Death

From Ganfyd

This has so far remained inevitable, but with long lives, low birth rates, nuclear families and a general expectation of good health and social and healthcare, citizens of current Western societies are arguably worse at dealing with it than in previous generations.

Doctors also find dealing with death difficult. There are two areas to explore here - the technical and legal aspects around death and the doctor's duties, and the medical/social/pastoral part of the relationship with survivors. The former is rather easy.

Determination

In general, the formal determination of death (the original life or death decision) is a task passed by society to doctors. Various tests have been described, but in the main the decision is easy, particularly if it is expected and hurry is moderated. There are, in the UK, exceptions - any suitable person may declare that an expected death has occurred, and the usefulness of a doctor attending who has not seen the patient or their family before is modest. However, it seems, in general, one of those things that goes toward defining what a doctor does remains the pronouncement of whether life is extinct. This seems proper.

Tests

Several tests for life are commonly used. In various circumstances one or more of them may not be possible, so it is as well to be used to several.

The absence of heart action and the breaking up of columns of blood in the fundi are common ones.

Practical Aspects

After pronouncing life extinct, you may want to close the patient's eyes. This gives the dead body a more serene and peaceful demeanour rather than an empty stare. Similarly, for the benefit of the relatives, the body should be straightened out and laid flat before rigor mortis sets in, especially if the patient was propped up in bed or lying in an awkward position.

In expected deaths which are unlikely to need discussion with the coroner, all tubes and dressings can be removed. However, in cases that may require further discussion with the coroner, it is best to consult the local guidance as there are no commonly agreed guidance on what to do with in situ medical devices at the time of death.

A common situation is what to do with endotracheal tubes at the time of death. Some coroners require that they be left in place because a misplaced tube could be a contributory factor to death. The difficulty with this approach is, firstly, that relatives may be inadvertently distressed, and secondly, there is no way of ensuring that the tube does not become dislodged between the place of death and the post mortem room. Nonetheless, if local guidelines are to leave the tube in, it is best to follow these rather than antagonise your local coroner.

If it is to be removed, it can be helpful (medicolegally) for the position of the tube to be checked by a separate qualified practitioner and for the information to be documented in the notes.

Situations Where Determination of Death is Difficult (Potential Pitfalls)

Hypothermia

A patient brought it with hypothermia is not dead until they are warm and dead.

This is common, particularly in the elderly. As temperatures drop cognitive processes are impaired and individuals will not try to make any effort to keep warm. Alcohol is often a contributing factor.

Near Drowning

Near drowning is often associated with hypothermia. There are well documented accounts of survival. Hypothermia may in fact by protective of the brain in near drownings. It is conventionally said that attempts to resuscitate should not be abandoned before rewarming is complete.

Drug Overdose

The overdose of some sedatives, hypnotics and opiates especially with alcohol can lead to marked respiratory depression which can mimic death if the proper safeguards are not followed. Overdose and hypothermia often co-exist.

Certification

see also Death certification

Death is usually diagnosed simply by the absence of heart sounds and breathing sounds, the absence of a pulse and dilated pupils. Other formalised testing is not required. However this form of death does not have a standard definition unlike brain death.

Brain death is death of the person, although the heart continues to beat and other automatic functions continue. It is not recoverable nor is the condition sustainable. This definition of death, tested most carefully on criteria that have evolved from the 1960's and used in the setting of an intensive care unit when decisions need to be made on prolonging treatment or harvesting organs for transplantation, is robust against criticism and compliant with law. Decisions on brain death need to be taken by senior clinicians who demonstrably have an independence from the transplant teams. In the presence of doubt or worry, prudent doctors avoid rapid action and recruit further advice whether medical, legal, or both.

Anomalously, death below an arbitrary age acquired a second reporting system neither aligned nor integrated with the pre-existing one. Deaths of children are to be immediately separately reported and analysis for avoidable factors conducted. The arrangements are at present immature.^[1]

The time of death, in the eyes of the law, for the purposes of death certification and cremation forms, is the time when the patient is pronounced dead by a qualified person (usually a doctor or a nurse) (or when they pronounce life extinct in quaint legal language), even if the actual time of death was hours or days earlier.^[2] (This may be confusing to relatives.)

Disposal

Around 60% of UK disposal is by cremation. Some other countries have a high rate of burial. Cremation certification is presently (2006) distinct from medical certification of the cause of death. Registration of deaths and stillbirths (also births and marriages) in the UK is via the General Registry Office.

Contrary to popular belief, there are relatively few communicable disease hazards associated with cadavers. See External links for guidance.

