How do you go about pronouncing death?

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Angry Birds

Angry Birds

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What criteria do you use?
What time do you use?
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I always use ultrasound. Even if there is PEA I can take a vid of a dead heart on US and put into epic under imaging. No one will dispute this and it's easy to do.

The time I take the video
 
Angry Birds said:
What criteria do you use?
What time do you use?
Click to expand...

My criteria are: not breathing, no pulse, resuscitation efforts have stopped.

I obviously use other things like the rhythm strip and POCUS to help me decide how long to continue resuscitative efforts, but I don't have electrographic or echographic criteria for declaring death.

I record time of death as whenever CPR was stopped. There is some talk that we should be using time of arrest as time of death, but that doesn't seem to have caught on yet in institutions I've worked in. I would like to switch to that as it seems to make more sense to me (they died when their heart stopped beating, we just failed to bring them back with CPR).

I assume you don't care about brain death.
 
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gro2001 said:
My criteria are: not breathing, no pulse, resuscitation efforts have stopped.

I obviously use other things like the rhythm strip and POCUS to help me decide how long to continue resuscitative efforts, but I don't have electrographic or echographic criteria for declaring death.

I record time of death as whenever CPR was stopped. There is some talk that we should be using time of arrest as time of death, but that doesn't seem to have caught on yet in institutions I've worked in. I would like to switch to that as it seems to make more sense to me (they died when their heart stopped beating, we just failed to bring them back with CPR).

I assume you don't care about brain death.
Click to expand...

By time of arrest, you mean the moment before you initiate CPR?

OK, let's say the patient is DNR. In that case, do you have a specific time you wait (2-5 minutes) to confirm no breathing or pulse during that time period?

As for brain death, I've never used it. Anyone have a different experience in the ER?
 
AlmostAnMD said:
I always use ultrasound. Even if there is PEA I can take a vid of a dead heart on US and put into epic under imaging. No one will dispute this and it's easy to do.

The time I take the video
Click to expand...

OK, what do you do if the patient is dying and you consider CPR futile. Do you just stop CPR and then wait at the bedside until they die, using u/s to confirm death and then use that as the time of death?
 
Excluding hypothermic arrest:
-I will call a code if there are signs of lividity upon presentation.
-If no signs of lividity, but there's been prolonged resuscitation efforts (30min) I will call a code if there is no pulse and no respiratory effort and no pupillary response.
-If downtime is unknown or a short resuscitation I will search for reversible causes and often do a POCUS before calling a code.
-If it's a kid, I'll run the code much longer. Less because I expect a different outcome & more to ensure the team feels that we've tried everything we can.
 
Angry Birds said:
OK, what do you do if the patient is dying and you consider CPR futile. Do you just stop CPR and then wait at the bedside until they die, using u/s to confirm death and then use that as the time of death?
Click to expand...
IDK what you mean by "if they're dying" but then say "stop CPR."

If you're doing CPR, they're dead. There is no need to "wait at the bedside until they die." Just record the time. I also typically record TOD as when we stop doing compressions, but like @gro2001 said, the real TOD should be the time of arrest. I think part of why it hasn't caught on is that a bunch of arrests are unwitnessed so you don't know the actual time. You can, however, look at the clock when you stop compressions.
 
Cardiac electrical activity is /= life. If you stop chest compressions and wait for the monitor to show asystole to declare TOD then your charting is going to look weird, with a documented gap where you're not doing any interventions.. If TOD is when the arrest started, do you update time if they develop ROSC during the code?
 
OK, so this thread confirms what I thought. There is no uniform practice amongst us ER docs.

BoardingDoc said:
IDK what you mean by "if they're dying" but then say "stop CPR."

If you're doing CPR, they're dead. There is no need to "wait at the bedside until they die." Just record the time. I also typically record TOD as when we stop doing compressions, but like @gro2001 said, the real TOD should be the time of arrest. I think part of why it hasn't caught on is that a bunch of arrests are unwitnessed so you don't know the actual time. You can, however, look at the clock when you stop compressions.
Click to expand...

So, I know we say that the patient "came back to life," but unless you believe in multiple lives and reincarnation (or at least reanimation), then the patient did not actually die when you brought them back. They were, rather, on the brink of death.
 
The key to all resuscitation is to know when to quit. I've seen some colleagues flog 80 year old out-of-hospital arrests for an hour before calling it. I usually do a "one and done" epinephrine on these as most of the time EMS has already worked them for at least 30 min.
 
