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Death

Last updated: November 2, 2023

Summarytoggle arrow icon

Death is the cessation of life, but where life ends and death begins is not always clear. In medical contexts, a distinction is drawn between cardiopulmonary death (irreversible cessation of heartbeat and respiration) and brain death (irreversible cessation of all brain and brainstem function). Considering that pronouncing death is usually a physician's responsibility, it is important to know the signs of death and the differences between reversible and irreversible clinical death. If there is a delay before death has been pronounced or the events leading up to death are unclear, knowing irreversible postmortem changes also helps in determining both the manner and time of death. These changes may be of medical and/or legal interest and include rigor mortis, livor mortis, Tardieu spots, and decomposition. When pronouncing death, it is important to understand the events leading up to death, if it was expected or not, and to conduct a careful examination before declaring the death and its time. Since addressing family and friends after death is a very emotional and vital responsibility, clinicians should be prepared by having a clear approach for dealing with this situation. In addition, special documentation must be handled, including writing a death note, death summary, and death certificate. Important steps should also be considered if the patient is a potential donor candidate or if a medical examiner/coroner should be notified for further investigation and possibly an autopsy. Clinical autopsies are performed for the purpose of medical diagnosis and research, while forensic (i.e., medicolegal) autopsies are performed for the purpose of establishing the cause and manner of death, especially if there is evidence of foul play.

Overviewtoggle arrow icon

  • A number of ethically challenging scenarios may arise in the context of end-of-life care.
  • At the end of life (as throughout life), the core ethical principles of medicine should be upheld and the physician should act in the best interest of the patient.
  • Proper knowledge of the legal and ethical aspects of end-of-life care allows the physician to practice efficient and evidence-based medicine while respecting the patient's wishes.
  • In disputes over end-of-life issues, the physician plays a key role in facilitating communication and emphasizing the importance of focusing on what patients themselves would have preferred.

Definitionstoggle arrow icon

  • Death: : An ambiguous term referring to the cessation of life. Death can be diagnosed if a patient meets the criteria for brain death or cardiopulmonary death.
  • Apparent death
    • Reduction of vital function to a minimum, creating the appearance of death without signs of certain death
    • Misdiagnosing apparent death as clinical death can have grave consequences such as postponing vital care, false alarms for organ donation, and unnecessary emotional stress for family members.
  • Clinical death (somatic/systemic death): a term for the cessation of respiration and circulation
    • May be reversible
    • Some descriptions may also consider the loss of brain activity as a component of clinical death.
  • Cardiopulmonary death: irreversible cessation of circulatory and respiratory functions
  • Brain death: irreversible, complete loss of function of the entire brain (including the brainstem), even if cardiopulmonary functions can be upheld by artificial life support
    • Two physicians are required to make the legal diagnosis of brain death.
    • See “Requirements for the diagnosis of brain death” for more information.
  • Intermediary life: the period of time between irreversible cardiopulmonary death and biological death
  • Biological death (molecular/cellular death)
    • Permanent and irreversible cellular damage with complete cessation of metabolic cell function
    • Tissue that has undergone biological death is unsuitable for transplantation.
  • Legal death
    • Recognition of a person's death under the law
    • Legal death comprises medically determined death (e.g., via a doctor's declaration of death) as well as the presumption under the law that a person is dead after a prolonged and unexplained absence with no signs of life (declaration of death in absentia).
  • Uniform determination of death act
    • In the US, legal provisions regarding death and the clinical examinations or legal investigations it may entail vary from state to state.
    • However, all states have adopted the “Uniform determination of death act” (1981), which specifies that the determination of death must be made in accordance with accepted medical standards and depends on either cardiopulmonary death or brain death.

Signs of deathtoggle arrow icon

  • Understanding the signs of clinical death is important for correctly declaring death.
  • Prematurely pronouncing death can have grave consequences, including neglecting potentially vital care, giving false alarms for organ donation, and unnecessary emotional stress for family members.
  • Uncertain signs of death must be considered in relation to certain and irreversible signs of death, such as cardiopulmonary and brain death.
  • If there is a delay before death has been pronounced or the events leading up to death are unclear, irreversible postmortem changes can help also in determining both the manner and time of death.

