Determination of Death

Pt has no Respirations, no Cardiac activity, no neurologic reflexes and one or more of the following...

1. Decapitation

2. Massive Crush injury.

3. Penetrating or blunt injury with evisceration of the heart, lung or brain

4. Decomposition

5. Incineration

6. Pulseless, non-breathing victims with extrication time greater than 15 min, where no resuscitative measures can be performed prior to extrication.

7. Blunt trauma pts who, based on paramedic's thorough pt assessment, are found apneic, pulseless, and without organized EKG activity upon arrival of EMS. (organized EKG activity is defined as narrow complex supraventricular.)

8. Pulseless, non-breathing victims of a multiple victim incident where insufficient medical resources preclude initiating resuscitative measures.

9. Drowning victims, when it is reasonably determined that submersion has been greater than one hour.

10. Rigor Mortis (requires assessment)

11. Post-Mortem lividity ( requires assessment)

Determination of Death

Required assessment for Pt's with Rigor mortis and/ or Post-Mortem lividity only.

1. Assessment of respiratory status:

  a) Assure that the pt has and open airway.

b) Look, listen and feel for respirations. Auscultate the lungs for a minimum of 30 seconds to confirm apnea.

2. Assessment of cardiac status:

a) Auscultate the apical pulse for a minimum of 60 seconds to confirm absence of heart sounds.

b) Adults and children: Palpate the carotid pulse for a minimum of 60 seconds to confirm absence of pulse.

c) Infants: Palpate the brachial pulse for a minimum of 60 seconds to confirm absence of pulse.

3. Assessment of neurological reflexes:

a) Check for pupil response with a penlight or flashlight to determine if pupils are fixed and dilated.

b) Check and copnfirm unresponsive to pain stimuli.

1. A valid DNR

2. A valid AHCD (Advanced Health Care Directive)

a) AN AHCD with written DNR instructions.

b) The agent identified in the AHCD requesting no resuscitation.

3. Immediate family member present at scene:

a) With a Living Will or DPAHC on scene requesting no resuscitation.

b) Without said documents at scene, with full agreement of others if present, requesting no resuscitation.

4. Parent or legal guardian is required and must be present at scene to withhold or terminate resuscitation for pt's under 18 years of age.

5. Pt in asystole without CPR and the estimated time from collapse to bystander CPR or EMS initiating BLS measures is greater than 10 min.

If one or more of the conditions above is met, BLS measures may be discontinued and the pt is determined to be dead.

1. Pediatric pt's (= or < 14 years of age) who do not meet DNR requirements or obvious signs of death, should receive immediate BLS measures while establishing base contact.

2. Base contact shall be established for all pt's who do not meet the conditions for obvious signs of death or DNR requirements. The following are general guidelines:

a) Continuing resuscitation on scene is appropriate for pt's in medical cardiopulmonary arrest until there is a return of spontaneous circulation (ROSC)

b) Transporting pt's without ROSC is discouraged.

3. The Base hospital physician may pronounce death when it is determined that further resuscitative efforts are futile. Pt's without ROSC after 20 min of resuscitative efforts by EMS personnel should be considered candidates for termination of resuscitation. Exceptions may include hypothermia or pt's who remain in, or whose rhythm changes to V-fib ro Pulseless V-tach.

1. Responsibility for medical management rests with the most medically qualified person on scene.

2. Authority for crime scene management shall be vested in law enforcement.

3. If law enforcement is not on scene, prehospital care personnel should attempt to create a "safe path and secure the scene until law enforcement arrives on scene.

1. The deceased should not be moved without the Coroner's authorization, any invasive equipment (i.e., IV line, ET Tube) used on the pt should be left in place.

2. If the pt is confirmed by law enforcement or the Coroner not to be a coroner's case and the personal physician is going to sign the death certificate, any invasive equipment used during the resuscitation may be removed.

3. Prehospital personnel should remain on scene until law enforcement arrives, during this time when appropriate, the provider should provide grief support to family member(s).

4. Consider Critical Incident Stress Debriefing for all involved prehospital personnel for unusual cases or upon request.

1. For all pt's determined to be dead, document the criteria utilized for death determination, condition, location, and position of the pt and any care provided.

2. If the deceased was moved, document the location and the reason why. If the Coroner authorized movement of the deceased, document the coroner's case number (if available) and the coroner's reqresentative who authorized the movement.

3. For pt's on whom base hospital contact is initiated, time of pronouncement and name of the pronouncing physician must be documented. Paramedics should provide a complete description of the circumstances, findings, medical hx, and estimated duration of full arrest.

4. The name of the agent identified in the AHCD or immediate family member who made the decision to withhold or withdraw resuscitative measures shall be documented along with their signature on the EMS report form.

5. If the pt was determined not to be coroner's case and the pt's personal physician is going to sign the death cert, document the name of the coroner's representative who authorized release of the pt and pt's personal physician signing the certificate, and any invasive equipment removed.