GeneralVeers said:
The key to all resuscitation is to know when to quit. I've seen some colleagues flog 80 year old out-of-hospital arrests for an hour before calling it. I usually do a "one and done" epinephrine on these as most of the time EMS has already worked them for at least 30 min.
Click to expand...
La Cumbre Lines said:
Not necessarily. You likely are just having a difficult time palpating a pulse, which isn’t surprising given how limited it is to use a Stone Age medical device such as a finger to check a pulse. Depending upon all of the factors including duration of arrest and suspected brain perfusion with ability to make a good neurological recovery, I’d put in an arterial line and try to optimize perfusion/pressure. If you have a waveform, you have an objective visual pulse. I’ve seen people survive with this strategy when people couldn’t feel a pulse, granted survival is still infrequent.
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Agreed. In a case of multiple poor prognostic factors (unwitnessed, initial rhythm of bradycardic PEA/asystole, multiple severe comorbidities, etc.) I tend not to use ultrasound to make a decision. If they cannot generate a pulse pressure to produce a palpable femoral, the presence of some underlying cardiac activity is less useful.

That said, if it's a younger person, unclear history, tachycardic PEA, intermittent field ROSC, I'll take a look to assess to see if the LV is slamming away.

RE: OP's question - no palpable pulse after adequate resuscitative effort (which depends on context), I use whatever time is on my watch when I reach the conclusion.
 
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Angry Birds said:
OK, so this thread confirms what I thought. There is no uniform practice amongst us ER docs.



So, I know we say that the patient "came back to life," but unless you believe in multiple lives and reincarnation (or at least reanimation), then the patient did not actually die when you brought them back. They were, rather, on the brink of death.
Click to expand...
Death is a spectrum. Haven't you seen the princess bride?

qr8YJhq.jpg
 
I am adamant about using ultrasound. Our shop is a very busy one with a lot of codes. Two patients THAT I KNOW OF in the last year (not mine) have been pronounced dead then a few minutes later someone finds them breathing. Both still had bad outcomes, yeah, but it's the idea of not actually being able to know for CERTAIN that drives me to US.

One of those patients actually made it to the ICU after being pronounced and the chart had already been dead-ified. Apparently once you do that it's a bitch to undo and no one could add any official notes to medical record in the following 12 hrs the patient was actually alive.

All preventable by US, or so I theorize.
 
AlmostAnMD said:
I am adamant about using ultrasound. Our shop is a very busy one with a lot of codes. Two patients THAT I KNOW OF in the last year (not mine) have been pronounced dead then a few minutes later someone finds them breathing. Both still had bad outcomes, yeah, but it's the idea of not actually being able to know for CERTAIN that drives me to US.

One of those patients actually made it to the ICU after being pronounced and the chart had already been dead-ified. Apparently once you do that it's a bitch to undo and no one could add any official notes to medical record in the following 12 hrs the patient was actually alive.

All preventable by US, or so I theorize.
Click to expand...
So you see some cardiac activity on ultrasound, you continue to do CPR until they progress to zero activity?
 
I don't count valvular activity, I only count ventricle activity as a sign of life. Occasionally I have a code with a few valves fluttering but total ventricular standstill. However, that still results in zero perfusion of any organ, so patient = dead. I haven't come across a situation yet where it takes an inordinate amount of time for ventricles to stop. They usually **** or get off the life bucket quickly.
 
Angry Birds said:
By time of arrest, you mean the moment before you initiate CPR?

OK, let's say the patient is DNR. In that case, do you have a specific time you wait (2-5 minutes) to confirm no breathing or pulse during that time period?

As for brain death, I've never used it. Anyone have a different experience in the ER?
Click to expand...

Yes, the discourse is shifting to the idea that we should be declaring time of death as the time that they were discovered to have lost their pulse. That's when they died. Otherwise we are saying that they were alive throughout our attempts at resuscitation and what killed them is us stopping CPR. Which is usually not true, and is a heavy burden for everyone involved to carry.

For people who I have not attempted to resuscitate I don't have a specific time period. I take a couple of minutes to make sure they in fact don't have a pulse, listen to the heart and lungs a little longer than I normally do, but don't have a specific time period that I deem necessary.

Yes, no one should be doing brain death testing in the ER. I only mentioned it because that is also declaring death (brain death is death, time of death on certificate is time brain death testing is complete) and has strict criteria.
 
