Letters

Diagnosing death

BMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7078.442a (Published 08 February 1997) Cite this as: BMJ 1997;314:442

Start resuscitation first

  1. Simon Mardel, MSc student in public health and health services researcha,
  2. Colin Thomas, Practitioner in resuscitation medicineb
  1. a Aberdeen AB24 3HX
  2. b Resuscitation Department, Hereford Hospitals NHS Trust, County Hospital, Hereford HR1 2ER
  3. c Addenbrooke's NHS Trust, Cambridge CB2 2QQ
  4. d St Catharine's College, Cambridge CB2 1RL
  5. e School of Postgraduate Medicine, Keele University, Stoke on Trent ST4 7QB

    Editor–The subtitle of Rodger Charlton's editorial on diagnosing death–Getting it right if vital opportunities for resuscitation are not to be missed–misleads readers.1 It does not emphasise the common need to start resuscitation when the diagnosis is in doubt, which in practice is often while information is still being gathered from attendants. Only when the clinician has decided not to try resuscitation does the thorough examination proposed by Charlton become relevant. Before making this decision respiration should not be checked until the airway is opened, and a pulse should not be sought until effective ventilation has been provided. Although we acknowledge the difficulties posed by diagnosing death in the community, the logical sequence of current resuscitation guidelines2 3 must be followed unless (or until) a positive decision not to resuscitate has been made. Furthermore, in the case of drowning these guidelines (including those referenced by Charlton) do not propose the Heimlich manoeuvre to expel water from the lungs but amply describe the reasons for not doing so.

    References

    1. 1.
    2. 2.
    3. 3.

    Death after electric shock and lightning strike is more clear cut than suggested

    1. Gregor Campbell-Hewson, Specialist registrar, accident and emergency medicinec,
    2. Conor V Egleston, Senior registrar, accident and emergency medicinec,
    3. Susan M Robinson, Consultant, accident and emergency medicinec
    1. a Aberdeen AB24 3HX
    2. b Resuscitation Department, Hereford Hospitals NHS Trust, County Hospital, Hereford HR1 2ER
    3. c Addenbrooke's NHS Trust, Cambridge CB2 2QQ
    4. d St Catharine's College, Cambridge CB2 1RL
    5. e School of Postgraduate Medicine, Keele University, Stoke on Trent ST4 7QB

      Editor–Some of Rodger Charlton's assertions about death from environmental causes are faulty.1 He says that death should not be confirmed after immersion until water has been expelled from the lungs by a Heimlich manoeuvre and that death should be confirmed with extreme caution after lightning strike, electric shock, and airway obstruction. There is little, if any, evidence for these statements.

      Heimlich evaluated the manoeuvre named after him in animal experiments in which anaesthetised beagles had the larynx obstructed by a plugged endotracheal tube and then by a meat bolus.2 In both cases the Heimlich manoeuvre dislodged the obstruction from the upper airway. There was no simulation of drowning in this work, and there is no good evidence that the manoeuvre is effective in expelling water from the lower airways.

      Drowning without aspiration of fluid accounts for 10-20% of deaths by drowning. There is a consensus that the amount of water obtained during attempts to empty the lungs when it has been tried does not justify the inherent delay in airway management and ventilation.3 In addition, the performance of the Heimlich manoeuvre on victims of immersion may exacerbate a cervical spine injury or expel swallowed water from the stomach, leading to aspiration. Attempts to empty the lungs deny casualties the more important intervention of cardiopulmonary resuscitation.

      The inference that cardiopulmonary arrest after lightning strike is particularly amenable to successful resuscitation with prolonged cardiopulmonary resuscitation has no substance in fact. It stems from a case report in 19614 that was misinterpreted in a classic article.5 There is no reason to distinguish apparent death from electric shock or lightning strike from other arrhythmia related deaths such as ventricular fibrillation. In the original case report the period of cardiac arrest was uncertain but was at most 12 minutes from loss of pulse to return of spontaneous circulation.

      The suggestion that death from upper airway obstruction requires an unusually prolonged resuscitation is illogical. Cardiac arrest from upper airway obstruction is preceded by profound hypoxia and hypercarbia and consequently results in a poor outcome from resuscitation efforts. We agree that the diagnosis of death in a domiciliary setting is beset with pitfalls. The specific instances we have detailed, however, are more clear cut than Charlton asserts.

