoned, to waiting ten minutes or longer after the onset of asystole and apnoea. The AOMRC guidelines suggest:
- Irreversible apnoea e.g. no sedative drugs present
- Absent circulation as observed for at least 5 minutes by palpation or auscultation. This could be supplemented by observing asystole or loss of cardiac contractility.
- Irreversible unconsciousness, no pupillary or corneal response.
- No response to pain
- All reversible causes considered
- A DNA CPR is appropriate, or resuscitation has failed
Geeky medics talks about this similarly:
Confirmation of circulatory failure is interesting. We know that palpating a pulse may not be accurate in a low flow state. Listening for 5 minutes is a conservative approach, and many other countries listen for less time.
Certifying death is a legal process, and can only be completed by a registered medical practitioner i.e. a doctor who has “seen” the patient in the last 28 days. It is vital to ensure that the information documented in the death certificate is correct as it contributes to census information, trust mortality reports and family memories. If a death certificate can be issued, the cause of death should be discussed with the specialty consultant and / or the medical examiner. It is generally accepted that seeing a patient who arrives in ED and then dies is sufficient for a death certificate to be completed. If a patient arrives in cardiac arrest, the death will be discussed with a coroners officer who may then agree a death certificate can be issued.
Medical examiners are relatively new post holders introduced as a liaison between hospital staff and families. They are all doctors, and between them they review every death in the hospital to ensure there are no learning opportunities, as well as streamlining the deaths that get referred to HM coroner.
Most hospitals will keep their death certificates in the bereavement office so bereavement staff can have some oversight of the process. The site management team may keep some for emergency out of hours use.
RCPath have issued an accepted cause of death list and this is well worth looking at if you are writing death certificates. 1a is the actual cause of death contributed to by 1b and 1c. 2 is other things relevant but not directly causing death – we get this wrong a lot. Modes of death are not acceptable unless supported as to why for example 1a Respiratory failure alone is not acceptable but 1a Respiratory failure 1b Chronic Obstructive Pulmonary Disease is acceptable.
Referring a Death to HM Coroner
There are certain deaths which require reporting to His Majesty’s Coroner, Notification of Deaths Regulations 2019 guidance – GOV.UK (www.gov.uk). Have a look at the full version of the guidelines but these will be deaths where foul play is suspected, or you can not on all balance of probabilities decide a likely cause of death.
For example, a 90 year old man attends with left sided flank pain. He suddenly deteriorates and drops his blood pressure and haemoglobin. His abdomen swells up in front of you. You initiate CPR but he dies. Cause of death? You can be 99% certain he had a ruptured abdominal aortic aneurysm and this can be documented on his death certificate.
The Cremation Form
Crem forms are always dependent on your local authority. Many hospitals assume a patient will be cremated and fill the form in readiness, shredding it if it’s not needed. There are two parts to a crem form, and both attract a fee for completing – which should be declared to the tax man. Some trusts siphon the fees straight to the doctors mess or similar.
The form is generally self explanatory. There are three questions that could be tricky. The bereavement office normally check the form to ensure it is fully completed, please ask the office staff any questions you may have.
Pecuniary Interest = financial interest = are you named in their will?
This just means whether you saw them and checked for pacemakers, ICDs, LVADs, fixation nails and other things that might cause problems at high temperature (see Annex A). If you verified the death ensure this is the same date and time as on the front page of the cremation form, for the examination section ‘verification of death’ is sufficient. If death was verified by another professional, for the examination section ‘external examination performed’.
Question 14 – Include at least one person’s name who cared for the patient ‘nursing staff on X ward, including nurse Y’
Question 15 – Name and relationship including telephone number if a family member or friend was present. If nursing staff answer as in question 14. If cardiac arrest team – ‘cardiac arrest team including Dr Z’.
After death many cases get reviewed and discussed at governance meetings. Your trust is very likely to have a trust wide mortality meeting where trust wide deaths are reviewed. There are also specific guidelines where some deaths like those of patients with learning disabilities and a diagnosis of sepsis must be reviewed.