Uncertain signs of deathtoggle arrow icon

Cardiopulmonary deathtoggle arrow icon

Cardiopulmonary death is the irreversible cessation of circulatory and respiratory functions. The following factors must be considered before making this determination:

  • Monitoring of the patient for a specific period of time to confirm continuous apnea, unconsciousness, and lack of circulation
  • Exclusion of factors that may be the cause of the cardiorespiratory arrest, such as:
  • No intention of beginning or continuing cardiopulmonary resuscitation (CPR); prohibition of any intervention that might restore cerebral blood flow [1]
  • Often synonymous with clinical death, but it is important to understand that clinical death is usually considered to be reversible

Brain deathtoggle arrow icon

Definition

  • The irreversible, complete loss of function of the entire brain (including the brainstem), even if cardiopulmonary functions can be upheld by artificial life support. [2]

Declaring brain death

Declaring brain death requires all of the following:

  • Establish irreversible coma and the possible cause (e.g., acute severe damage to the CNS consistent with brain death as established by clinical or radiologic evidence).
  • Brain death may not be established if one of the following is present in the patient:

Neurological examination

Confirms coma, brainstem areflexia, and apnea.

Ancillary brain death tests

Confounding conditions

Ethical issues concerning brain death [3][4]

  • If a patient has been declared to have brain death, no consent is needed to withdraw life-sustaining therapy.
  • The patient's family should be informed that the patient is being assessed for brain death as soon as the evaluation has started.
  • The patient's family should be given a reasonable amount of time to visit the patient and accept the diagnosis before discontinuation of life-sustaining treatment. [5]
  • If the patient's family disagrees with a diagnosis of brain death:
    • Discuss the family members' concerns with them; express empathy and respect for their position and provide additional information to eliminate any misunderstandings regarding the diagnosis. [6]
    • Involving a hospital ethical committee may be helpful in resolving disagreements. [3]
    • If the disagreement stems from religious or cultural beliefs, consider involving chaplains and/or local cultural leaders in the discussion. [6]

If spontaneous breathing is present, the medulla is intact. If the corneal reflex is present, the pons is intact. If the pupillary light reflex is present, the midbrain is intact.

Postmortem changestoggle arrow icon

With the onset of death, all organisms undergo changes, mainly as a result of decomposition from putrefaction and autolysis, although external factors such as climate and location can also affect the state of a cadaver. Postmortem changes are signs of certain death that can provide information regarding the time, cause, mode, mechanism, and manner of death, as well as whether the location of the body corresponds to the place of death. These changes may be of medical and/or legal interest.

Early postmortem changes

  • Rigor mortis
    • The stiffening of the muscles after death, potentially with muscle shortening
    • Usually occurs within 1–2 hours of death
    • Starts to reside after about 24 hours
    • Caused by persistent attachment of actin to myosin due to lack of ATP
  • Livor mortis
    • Definition: purple-red discoloration of dependent areas of skin not exposed to pressure that begins 20–30 minutes after circulation stops due to blood settling under the force of gravity (hypostasis)
    • Occurrence
      • At least 30 minutes to 2 hours after onset of death [7]
      • Maximum observed at 6–12 hours [8]
    • Location: blood pools in areas of dependency under the force of gravity [9]
      • Person died lying face-up: back of the corpse
      • Hanging death: feet, fingertips and ear lobes [8]
      • Drowning: face, upper chest, hands, lower arms, feet, and calves [10]
      • Lividity is evident on the ear lobes and the nail beds
      • Also occurs in visceral organs (e.g., lungs)
    • Features
      • Redistribution: lividity can be altered up to 6 hours after onset of death [11]
      • Blanching: skin will turn white when applying pressure within the first ∼ 12 hours [12]
    • Color: the intensity of color depends on the amount of hemoglobin in the blood [13]
  • Injuries incompatible with life (e.g., incineration, decapitation)
  • Post mortem clots: separation of red blood cells and plasma creates clots of plasma that resemble “chicken fat” and blackish-red erythrocyte clots that resemble “currant jelly”

Livor mortis occurs approx. 30 minutes to 2 hours after the onset of death and is the first definite sign of death.

Late postmortem changes

  • Decomposition: breakdown of bone and tissue through aerobic and anaerobic processes
  • Vibices: pale marks caused by pressure (e.g. from a rope in hanging death or generally from tight clothing, e.g., socks, belt, and bra)
  • Tardieu spots: dark pinpoint spots develop in dependent areas (e.g., in the legs of a hanged person due to increased gravitational pressure)