Honestly, we should have a standardized rule. For > 60 yo with no signs of life after 30 min (including EMS), any efforts should be terminated. Even if they get a pulse back after that time, there is zero chance of a good neurologic outcome.
 
Agreed on standardizing. Certain local EMS units have a policy on pronouncing a patient in the field after 20 minutes of CPR with a patient in asystole with no ROSC. But unfortunately it's not across the board.
 
bravotwozero said:
Agreed on standardizing. Certain local EMS units have a policy on pronouncing a patient in the field after 20 minutes of CPR with a patient in asystole with no ROSC. But unfortunately it's not across the board.
Click to expand...

The reimbursement for on-scene treatment is abysmal. Private ambulance services will always opt to transport instead of tying up their units onscene for little reimbursement. It's sad, but that's how it is. I've advocated to no avail that CMS should have a cardiac arrest treatment reimbursement code that will reimburse a set amount regardless if patient was transported or not. I don't get it. They fail to act on it, but instead it causes unnecessary transports and even more bills in the ER for someone who isn't going to survive.

Most protocols say a non-shockable rhythm (asystole or PEA) with 20 minutes of CPR and 2 rounds of epi should be considered for field termination.
 
southerndoc said:
The reimbursement for on-scene treatment is abysmal. Private ambulance services will always opt to transport instead of tying up their units onscene for little reimbursement. It's sad, but that's how it is. I've advocated to no avail that CMS should have a cardiac arrest treatment reimbursement code that will reimburse a set amount regardless if patient was transported or not. I don't get it. They fail to act on it, but instead it causes unnecessary transports and even more bills in the ER for someone who isn't going to survive.

Most protocols say a non-shockable rhythm (asystole or PEA) with 20 minutes of CPR and 2 rounds of epi should be considered for field termination.
Click to expand...
25 years ago, our protocols allowed code and leave them. Our private service never, ever, ever told us to take all codes to the hospital. And, we were ALL about the $$.
 
Angry Birds said:
OK, what do you do if the patient is dying and you consider CPR futile. Do you just stop CPR and then wait at the bedside until they die, using u/s to confirm death and then use that as the time of death?
Click to expand...

If I have a dying patient who is DNR I ask family to come back and be with them. I will usually keep on the monitor, although sometimes not. at some point the nurse says "the pt's dying or dead", I walk in, look to see if they are breathing, check a pulse, flash a light in their eyes, offer my sympathies, and pronounce them dead whatever time that is. I'm not going to plop an US on their chest to see if there is myocardial contraction. That will just muddy the picture for the family.

Accuracy down to the level of the minute isn't important here.

We all know more or less when a patient is functionally dead, it matter not whether their super weak heart contraction can produce a systolic BP of 10.
 
turkeyjerky said:
I think in austrailia they don't attempt resuscitation in patients with unwitnessed arrest with initial asystole. To me, this seems extremely reasonable.
Click to expand...

agreed

but there are TV shows here of miracles occurring!

Any medical problem whose first rhythm is asystole should probably not undergo CPR.
 
WilcoWorld said:
Excluding hypothermic arrest:
-I will call a code if there are signs of lividity upon presentation.
-If no signs of lividity, but there's been prolonged resuscitation efforts (30min) I will call a code if there is no pulse and no respiratory effort and no pupillary response.
-If downtime is unknown or a short resuscitation I will search for reversible causes and often do a POCUS before calling a code.
-If it's a kid, I'll run the code much longer. Less because I expect a different outcome & more to ensure the team feels that we've tried everything we can.
Click to expand...

All very reasonable. The hypothermia thing is interesting. Some people are hypothermic because they are dead. Others are hypothermic because they are in an environment to cause them to become hypothermic. Like they fell into a cold lake or are naked outside on the ground when it's 5 degrees out. The worst are those who are dead and outside naked when it's 5 degrees out and they have two reasons to be hypothermic.

If there is really no good reason to be hypothermic and the pt is...then they are probably stone cold dead and we should stop all resus efforts immediately. e.g. 72 yo man went to bed last night normal, and in the AM was found in his bed cold, unresponsive and in asystole. I'm not going to warm that guy.
 