Most of these deaths are reviewed using a structured judgement review process. These reports must be judgmental and the reviewer should comment on good and bad care. They are designed to help us learn from deaths. They form part of the patient’s documentation so if the case later goes on to become a serious incident, or require a coroner’s inquest they will be part of the evidence submitted. The coroner may scrutinize the quality of the SJR, and a recent outcome highlighted the problems of ill researched SJRs – so be careful what you write.
I review all of our department’s deaths and find it really interesting. It is very rare that deaths are reversible, but there’s always something we can improve on and I can identify a trend. I’ve found NPAs put in by paramedics miraculously disappear on transfer to the ED trolley. I’ve found oxygen concentrations not being documented. I’ve found we thrombolyse with the wrong thing. Nothing of significance, generally, but interesting. I’ve also found it really useful to notice that one staff member has been involved in a lot of arrests and might need a bit of support, or that one arrest seemed a little bit difficult and a debrief might be needed.
The documentation in deceased patients also feeds into the SHIMI score, and accurate documentation helps accurately portray how the trust is actually doing.
Death Verifying in the Ambulance Service
The ambulance service have a specific set of criteria that must be met before they can recognise life as extinct. These deaths then go on to be certified by a practitioner outside of the hospital, so it is important that the guidelines are followed. This might explain why you get so many patients brought in where you think paramedics should have stopped CPR but they haven’t – they have their guidelines to follow just like we do.
Death in Children
Although a lot more emotive, verifying and certifying death in children is identical. A Consultant does not need to be present. The process for reviewing child deaths is robust, and requires lots of post-mortem samples to be taken. For this reason, a senior paediatrician is often required to be part of the death verification process.
Each hospital will have a SUDIC (sudden unexpected death in a child) protocol to follow, for deaths in people up to 18 years of age. This dictates which samples are collected and who should be notified (e.g. health visitor) and has its own paperwork to be completed. There are also guidelines about meetings, which are held following the death of a child, usually led by the designated doctor for child deaths, and including acute health care, primary care, education, social care and police. These form part of the Child Death Review process.
Any foetal remains should be disposed of sensitively, and the relevant consent forms completed. Most trusts have arrangements with their local facilities for these to be cremated, and a clear guideline.
Generally if gestation is estimated to be <12 weeks, and foetal remains are unrecognisable, they should be put in a specimen pot with a:
- Trust specific sensitive handling of remains form
- Histology form – make it clear to parents that unless this is a recurrent miscarriage, analysis is unlikely to happen.
12-15weeks +6 or recognisable baby baby parts will need to be transferred to the mortuary in a dry pot, with a mortuary form.
We hope that has been a useful reminder about some of the legalities and processes around death.
- Cheyne–Stokes respiration. Wikipedia.
- Confirmation or verification of death by registered nurses. Advice guides. Royal College of Nurses.
- Gardiner D, Shemie S, Manara A, Opdam H. International perspective on the diagnosis of death. Br J Anaesth. 2012 Jan;108 Suppl 1:i14-28.
- A Code of Practice for the Diagnosis and Confirmation of Death. Academy of Medical Colleges, 2008.
- Davis M. Death Confirmation – OSCE Guide. Geeky Medics, 2023.
- Gardiner D. et al. International perspective on the diagnosis of death. British Journal of Anaesthesia (BJA). 108, SUPPLEMENT 1, I14-I28, 2012.
- Guidance for doctors completing Medical Certificates of Cause of Death in England and Wales. Office for National Statistics.
- Cremation forms and guidance. Gov.UK, 2010. Updated in 2022.
- The Cremation (England and Wales) Regulations 2008. Guidance to medical practitioners completing form Cremation 4. Ministry of Justice, 2022.
- Hutchinson A. Using the structured judgement review method A guide for reviewers (England). National Mortality Case Record Review Programme. Royal College of Physicians, 2016.
- Learning from deaths in the NHS. NHS England.
- Summary Hospital-level Mortality Indicator (SHMI), Deaths associated with hospitalisation, England, November 2020 – October 2021. National Statistics. Gov.UK 2022.
- Skellett S, Maconochie I, et al. Paediatric advanced life support Guidelines. Resuscitation Council UK.
- Child death review: statutory and operational guidance (England). Statutory Guidance. Gov.UK, 2018. Updated in 2019.
- Disposal of pregnancy remains FAQs. Human Tissue Authority. Updated in 2021.