Life support and end-of-life issuestoggle arrow icon

Orders and legal considerations in end-of-life care

  • Code status
    • A term used to describe a patient’s expressed preferences regarding cardiopulmonary resuscitation and endotracheal intubation; there are three possible codes:
    • The term is unlikely to be familiar to a layperson; therefore it should not be used in discussion with patients or their family members.
    • A patient's code status should be confirmed verbally with the patient or their appropriate surrogate at each hospital admission, regardless of the previous status, and documented. A patient's code status may nonetheless be unknown at the time vital interventions are necessary.
  • Withdrawal of care [15]
    • Patients with decision-making capacity (or their surrogate) have the right to refuse any form of treatment at any time, even if doing so would result in the patient's death.
    • There is no ethical distinction between withholding care and withdrawing care at a later time.
    • The physician should make an effort to understand the reasons behind the patient's decision for refusing treatment.
    • Patients who opt to withdraw from treatment and have limited life expectancy may be approved for hospice care.
    • Involve palliative care if necessary.
    • Provide extra help and information for families that are interested, e.g., on chaplain services or accessing psychosocial counseling.
  • Futile treatment [16][17]
    • Medical treatment or intervention for a terminally ill patient that is deemed nonbeneficial by the healthcare team or family
      • The concept of medical futility is vague and there are many interpretations of the practice; there is no universally accepted definition.
      • Some believe that futility only applies to end-of-life care, while others apply the term to any medical intervention that appears to lack a significant medical benefit.
    • The physician is not ethically obligated to provide treatment if it is considered medically futile.
    • Treatment can be considered medically inappropriate or futile if:
      • There is no evidence for the effectiveness of treatment.
      • The intervention has previously failed.
      • Last-line therapy is failing.
      • Treatment will not fulfill the goals of care.
  • No escalation of treatment (NEOT) designation
    • An order to continue ongoing treatment but not initiate new or increase the intensity of ongoing treatment, regardless of patient status (comfort measures are generally exempt)
    • Issued by a physician for a terminally ill patient who is not expected to benefit from treatment escalation
  • Persistent vegetative state (PVS): The decision to maintain a patient in PVS depends on their advance directive or surrogate decision-maker and should be made with the patient's best interests in mind. [18]

Standardized forms for end-of-life care directives [19][20]

  • Individuals with life-limiting conditions, multiple chronic conditions, or conditions that cause frailty can begin planning end-of-life care with their health care providers.
  • Standardized advance directive forms such as the Medical Orders for Life-Sustaining Treatment and the Physician Orders for Life-Sustaining Treatment forms allow for documentation of the patient's preferences regarding end-of-life medical care, including the following:
  • The advance directive form can be completed and signed either by the patient or, if the patient lacks capacity, a surrogate.
  • The form is completed after a series of conversations between the patient and health care providers about the patient's medical condition, prognosis, and values and personal goals for end-of-life care.
  • In contrast to a living will or healthcare proxy, which act only if the patient loses decision-making capacity, advance care directive forms apply independent of the decision-making capacity of the patient at the time of application.

Medical aid in dyingtoggle arrow icon

  • Physician-assisted dying [21][22]
    • Physician provision of medication, intervention, or information to a patient to enable or accelerate their death
    • Illegal in most states
    • The U.S. Supreme Court has ruled three times that the laws of physician-assisted death are to be decided on a state-by-state basis.
  • Euthanasia
    • Active and intentional termination of a patient's life, usually by sedative or paralytic, performed by the physician at the explicit request of the patient
    • Requires the full process of informed consent before initiation
    • Currently illegal in the U.S.
  • Terminal sedation [23]
    • The administration of sedative medication to a terminally ill patient to relieve intractable end-of-life pain
    • Legal and distinct from euthanasia
    • The intent must be to relieve pain rather than bring about death, even though doing so may hasten the dying process.
    • Not an appropriate means of addressing suffering that is primarily existential (e.g., death anxiety). [24]
    • Relies on the principle of double effect
      • An ethical principle that legitimizes an act of good intent despite causing serious harm
      • An act may be justified when the positive effects outweigh the negative ones (e.g., administering large amounts of opioids to relieve pain despite causing respiratory depression).

Pronouncing deathtoggle arrow icon

  • Laws regarding who is authorized to pronounce a person clinically and/or legally dead as well as who is authorized to order an investigation into the circumstances of death vary from state to state.
  • If a patient dies while under care, it is generally the physician's responsibility to examine the body to pronounce the death and record the time. Clinicians may also be called to the bedside for declaration of death.
  • In some states, registered nurses (especially in hospice settings) are authorized to pronounce death.
  • If no physician or registered nurse is readily available, a medical examiner or coroner is called to the scene to declare death.
  • Emergency response teams may pronounce a person “Dead on Arrival” (DOA) if certain criteria are met (e.g., obvious postmortem changes or injuries that are incompatible with life such as decapitation or evisceration of thoracic contents).
  • The specific procedures vary depending on the clinical scenario (e.g., cardiac death vs. brain death). Signs of death aid in diagnosing certain death and determining the time of death.

