Makindo Medical Notes

⚖️ There are regional differences across the UK, but the core legal and professional principles remain the same. ⏱️ A careful assessment must be performed, lasting at least 2 minutes.

ℹ️ About

• 💀 Death is a process involving the cessation of physiological functions. The determination of death is the final event in that process.
• ❤️🫁 For most, this is confirmed by irreversible cessation of cardiorespiratory function. For some (e.g. on ITU ventilators), brainstem testing is required.
• 🫀 Being ventilated does not necessarily equate to being alive if brainstem function is lost.
• 🔄 Brain death and circulatory death are not separate entities but two routes to identifying the same endpoint: death.

📝 Confirming Death in Usual Clinical Practice

• 🧼 Wash hands, identify the patient, draw screens around. Take time. Be sensitive to family presence.
• ⏳ Assess over ~5 minutes (some steps simultaneously):
• 🫀 Absence of carotid/femoral pulse.
• 🎧 Absence of heart sounds on auscultation.
• 🫁 Absence of breathing/respiratory effort.
• 👁️ Absence of pupillary responses to light (usually fixed and dilated).
• 📖 Record the time of death as the time these criteria are met. Document findings, date, time, GMC number. Speak with family, offer condolences, and direct them to bereavement services.

🧪 Instrumental Tests (if indicated)

• 📉 Asystole or pulseless electrical activity on continuous ECG.
• 📊 Absence of pulsatile flow on intra-arterial monitoring.
• 🖤 Absence of cardiac contractility on echocardiography.
• ⚠️ These are not mandatory, but may be required in patients on advanced life support or in critical care when withdrawing therapy.

🧠 Brain Death Criteria

Definition: Coma + absent brainstem reflexes + apnoea (with confirmed aetiology of catastrophic brain injury).

• 🚫 Exclude confounders: depressant drugs, neuromuscular blockade, severe metabolic/acid-base disturbances, hypothermia (<32°C).
• 🧾 Confirm known aetiology (structural brain damage, imaging, clinical context).
• ❌ Brainstem reflexes absent: pupillary, corneal, vestibulo-ocular, facial motor, gag, cough.
• 🫁 Apnoea confirmed in presence of raised PaCO₂ (>6 kPa / 60 mmHg, pH <7.30).
• 👩‍⚕️👨‍⚕️ Two examinations ≥2 hours apart, each by separate, appropriately trained doctors (registrar grade or above).
• 🧪 Angiography or ancillary tests if assessment incomplete (e.g. ocular injury).
• 👶 Modified criteria apply for children under 1 year due to greater recovery potential.

📚 References

• 📑 Academy of Medical Royal Colleges: Code of Practice for the Diagnosis and Confirmation of Death (UK)
• 🌍 WHO Technical Expert Consultation: Clinical Criteria for the Determination of Death