Signs

The principal clinical signs of death are apnea and asystole. Other indications, including loss of cranial nerve reflexes and the cessation of the electrical activity of the brain, may be necessary for those receiving mechanical life support.

Patient care

Legal procedures and institutional protocols should be followed in the determination of death. The times of cessation of breathing and heartbeat are documented, and the physician or other legally authorized health care professional is notified and asked to certify death. The family is notified according to institutional policy, and emotional support is provided. Auxiliary equipment is removed, but the hospital identification bracelet is left in place. The body is cleansed, clean dressings are applied as necessary, and the rectum is packed with absorbent material to prevent drainage. The deceased is placed in a supine position with the limbs extended and the head slightly elevated. Dentures are inserted, if appropriate; the mouth and eyes are closed; and the body is covered to the chin with a sheet.

The deceased's belongings are collected and documented. Witnesses should be present, esp. if personal items have great sentimental or monetary value. The family is encouraged to visit, touch, and hold the patient's body as desired. In some situations (as in neonatal death or accidental death) and according to protocol, a photograph of the deceased is obtained to assist the family in grieving and remembering their loved one. A health care professional and a family member sign for and remove the patient's belongings.

After the family has gone, the body is prepared for the morgue. Body tags, imprinted with the patient's identification plate or card information (name, identification number, room and bed number, attending physician), along with the date and time of death, are tied to the patient's foot or wrist as well as to the outside of the shroud. The body is then transported to the morgue and placed in a refrigerated unit according to protocol.

CAUTION!

Patient care

The determination of brain death has both medical and legal consequences. It establishes a criterion for the withdrawal of life support from the critically ill who no longer have measurable brain function. At the same time it may initiate a discussion with family members of the deceased about organ donation. Those who have unequivocally specified that they would like to donate their organs at death currently make up a very small percentage of the population. Most of those who die have not made plans for organ donation, and some (such as those who die from trauma) may have never considered making a living will, a directive to physicians, or plans for organ donation. Discussions with family members in the immediate postmortem period may be emotionally challenging both for health care professionals and the grieving.

Brain death differs from the death of the heart, lungs, or other internal organs, and family members may often be confused about its meaning. They may wonder why they can still observe evidence of cardiac activity or effective mechanical ventilation. Family members may be unwilling to consent to withdrawal of ventilator support even when clinicians recognize that continued treatment will be of no benefit. There is a procedure to protect the rights of patients and their families in resolving disputes when family members do not agree with clinicians’ decisions regarding discontinuance of life support in situations of medical futility. It is important for health care providers to explain that the brain-dead patient may still have an active heart rhythm but no longer has the ability to think, see, hear, or feel. The pulse and breath of the brain-dead patient can be artificially maintained for a short time. The central nervous system has already failed. If organ donation is being considered, an expert counselor should discuss this with the next of kin and help make the necessary arrangements. For some families, organ donation by the deceased provides some solace at a time of deep loss. If time is needed for a significant loved one to be present with the patient before he or she is removed from life-support, the involved physicians should be notified and a time arranged. It is often helpful for families to do this. If a close family member cannot be present and the family is concerned about this, it may help them to have a photograph of the patient once he or she has died that can be shared with others. After life support has been withdrawn, it is considerate to provide private time for the family to be with the deceased, supporting them as necessary. A hospital chaplain or the patient’s or family’s priest, rabbi, minister, or pastor will often provide spiritual comfort for survivors in addition to the support and comfort provided by professional staff.

A defibrillator may be used with conductive pads applied to the chest wall or may be surgically implanted in the chest, e.g., in patients who have previously been resuscitated from sudden death.