La Cumbre Lines said:
Not necessarily. You likely are just having a difficult time palpating a pulse, which isn’t surprising given how limited it is to use a Stone Age medical device such as a finger to check a pulse. Depending upon all of the factors including duration of arrest and suspected brain perfusion with ability to make a good neurological recovery, I’d put in an arterial line and try to optimize perfusion/pressure. If you have a waveform, you have an objective visual pulse. I’ve seen people survive with this strategy when people couldn’t feel a pulse, granted survival is still infrequent.
Click to expand...

I'm a little weary of this. And of course there is judgement.

If CPR produces a great pulse....and stopping CPR produces no pulse, then they unlikely have enough "native" perfusion. You can dick around if the art line says 32/12, but that is for all intents and purposes dead.

Now occasionally we can't feel a pulse at all. And we have reason to think they can have a perfusing cardiac rhythm. If the monitor looks like
normal.png


you better sure as hell make sure they don't have a pulse via ultrasound. That is a perfusing rhythm. Remember it's the myocardium making the electrical signal and not the purkinje fibers.

I have done femoral US in someone who is pulseless, realized there is a very loud "swish swish" on the doppler, and I continue to treat them as if they have a pulse.
 
turkeyjerky said:
I think in austrailia they don't attempt resuscitation in patients with unwitnessed arrest with initial asystole. To me, this seems extremely reasonable.
Click to expand...

Not sure about the rest of Australia, but clinical practice guidelines for Melbourne are that it's not recommended to begin resus in unwitnessed cardiac arrests with asystole if the estimated downtime between collapse and ambos on scene exceeds 10 minutes (including whether or not bystander CPR is being done). I don't actually work in the industry, so I'm not sure how many would still go through the motions depending on family members or bystanders presents, or if it's child vs adult.
 
thegenius said:
All very reasonable. The hypothermia thing is interesting. Some people are hypothermic because they are dead. Others are hypothermic because they are in an environment to cause them to become hypothermic. Like they fell into a cold lake or are naked outside on the ground when it's 5 degrees out. The worst are those who are dead and outside naked when it's 5 degrees out and they have two reasons to be hypothermic.

If there is really no good reason to be hypothermic and the pt is...then they are probably stone cold dead and we should stop all resus efforts immediately. e.g. 72 yo man went to bed last night normal, and in the AM was found in his bed cold, unresponsive and in asystole. I'm not going to warm that guy.
Click to expand...
True story - it's only anecdotal, but, in my EMS days, the "woke up dead today" group were always warm, because they were warm when alive, and under the covers.
 
La Cumbre Lines said:
I think we pretty much agree and are on the same page. I also will occasionally US with doppler/color the femoral artery. I’ve just seen so many times where a central arterial line pressure is wildly different than a manual cuff pressure, and a ‘pulseless’ patient has a great arterial waveform with a decent pressure. Certainly there are times where the arterial waveform is weak sauce and the pressure is in the tank. If there is great squeeze on US, then I think an arterial line might be beneficial depending upon the circumstances.
Click to expand...

I've always argued for a-line support in the ED for this very reason. It's not often...but occasionally a quick a-line can provide very valuable information to guide resuscitative efforts, especially in the hypotensive pt who is clamped down peripherally preventing you from feeling a pulse. I once got everything stocked in our ED and the nurses trained but we put them in so infrequently that they quickly lost any training they had learned and were not able to get it set up when time mattered.

As for calling it...I think we all approach it in similar ways. I generally always use ultrasound when pronouncing. I think it serves two purposes: 1) Personally, I like to know that there is nothing reversible and I prefer to see tangible diagnostic information to help guide my decision making. 2) It's something that the entire code team can see. When I say that there is no organized ventricular activity and that this resuscitation is a futile effort...everyone can see evidence of my statement on the screen. I like to think it helps prevent any doubt or uncertainty. Also, there's been a few times that I have called the rhythm PEA or asystole only to see some slight quivering of the ventricle more suggestive of v-fib and have defibrillated "PEA" out of suspicion. Most of the time it rarely made a difference.

I also give the code team a heads up when I am preparing to call it. I'll often say "Guys...let's take this one more round and then I'm going to take another look with ultrasound and likely call this code." I also give them an opportunity to speak up and offer any suggestions. I'll say "I want to thank everyone for their efforts, does anyone have any questions or suggestions?" Then I'll call it. I'll naturally document lack of respirations, heart sounds and neurologic activity. I use TOD as when we stopped resuscitative efforts. I think this whole analysis on TOD in the field versus when you stop compressions is a bit of mental masturbation on something that has very little consequence.