      References

      1. 1.
      2. 2.
      3. 3.
      4. 4.
      5. 5.

      Death of the brain stem means death of the individual

      1. Terence English, Masterd
      1. a Aberdeen AB24 3HX
      2. b Resuscitation Department, Hereford Hospitals NHS Trust, County Hospital, Hereford HR1 2ER
      3. c Addenbrooke's NHS Trust, Cambridge CB2 2QQ
      4. d St Catharine's College, Cambridge CB2 1RL
      5. e School of Postgraduate Medicine, Keele University, Stoke on Trent ST4 7QB

        Editor–Rodger Charlton says in his editorial on diagnosing death that “complete cessation of circulation to the normothermic adult brain for more than 10 minutes is incompatible with survival of brain tissue.” 1 This implies that shorter periods are compatible with recovery of the brain, whereas it is well known that the safe period of normothermic circulatory arrest does not exceed 3 minutes. He also suggests that an isoelectric electroencephalogram is one of the criteria for diagnosing brain death, whereas this is not so in Britain.

        Of more importance is the obfuscation introduced by concepts such as somatic death and molecular death. There is only one kind of human death and that is the irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breathe (and hence to sustain a spontaneous heart beat). Hence the importance of clearly defining the criteria for the diagnosis of brain stem death, which were issued by the medical royal colleges in 19762 and which led to the acceptance that death of the brain stem was the necessary and sufficient condition of death of the brain as a whole and that death of the brain means death of the individual.

        References

        1. 1.
        2. 2.

        Author's reply

        1. Rodger Charlton, Senior lecturer in primary health caree
        1. a Aberdeen AB24 3HX
        2. b Resuscitation Department, Hereford Hospitals NHS Trust, County Hospital, Hereford HR1 2ER
        3. c Addenbrooke's NHS Trust, Cambridge CB2 2QQ
        4. d St Catharine's College, Cambridge CB2 1RL
        5. e School of Postgraduate Medicine, Keele University, Stoke on Trent ST4 7QB

          Editor–I thank the correspondents for their remarks and the additional information given. In reply to Simon Mardel and Colin Thomas, I would strongly affirm, as I hope my editorial does, that when the diagnosis of death is in doubt resuscitation should be started while vital information is gathered from attendants.

          In reply to Gregor Campbell-Hewson and colleagues, the unfortunate circumstance of apparent death may indeed occur as a result of lightning strike. Two recent case reports vividly describe patients who suffered lightning strike and were reported as “comatose at the scene, with dilated non-reactive pupils and circulatory arrest.” Through aggressive and prolonged resuscitation these two patients were revived.1 A similar argument may be made for cardiac arrest as a result of electric shock.2

          The diagnosis of death is not always straightforward, and it is coincidental that another paper on this subject recently reiterated two questions posed by my editorial.3 Firstly, although the heart may have stopped and respiration ceased, the tissues retain the “vital principle of life” for some time. During this period of somatic or systemic death (cessation of vital processes) and lingering vitality can death truly be confirmed? Secondly, are we to wait for molecular death (the progressive and irreversible disintegration of the body tissues) before death can be pronounced with absolute certainty but at the risk of considerable distress to attendants? Thus, in reply to Sir Terence English, the use of the concepts, somatic death and molecular death are not to obfuscate but rather to clarify that death is a process rather than an event.

          These philosophical concerns about the definition of death highlight that dilemmas remain about the scientific criteria currently used to diagnose and predict death. This argument is borne out by the criteria used to diagnose brain stem death, which in America include an isoelectric electroencephalogram but in Britain do not.4 Similarly, when outcome after resuscitation is considered, views on the likelihood of good neurological recovery as a result of cerebral anoxia are diverse, the upper limit varying between articles; a recent paper suggested a time limit of up to 5 minutes.5 Evidently, a challenge exists to refine consensus guidelines to diagnose death.

          References

          1. 1.
          2. 2.
          3. 3.
          4. 4.
          5. 5.
          View Abstract

          Sign in

          Log in through your institution

          Subscribe