PROCEDURE 135 • Death is determined with either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem. • Historically, death had been described as the cessation of circulation and respiration (cardiopulmonary death). The advent of mechanical ventilation and cardiovascular support, however, presented new challenges for determination of death in patients with catastrophic cerebral insults whose cardiopulmonary function could be preserved with complex technology.3,5 • Initial efforts to define death in an age of technologic advancement included the development of the Harvard criteria, which described determination of a condition known as irreversible coma, cerebral death, or brain death.1 • Since the initial introduction of the Harvard criteria, the Uniform Determination of Death Act (UDDA) was published in 1980 and was recommended by the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Biobehavioral Research as a model statute for state legislation defining death.3 • UDDA asserts that “an individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brainstem, is dead. A determination of death must be made in accordance with accepted medical standards.”3 • In cases of either cardiopulmonary or brain death, diagnosis of death requires both cessation of function and irreversibility. • In cardiopulmonary death, cessation of function is determined with clinical examination. • In cardiopulmonary death, irreversibility is confirmed with persistent cessation of functions during a period of observation. • In brain death, cessation of function is determined when clinical evaluation discloses absence of both cerebral and brain stem function. • In brain death, irreversibility is determined when the etiology of the coma is sufficient to account for the loss of brain function is established, the possibility of recovery of brain function is excluded, and the cessation of all brain function persists for a period of observation or therapy.3,5 • The concept of brain death continues to be a topic of international debate among clinicians, anthropologists, philosophers, and ethicists. This ongoing dialogue concerning the determination of death is a process of developing multidisciplinary consensus that is responsive to continually changing technology.6,7 • Although conceptualization of death continues to evolve, experts have generated clinical practice parameters for brain death diagnosis that are grounded in empirical knowledge, supported by sufficiently rigorous research, and substantiated by high degrees of clinical certainty.6,7 • Cardinal findings in brain death include coma or unresponsiveness, apnea, absence of cerebral motor responses to pain in all extremities, and absence of brain stem reflexes, including pupillary signs, ocular movements, facial sensory and motor responses, and pharyngeal and tracheal reflexes. • Legal responsibility for assessment and declaration of death varies by state. Some states permit registered nurses and advanced practice nurses to determine death. • For cardiopulmonary death determination: • For brain death determination:
Determination of Death in Adult Patients
PREREQUISITE NURSING KNOWLEDGE
EQUIPMENT
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135: Determination of Death in Adult Patients