If they've been coded for 20-30 mins, most of the time I'm performing a short code and calling it. If the downtime is uncertain, I might take a little more time. I generally go long for kids for all the reasons listed above. Kids will surprise you and I think the code team needs to feel they have adequately contributed to a reasonable resuscitation. I will also bring in the parents sometimes to let them observe. Parents can be understandably unpredictable after a peds code. I once let a mother observe a lengthy code before calling it (smothered baby) and tried laying a comforting hand on the father's back when he arrived to the hospital and almost got punched in the face for not "saving his baby".

The pacemaker geezers...I will put a magnet over the pacer/ICDs to prevent defibrillation but the innate pacing stimulus of the device itself does not prevent me from calling the code though it can be a little weird calling it and seeing the ventricle slightly moving with pacemaker stimulation.

Is anyone routinely doing post-ROSC tracheal intubation and just bagging and/or LMA for the duration of the code until ROSC and then intubating?
 
Last edited:
I never BVM. If they don’t come in with SGA, I’ll put one in immediately. I usually try to change them out fir an ETT after a few rounds, based on the (poorly evidenced and mostly theoretical) decreased cerebral perfusion from carotid compression, as well as anecdotal evidence and personal preference.
 
Yeah if the patient doesn't have a secure airway when they come in while coding, I make sure they end up with one before pronouncing them.
 
The reason I ask is due to the shift in thinking and practice since the updated 2015 AHA guidelines showing some evidence that delayed intubation past the first 15 mins, assuming satisfactory BVM, showed improved outcomes.

I was trained to tube in the first 15 mins but slowly have started changing my practice since 2015 when the new guidelines were released. Before...where I might have never called a code without tracheal intubation, it's now not necessarily uncommon for me. It depends on the clinical scenario. I was just curious what the rest of you were doing.

coreem.net

The Role of Intubation in In-Hospital Cardiac Arrest

Recent years have seen a paradigm shift in cardiac arrest from the traditional mantra of airway, breathing circulation (ABC’s) to circulation, airway, breathing (CAB). This change represents the understanding that circulation is of paramount importance and thus, advanced airway management has...
coreem.net coreem.net

pulmccm.org

PulmCCM | Substack

Life, death and the ICU. Click to read PulmCCM, a Substack publication with tens of thousands of subscribers.
pulmccm.org pulmccm.org

pulmccm.org

PulmCCM | Substack

Life, death and the ICU. Click to read PulmCCM, a Substack publication with tens of thousands of subscribers.
pulmccm.org pulmccm.org
 
I’ve seen a few patients come back after cpr stopped over the years. I think most of them had obstructive lung disease and had developed significant elevation in intrathoracic pressure due to being bagged too aggressively. Stop bagging and the pulse comes back in a minute or two. I remember a couple actually surviving.
 
With regard to intubation, it depends on the setting. Obvious primary respiratory arrest try to get a tube in early. Otherwise I wouldn't generally terminate an arrest without a definitive airway but delay tube for a few cycles

Angry Birds said:
As for brain death, I've never used it. Anyone have a different experience in the ER?
Click to expand...

Maybe there's state to state variation in this, but where I've worked a brain death declaration requires 2 separate exams separated by 24 hours (in addition to several other physiologic and lab criteria being met)

Edit: looks like there is state to state variation. Seems like some states will allow 1 exam dependent on timing of the presumed initial insult
 
Last edited:
WheezyBaby said:
With regard to intubation, it depends on the setting. Obvious primary respiratory arrest try to get a tube in early. Otherwise I wouldn't generally terminate an arrest without a definitive airway but delay tube for a few cycles



Maybe there's state to state variation in this, but where I've worked a brain death declaration requires 2 separate exams separated by 24 hours (in addition to several other physiologic and lab criteria being met)

Edit: looks like there is state to state variation. Seems like some states will allow 1 exam dependent on timing of the presumed initial insult
Click to expand...

Yea. A lot of state and even hospital bylaw specific stuff
 
bigtuna said:
I’ve seen a few patients come back after cpr stopped over the years. I think most of them had obstructive lung disease and had developed significant elevation in intrathoracic pressure due to being bagged too aggressively. Stop bagging and the pulse comes back in a minute or two. I remember a couple actually surviving.
Click to expand...

1) Call code
2) Turn off monitor
 
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