Leaving your body to medical research

Some people wish, often for altruistic reasons, to arrange that after their death their body can be used for medical research, or for teaching (teaching anatomy, or for other teaching purposes).

Originally, HM Anatomy Inspector was responsible for administering body donation, but this is now historical as the post no longer exists.^[3] The Human Tissue Authority (HTA) has inherited the role, but do not directly co-ordinate donations, being primarily concerned with overseeing the consent process. The HTA rules require that patients who would like to donate their bodies to medical science must provide written release and consent forms during life. Making the necessary arrangements after death can be difficult, if not impossible. Guidance on the consent process is available from the HTA web-site on How to donate your body

Anatomical Teaching

Those who wish to donate their bodies for anatomical teaching and dissection can contact the Royal College of Surgeons of England (see their guidance) or alternatively their local medical school or anatomy department. A list of contacts is available:

• via HTA medical finder: http://www.hta.gov.uk/schools/
• List of medical schools by postcode, with details of contact person
• Guidance from University of Bristol

Not all bodies will be suitable for dissection, of course, particularly if the anatomy is too distorted by disease. Medical schools will prefer intact bodies, not too much changed by disease, trauma or surgery. As a rough guide, a bequest may be turned down if:

• Post-mortem performed
• Transmissible disease - Hepatitis, HIV, Septicaemia
• Malignant disease
• Dementia
• Jaundice
• Multiple sclerosis
• Stoma
• Bedsores/Varicose ulcers
• Peripheral vascular disease
• Recent operations where wound not healed
• Amputation
• Arthritic deformity
• Obesity

Brain Banks

If the entire body is not suitable for donation, the brain by itself can be donated. There are a number of Brain Banks across the UK who will accept donations, some of which will also organise retrieval and transport.

A list is available from the Medical Research Council web-site. An example FAQ for potential donors is available here.

Other Avenues

Prospective body donors might also wish to contact Prof von Hagens^[4]

External Links

Links that may be helpful for people who wish to leave their body for research or dissection include:

• New Zealand (Otago Daily Times) article on a documentary film about people who donate their bodies for medical research^[5]

Survivors

Reporter:  "And how did you feel, little girl, when you saw your daddy hanging there?" 

There is no universal form of words or behaviour suitable for the occasion of a death, but some effort to express condolences is in order.

Deliberate attempts to provide post-trauma counselling will commonly cause harm, but thought should be given to the survivors after a month or so, in order to distinguish those who require some special management and to assist everyone in resolving lingering doubts.\

The medical, nursing and other professional attendants may also be counted among the survivors, and a minority of deaths have sufficient effect that leaders and members of the teams involved should take care of each other. Again, formal debriefing seems uncertainly productive.

Sub- and Cross-Cultural Aspects

Events around death are among the more obvious religious and cultural aspects of medical care. Brain death may not be accepted by certain faiths, so adherents to these may time the death from the cessation of circulation.

Causes

UK age sex and cause of death from

Access to medical records of deceased patients

This information applies to the UK

In the UK access to the health records of a deceased person is governed by the Access to Health Records Act 1990.^[6][7] The Department of Health has provided some FAQs Can I access the medical records (health records) of someone who has died?. The BMA has also published guidance on access to records of deceased patients.^[8]

In UK general practice the medical records technically belong to the secretary of state for health, and the paper copies have to be returned on the patient's death.

Once the records have gone, however, it can become much more difficult, if not impossible, to defend any medicolegal claim relating to the deceased patient. Mainly for this reason, an exception was negotiated with the Information Commissioner's Office (ICO) that under the 1998 Data Protection Act GPs would be expected to retain the electronic record of any patient they ever treat. This is not compulsory; but the ICO will not pursue a GP for unlawful retention. (In any case, the ICO has no power over deceased records.) That exception persists under GDPR and DPA 2018.

If records are kept by a GPs, as above, the GP remains the data controller for them: Data controllership acts independently of registration. Records would only disappear from GPs' data controllership if the GPs had no control over them, and as the original author that would be unlikely.

Why would anybody want access to such records? Remember that important evidence in Dr Shipman's conviction related to falsified electronic patient records!

The GMC can, under section 35A(1), demand access to a deceased person's records.

In general, however, a deceased person's records are protected by Section 41 of the Freedom of information act 2000, which case law has determined exempts the information from being released, unless covered by other legislation - eg the Access to Health Records Act 1990 ("where the patient has died, the patient’s personal representative and any person who may have a claim arising out of the patient’s death…").

References

External links

• HSE guidance "Controlling the risks of infection at work from human remains. A guide for those involved in funeral services (including embalmers) and those involved in exhumation"
• HPA guidance (and links): "Management of infection control associated with human cadavers."

References