Approach

  • If called to declare death, determine:
    • If it was expected or not
      • If it was unexpected, efforts should be made to go immediately to the patient for assessment.
    • Who has already been informed
    • If family members are present
  • Assess the patient [25][26][27]
  • Pronounce the time of death
    • The official time of death is the time at which the examination confirms death.
    • If family or friends are present, determining the time of death via phone should be avoided. Instead, a watch or wall clock should be used.
  • Determine further information
  • Communicate with loved ones: See “Addressing family and friends after death.”
  • Complete documentation: See “Documentation of death.”

Documentation of deathtoggle arrow icon

Physicians should follow local institutional protocols. They generally include:

Death certificatetoggle arrow icon

  • In the US, the authority to sign death certificates varies from state to state.
  • Generally, physicians are authorized to sign death certificates when the manner of death is natural, whereas in, e.g., violent or suspicious deaths, the authority lies with a coroner or medical examiner.
  • The U.S. Standard Certificate of Death provided by the CDC's National Center for Health Statistics (NCHS) records the following information:
    • To be provided/verified by the funeral director
      • Decedent's personal information (name, address, relations, race, education, occupation, etc.)
      • Place of death
      • Method and place of disposition
      • Funeral facility information
    • To be provided by the medical certifier

Investigation of deathtoggle arrow icon

Reportable types of death

The initial postmortem examination may not provide conclusive information regarding the manner, cause, mechanism, or mode of death. In certain types of death, an investigation is required by law. The specific characteristics of death that require an investigation vary from state to state. Below is a selection of the types of death that most commonly require reporting:

  • Undetermined death
  • Suspicious/unusual/unnatural circumstances
  • Accident/casualty
  • Suicide
  • Violence
  • Homicide
  • Fetal/infant death
  • Sudden death when in apparent good health
  • Abortion/criminal abortion (maternal or fetal)
  • Death from injury
  • Therapeutic death or circumstances suggesting gross negligence in a healthcare setting
  • Death that may constitute threat to public health
  • Death in jail/police custody
  • Drug and/or chemical overdose or poisoning

Professionals involved in the investigation of death

  • Physician
    • Conducts postmortem examination
    • Determines the cause, time, and manner of deaths that occurred under natural circumstances; declares death; issues death certificates
    • Notifies local death investigation office if the type of death requires reporting (e.g., if it occurs under unnatural circumstances)
  • Coroner
    • Elected government official tasked with running the investigation to determine the cause, time, and manner of deaths that occurred under unexpected, violent, and suspicious circumstances or in the absence of a physician
    • Declares death; issues death certificates; initiates inquests; requests autopsies; qualifications, functions, and authority vary from state to state; does not require medical training
  • Medical examiner: medically trained government official qualified to perform autopsies; otherwise similar functions and authority as coroner
  • Forensic pathologist: establishes cause of death and performs autopsy upon the request of the medical examiner or coroner
  • Death investigator: assists the medical examiner/coroner in investigating deaths, focusing on the collection of information on the decedent and guiding the investigation process.

Inquest

  • A legal inquiry before a coroner or medical examiner to establish the identity of the decedent and the time, place, cause, and manner of death.
  • Often involves a jury; inquiries are conducted almost exclusively in the event of deaths taking place under unexpected, violent, or mysterious circumstances.

Manner of deathtoggle arrow icon

The first step in investigating a death is determining the manner by which a person died. If the manner of death is determined to be natural, a further investigation is not legally obligatory, while unnatural manners of death elicit an inquiry into the precise circumstances. The manner of death is distinct from the mode, cause, and mechanism of death in so far as the manner is the root cause of how the death occurred (e.g., “homicide” involving an axe attack), while the cause is the disease or injury that causes death (e.g., an “axe wound”), the mechanism is the physiological derangement that causes death (e.g., “exsanguination” due to an axe wound), and mode is the abnormal physiological state in an individual at the time of death (coma = failure of brain function, syncope = failure of heart function, asphyxia = failure of respiratory system; e.g., “coma” from axe wound). The manner of death is of particular importance because of the legal consequences that inevitably follow any unnatural manner of death.

