Diagnosis of Death Abbreviated

7/27/2019 Diagnosis of Death Abbreviated

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October 2012 1

Form for the Diagnosis of Death using Neurological Criteria

{abbreviated guidance version}

Dateandtime:.……………………………………………PatientLocation:……………………………………

Doctor One, Name and Designation Doctor Two, Name and Designation

Name…………………………... Name…………………………..

Signature………………………. Signature………………………

Grade…………………………... Grade…………………………...

PrimaryDiagnosis:……………………………………………………………………………………………………….

EvidenceforIrreversibleBrainDamageofknownAetiology:

……………………………………………………………………………………………………………………………………...

……………………………………………………………………………………………………………………………………...

HOSPITAL ADDRESSOGRAPH or

Surname

First Name

Date of Birth

NHS Number

This form is consistent with and should be used in

conjunction with, the AoMRC (2008) A Code of

Practice for the Diagnosis and Confirmation ofDeath

and has been endorsed for use by the following

institutions: Faculty of Intensive Care Medicine,Intensive Care Society and the National Organ

DonationCommittee.

ExclusionofReversibleCausesofComaandApnoea

Is the apnoea due to neuromuscular

blocking agents, other drugs or a non

brain-stem cause (eg . cervical injury,

profound neuromuscular weakness)?

Is the patient’s body temperature ≤34°C?

Is the coma due to depressant drugs?

Drug Levels (if taken):

Is the coma due to a circulatory,

metabolic or endocrine disorder?

1st Test

DrOne

1st Test

DrTwo

2ndTest

DrOne

2ndTest

DrTwo

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

EvidenceforIrreversibleBrainDamageofknownAetiology



October 2012 2



B r a i n - S t e m R

e f l e x e s

A p n o e

a T e s t

TestsforAbsenceofBrain-StemFunction

1st Test

DrOneExamining

1st Test

DrTwoObserving

2ndTest

DrOneObserving

2ndTest

DrTwoExamining

Do the pupils react to light?

Is there any eye movement when each

cornea is touched in turn?

Yes/No Yes/No

Yes/No

Yes/No

Yes/No Yes/No

Yes/No

Yes/No

Is there any eye movement during

caloric testing in each ear? Yes/No Yes/No

Yes/No

Yes/No

Yes/No

Is there any motor response when

su raorbital ressure is a lied?Yes/No Yes/No

Yes/No

Yes/No

Is the gag reflex present? Yes/No Yes/No

Yes/No

Yes/No

Is the cough reflex present? Yes/No Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Is there any spontaneous respiration

within 5 (five) minutes following

disconnection from the ventilator?

Arterial Blood Gas pre apnoea test:

(Starting paCO2 should be > 6.0 KPa)

(Starting pH should be <7.4)

1st Test

StartingpaCO2:

StartingpH:

2ndTest

StartingpaCO2:

StartingpH:

Arterial Blood Gas Result post apnoea

test: (paCO2 rise should be > 0.5 KPa)

1st

Test

Final paCO2:2ndTest

FinalpaCO2:

AncillaryInvestigationsUsedtoConfirmtheDiagnosis Is there a need for any ancillary

investigations? Yes/No

Yes/No

If yes please outline the results of these investigations:

CompletionofDiagnosis

Are you satisfied that death has been

confirmed following the irreversible

cessation of brain-stem-function?

Yes/No

Yes/No

Legal time of death is when the 1st

Test

indicates death due to the absence of

brain-stem reflexes.

Death is confirmed following the 2nd

Test.

Date:

Time:

DrOneinitialsDrTwoinitials

Date:

Time:

DrOneinitialsDrTwoinitials

PatientName: NHSNumber:



October 2012 3



Itremainsthedutyofthe twodoctorscarryingout the testingtobe satisfiedwith theaetiology, the

exclusionofallpotentiallyreversiblecauses,theclinicaltestsofbrain-stemfunctionandofanyancillary

investigationssothateachdoctormayindependentlyconfirmdeathfollowingirreversiblecessationof

brain-stemfunction.

GuidanceSummaryoftheAoMRCCodeofPractice

Thediagnosisofdeathbyneurologicalcriteriashouldbemadebyatleasttwomedicalpractitionerswho have been registered for more than five years and are competent in the conduct and

interpretationofbrain-stemtesting.Atleastoneofthedoctorsmustbeaconsultant.Testingshould

beperformedcompletelyandsuccessfullyontwooccasionswithbothdoctorspresent.

EvidenceforIrreversibleBrainDamageofKnownAetiology

• There should be no doubt that the patient’s condition is due to irreversible brain damage of

knownaetiology.

• Occasionally it may take a period of continued clinical observation and investigation to be

confidentoftheirreversiblenatureoftheprognosis.Thetimingofthefirsttestandthetiming

betweenthetwotestsshouldbeadequateforthereassuranceofallthosedirectlyconcerned.• Itissuggestedthatthereisaminimumoftwenty-fourhours,ofcontinuedclinicalobservation,in

patientswhere anoxicdamage following cardiorespiratoryarrest, is theaetiology of thebraininjury,andiftreatmentincludedinducedhypothermia,theobservationperiodshouldcommence

followingre-warmingtonormothermia.

Children(oneexaminingdoctorshouldnormallybeapaediatricianorshouldhaveexperience

withchildrenandoneofthedoctorsshouldnotbeprimarilyinvolvedinthechild’scare)

• Olderthan2months:Thisguidelinecanbeusedinchildrenolderthan2monthsofage.

