SICU Declaration of Death

DECLARATION OF DEATH

Death occurs when:

  • There is irreversible cessation of the heart and lung activity
  • There is irreversible cessation of brain activity

NEUROLOGIC CRITERIA FOR ESTABLISHING BRAIN DEATH

        Consultation by a Neurologist or Neurosurgeon (Attending, Fellow or Chief Resident) must be obtained to determine whether neurological criteria for death have been met.

  • Establishing Irreversibility
    • Irreversibility is demonstrated by establishing the etiology and natural history of coma and/or through repeated assessments over time.
    • Etiology should be determined through history, physical examination and/or imaging. Natural history should be based on the medical literature.
  • Repetition of the assessment after a period of time is generally advisable except in those instances in which massive remediable anatomic injury to the brain can be directly visualized by physical examination, at craniotomy, or by imaging procedures. The need to repeat the evaluation and the duration of interval should be made by the consulting neurologist or neurosurgeon based on the individual characteristics of each patient.
  • Excluding Confounding Conditions
  • The attending neurologist or neurosurgeon must determine if any conditions exist that may depress or otherwise limit the assessment of neurologic function.
    • Hypothermia (T<36 C)
    • Shock
    • Severe electrolyte disturbance
    • Hepatic or renal encephalopathy
    • Severe endocrine disturbance
    • Severe hyperosmolar state
    • Presence of excessive levels of sedative drugs
    • Presence of neuromuscular agents
  • The thresholds of these conditions should be determined by the consulting neurologist or neurosurgeon. If one of these conditions is present and cannot be corrected a test of cerebral perfusion should be performed after correction of hypothermia and/or shock.
    • Clinical Criteria
    • The cause and/or irreversibility of the condition have been established
    • There must be complete loss of brain function
    • Unresponsive
    • There must be no brain-mediated responses (decorticate or decerebrate) to noxious stimuli applied centrally or peripherally
    • Since the spinal cord may be intact some reflex responses may be present including deep tendon reflexes, and reaction of the blood pressure to noxious stimulation.
    • Absence of Brainstem Reflexes
    • The pupils must be dilated or mid position and nonreactive to bright light
    • Oculocephalic (doll’s eye) and oculovestibular (ice water caloric) responses must be absent
    • No cough response to suctioning
    • No movement of the head, lids, or eyes in response to painful stimulation
    • Apnea: An apnea test should be performed as the final test.
  • Ancillary Tests: The functions of the brain that are relevant to the diagnosis of death based on neurological criteria are those that are clinically ascertainable. The use of confirmatory studies such asEEG or nuclear cerebral blood flow study may be of value when the ability to perform a complete clinical assessment is limited or confounding factors are present. The decision whether or not to employ such tests and which test to employ (EEG is NOT appropriate in cases of drug intoxication or hypothermia) should be made by the attending physician and consulting neurologist or neurosurgeon based on the individual characteristics of each patient. Documentation of cerebral circulatory failure may be used to support the diagnosis of death. Methodologies available include four vessel cerebral arteriography and cerebral radionuclide angiography. These tests are considered supportive. The diagnosis remains a clinical one.

CERTIFICATION OF DEATH

  • The neurological specialist certifies in writing in the patient’s chart whether or not the patient “meets the neurological criteria for death.” If the attending physician is a neurological specialist, he/she may act as the attending physician and the neurological specialist. If organ or tissue donation is to be requested, the neurological specialist making the determination of death should not be involved with the team who will perform the transplantation or in the care of a potential recipient of an organ from the patient involved.
  • Death is declared while the patient is still receiving mechanical ventilation
  • If organ procurement is to be requested, it is recommended that the following information be conveyed to the family by the attending physician or his/her designee in concert with representative of Mid America Transplant Services and Spiritual Care.
  • That even though the patient has spontaneous cardiac activity the patient is legally dead and that respiration is being artificially maintained
  • In this situation other organs and tissues can be used for life-saving humanitarian purposes. The permission of the family is being requested for the use of the organs and tissues to help others.
  • If the family requests to be present when ventilator support is discontinued (this is not recommended) they should be alerted that possible agonal movements of the trunk and limbs in brain dead patients have been reported and can easily be misinterpreted as indicating volitional activity.
  • Organ donation – Although it is obviously a terrible time for the families of a braindead patient, many will want the patient to be an organ donor. If the diagnosis of brain death is considered, Mid-America Transplant should be notified. Discussions related to organ donation should NOT be initiated by the resident physician taking care of the patient.

EXPIRATION SUMMARY NOTES

         The expiration note is written on all patients that die in the ICU. The expiration summary must at least contain the diagnosis, (what diagnosis led to hospital admission or the presumed cause of death), date, and time of death. This is done under the Documents tab in Epic.