  • Natural manner of death
    • Due (nearly) exclusively to disease and/or age
    • Patient history characteristic of a specific cause of death
    • Clear and objectifiable findings characteristic of underlying disease
    • No evidence of third-party interference in the course of the disease
  • Unnatural manners of death: death caused by external events or a third party
    • Accident: death from injury or poisoning without evidence of third party intent to kill or cause harm
    • Suicide: death from intentional, self-inflicted injury or poisoning for the purpose of causing self-harm or death
    • Homicide: death from intentional injury or poisoning committed by another person for the purpose of causing fear, harm, or death. Intent is a common element, but it is not required for classification.
  • Could not be determined: applied to deaths in which the manner could not be determined even after consideration of all information available
  • Pending investigation: if determination of the manner of death depends on further information

Types of autopsytoggle arrow icon

Overview

  • Close examination of a body to determine the cause of death; typically involves dissection of the body
  • Many states require that a pathologist performs the autopsy.
  • However, in some states, autopsies may also be performed by medical examiners without a degree in pathology.

Clinical autopsy

  • Purposes
    • Medical investigation into the cause of a natural death (i.e. does not consider the manner of death) and any pre-existing illnesses
    • Diagnosis of diseases that can only be confirmed postmortem (e.g., Parkinson's disease) or where antemortem efforts failed
    • Confirmation that the diagnosis made before death was correct and that the treatments administered were reasonable
    • Requested by next of kin
    • Research
  • Authorization
    • In life: patient or healthcare surrogate
    • Postmortem: next of kin

Forensic autopsy

  • Purposes
    • Medicolegal investigation into the circumstances of unexplained or (possibly) unnatural deaths
    • Establishing the identity of the decedent and the time, place, and manner of death
    • Collect forensic evidence
    • Reconstruct a crime or accident
  • Authorization
  • Characteristics of death that may require a forensic autopsy

Autopsy findingstoggle arrow icon

Signs of vitality (vital reactions)

Signs of vitality (not to be confused with vital signs) are signs that a body was still alive at the time of having sustained damage as opposed to the damage having occurred postmortem.

  • Circulation
    • Signs of exsanguination
    • Signs of venous obstruction
    • Embolisms
  • Metabolism: metabolism of toxins (metabolites of toxins detectable in urine)
  • Respiration
  • Central nervous system
    • Soot-free radial bands beside the eyes (crow's feet) in individuals involved in a fire
    • Evidence of a functioning autonomic nervous system at the time of injury: blood that has been swallowed or coughed up

Signs of vitality provide clues that damage to an organism occurred before the onset of death.

Supravital reactions

Supravital reactions are certain physical functions that persist for some time after the onset of death. They provide specific clues regarding the time of death.

  • Up to 8 hours after onset of death: skeletal musculature
    • Up to 8 hours postmortem: Mechanical stimulation causes slight idiomuscular bulging that may persist for up to 24 hours.
    • 3–5 hours postmortem: Mechanical stimulation causes pronounced reversible idiomuscular bulging.
    • 1.5–2.5 hours postmortem: Zsako's muscle phenomenon, i.e., mechanical stimulation causes propagated excitation
  • Up to 17 hours: pupillary response
  • Up to 80 hours: motile sperm cells

Special circumstancestoggle arrow icon

Evidence of live birth

The condition of the lungs and the gastrointestinal tract can provide evidence of whether an infant was alive at birth or stillborn.

Training healthcare providers on deceased patientstoggle arrow icon

  • Performing procedures on newly deceased patients can provide valuable hands-on training for inexperienced health care providers.
  • Training procedures may be performed if the deceased patient has consented through advanced directives.
    • In the absence of an advanced directive, consent may be obtained from the next-of-kin.
  • If the deceased patient's identity is unknown, health care providers may search through the patient's belongings and share the patient's personal information (e.g., social security number) with authorities to determine their identity and contact next-of-kin. [30]
  • Performing any kind of unnecessary procedure on a deceased person's body without written consent from the patient or the next-of-kin is unethical, regardless of the procedure's degree of invasiveness.
  • If consent is obtained, the patient's body should be treated with respect, and the educational/research procedures should be conducted according to a plan and under direct supervision of an expert.
  • All procedures undertaken on the cadaver should be documented in the patient's medical record.

Referencestoggle arrow icon

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  12. $ETHICAL ISSUES IN THE PERSISTENT VEGETATIVE STATE PATIENT.
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  16. Code of Medical Ethics Opinion 5.7: Physician Assisted Suicide. https://www.ama-assn.org/delivering-care/ethics/physician-assisted-suicide. . Accessed: March 16, 2023.
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