• Between thirty seven weeks gestation to 2 months of age: given the current state ofknowledge,itisrarelypossibletoconfidentlydiagnosebrain-stemdeathinthisagegroup.

• Infantsbelow37weeksgestation:theconceptofbrain-stemdeathisinappropriateforinfantsinthisagegroup.

Drugs

• The patient should not have received any drugs that might be contributing to the

unconsciousness, apnoea and loss of brainstem reflexes (narcotics, hypnotics, sedatives or

tranquillisers);norshouldtheyhaveanyresidualeffectfromanyneuromuscularblockingagents

(atracurium,vecuroniumorsuxamethonium).

• Renalorhepaticfailuremayprolongmetabolism/excretionofthesedrugs.

• Wherethereisanydoubtspecificdruglevelsshouldbecarriedout(midazolamshouldbeless

than<10mcg/L,thiopentone<5mg/L),residualneuromuscularblockadeshouldbetestedforbyperipheral nerve stimulation.Alternativelyancillaryinvestigationsmaybeused toconfirmthe

clinicaldiagnosis.

Temperature,Circulatory,MetabolicorEndocrineDisorders

• Ifthecoretemperatureis≤34°Cbrainstemtestingcannotbecarriedout.

• Priortotestingthemeanarterialpressureshouldbeconsistently>60mmHg(orageappropriate

parametersforchildren)withmaintenanceofnormocarbiaandavoidanceofhypoxia,acidaemia

oralkalaemia(PaCO2<6.0KPa,PaO2>10KPaandpH7.35–7.45).

• SerumNa+shouldbebetween115-160mmol/L;SerumK+shouldbe>2mmol/L;SerumPO43-and

Mg2+shouldnotbeprofoundlyelevated(>3.0mmol/L)orlowered(<0.5mmol/L)fromnormal.

• Bloodglucoseshouldbebetween3.0-20mmol/Landshouldbetestedpriortoeachbrain-stem

test.

• If there isany clinicalreason toexpect endocrine disturbances then it isobligatory toensureappropriatehormonalassaysareundertaken.



October 2012 4



BrainStemReflexes

• Pupilsshouldbefixedindiameterandunresponsivetolight.

• Thereshouldbenocornealreflex(careshouldbetakentoavoiddamagetocornea).

• Nystagmusoranyeyemovementshouldnotoccurwheneachearisinstilled,overoneminute,

with50mlsoficecoldwater,head30o

.Eacheardrumshouldbeclearlyvisualisedbeforethetest.• Thereshouldbenomotorresponsewithinthecranialnerveorsomaticdistributioninresponse

tosupraorbitalpressure.Reflexlimbandtrunkmovements(spinalreflexes)maystillbepresent.

• Thereshould benogag reflex following stimulation to the posterior pharynx orcough reflex

followingsuctioncatheterplaceddownthetracheatothecarina.

ApnoeaTest

• End tidalcarbondioxidecan beused toguide the startingof eachapnoea test but should not

replacethepreandpostarterialpaCO2.

• Oxygenationandcardiovascularstabilityshouldbemaintainedthrougheachapnoeatest.

• EnsurethepaCO2>6.0KPaandthepH<7.4.InpatientswithchronicCO2retention,orthose

whohavereceivedintravenousbicarbonate,ensurethepaCO2>6.5KPaandthepH<7.4.

• Disconnectthepatientfromtheventilatorandadministeroxygenviaacatheterinthetracheaatarateof>6L/minute.IfoxygenationisaproblemconsidertheuseofaCPAPcircuit.

• There should beno spontaneous respirationwithin aminimum of 5 (five) minutes followingdisconnectionfromtheventilator.

• ConfirmthatthePaCO2hasincreasedfromthestartinglevelbymorethan0.5KPa.

• At the conclusion of the apnoea test, manual recruitmentmanoeuvres should be carried outbeforeresumingmechanicalventilationandventilationparametersnormalised.

AncillaryInvestigations

• Ancillary investigations areNOT required for the diagnosis and confirmation of death usingneurological criteria. Any ancillary or confirmatory investigation should be considered

ADDITIONAL to the fullest clinical testing and examination to the best of the two doctorscapabilitiesinthegivencircumstances.

OrganDonation

• National professional guidance advocates the confirmation of death by neurological criteria

whereverthisseemsalikelydiagnosisandregardlessofthelikelihoodoforgandonation.

• NICE guidance recommends that the specialist nurse for organ donation (SN-OD) should be

notifiedat thepointwhenthe clinicalteamdeclarethe intentionto performbrain-stemdeath

testsandthisissupportedbyGMCguidance.

References

AcademyofMedicalRoyalColleges(2008)“ACodeofPracticefortheDiagnosisandConfirmationof

Death”http://www.aomrc.org.ukGMC (2010) “Treatment and care towards the end of life.” www.gmc-

uk.org/guidance/ethical_guidance/end_of_life_care.asp

Heranetal (2008)“Areviewofancillarytestsinevaluatingbraindeath.”CanJNeurolSci;35:409–19NICE(2011)“OrganDonationforTransplantation”http://guidance.nice.org.uk/CG135

Report from the Organ Donation Taskforce (2008) “Organs for Transplant”

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/

DH_082122MapofMedicinehttp://organdonor.mapofmedicine.com/

WijdicksE(2001)“TheDiagnosisofBrainDeath”NEJM344:1215-21.

FormauthorshipandfeedbackThisformwaswrittenbyDrDaleGardiner,NottinghamandDrAlexManara,[email protected]

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Diagnosis of Death Abbreviated