Death is a process, and every process has a moment.

Death. The clinical significance.

We arbitrarily define death as the moment when a person simultaneously becomes apnoeic, unconscious, with an absent circulation. The moment of death, and therefore its diagnosis, is of paramount importance to the practising clinician, given an ever-expanding and utterly crucial organ transplant program. Timely confirming death enables clinicians to harvest body organs from consenting donors with as minimal damage as possible due to hypoxia. It is, therefore, imperative that as a practising health care worker, you timely recognise death.  In today’s article, we highlight the criteria for diagnosing death and its clinical significance.

Death is a process, and every process has a moment. We ought to identify it. Following a tragic accident, it may be easy to confirm death to the victim. However, the process isn’t the same for a person undergoing cardiopulmonary resuscitation for which the attempts have become futile or a patient in an intensive care unit on mechanical ventilation whose clinical status has plummeted.

As the accident and emergency care services sprout and steadily improve, with a robust transport system, clinicians will receive more acutely ill patients that may not survive despite all the care. Such patients may have consented to donate their organs in the afterlife. So, a timely diagnosis of death will become more crucial than ever. A consensus is that five minutes after the heart has stopped and there’s no central pulse, the brainstem suffers irreversible damage. Clinicians must confirm the absence of pupillary responses to light, corneal reflex, and motor response to supra-orbital pressure. It is at this juncture that they diagnose death.

A Good Death. What Constitutes Successful Dying?

The UK brain criteria have three components.

First, the patient must suffer from a condition that has led to irreversible brain damage. Second, clinicians must rule out all the potentially reversible causes.

Third, clinicians must have formally demonstrated coma, apnoea, and absent brainstem reflexes.

The following brainstem reflexes must be absent: pupils unresponsive to light. The corneal reflex is absent. Oculo-vestibular reflexes absent. No motor movement occurs when any cranial nerve undergoes stimulation. No gag or cough reflex occurs upon stimulation. Lastly, an apnoeic test shows no respiratory response.

In many remote settings, nurses and midwives continually diagnose death in the absence of doctors. However, it is imperative that two doctors registered for at least five years, one of whom is a consultant, confirm the death of any person. It minimises the probability of burying an alive person who is deeply comatose. It’s believed that many people in resource-limited countries die after burial due to the profound lack of experienced health care workers who can diagnose death with utmost satisfaction.

A timely diagnosis, especially for patients on mechanical ventilation, allows caretakers time to decide when to halt such support and if the dead would wish to donate their organs. More people globally are in dire need of organs to survive.

Death is an inevitable consequence of life. However, in medical practice, we regard it as a medical failure. We trained to prevent death but not postpone it.

The ability to regard it as a medical failure has driven the pursuit of clinical audits – to ascertain the cause of death, that if it was a preventable one, we ought to do better. The advancement in maternal and perinatal death reviews have led to a substantial reduction in the number of pregnant women who succumb during pregnancy and childbirth. To audit death in clinical care allows health care providers a window of opportunity to prevent a similar outcome in another unsuspecting victim.

The dead allow pathologists and forensic specialists to analyse the dead and study diseases in great detail. Such insights have improved the care for the living. For example, clinicians have understood how Covid-19 affects the lungs and other body organs using autopsy reports. For that matter, death becomes a necessary evil.

In treating people with debilitating diseases, clinicians must assert that patients die in dignity with satisfaction. It becomes imperative that as a health care provider, you do whatever you can to prevent the catastrophe, including a timely referral to a higher setting or a consult from senior doctors. There’s a reason they exist.

In a nutshell, death is the enemy we all fight with but wins in the end. Health care workers trained to prevent but not postpone it. A timely death diagnosis allows organ donation with minimal hypoxic damage. Doctors must always diagnose death and not leave it to nurses and midwives, especially in resource-limited settings.

We sought help from the Oxford Handbook of Clinical Medicine to prepare today’s article. Grab a copy from here.

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