Assessment of the Extinction of Life and the Certification of Death
This Circular is a guide to public hospitals and health services on the assessment of the extinction of life, and the certification of death where patients die in health facilities such as hospitals and nursing homes or where deceased persons are brought to hospitals.
ASSESSMENT OF THE EXTINCTION OF LIFE AND CERTIFICATION OF DEATH:
This circular makes a distinction between the procedures for assessment of the extinction of life, and certification of death.
Assessment of the extinction of life: is a clinical assessment process undertaken to establish that life is extinct. By evaluating cardiac output, neurological signs and respiratory status, using a standard regime of clinical assessment tools, a registered medical practitioner or registered nurse can generally establish that life is extinct.
Certification of death: is a process by which the issuer of the certificate (a medical practitioner) certifies the fact and circumstances of death, pursuant to legislative requirements in the Births Deaths and Marriages Registration Act 1998.
- It is recommended that hospitals/health services make a distinction between the assessment of the extinction of life, and the certification of death and deal with them as two procedures.
- Nothing in this Circular should be taken to detract from the† legislative requirement in the Births, Deaths and Marriages Registration Act 1998 that a medical practitioner who was responsible for a person's medical care immediately before death, or who examines a body after death, must sign a death certificate within 48 hours unless the death is a Coroner's case - see paragraphs 5 and 6).† This Circular merely recognises that steps regarding the assessment of the extinction of life and management of the body may have to be taken in the period prior to the attendance of the medical practitioner.
- Hospitals and health services where there is a medical practitioner available on site should require that the medical practitioner has the responsibility for assessment of, or at least confirmation of, the extinction of life (this is usually done at the same time as certifying death).
- In the situation where a medical practitioner is not available on site, a registered nurse may perform the normal nursing role of assessing the extinction of life and managing the body appropriately prior to a medical practitioner certifying death unless:
- the cause of death is unclear, †or
- there is uncertainty as to whether life is extinct, or
- medical tests need to be undertaken to pronounce life extinct (e.g., brain death) or
- the registered nurse otherwise considers it necessary for a medical practitioner to attend.
In some circumstances (e.g. in hot weather, or where a medical practitioner's attendance involves a long delay) appropriate management of the body may involve removal of the body to the mortuary and sometimes, refrigeration of the body.† Preservation of the body is important at this time until decisions are made regarding the contacting of relatives, post mortem examination and funeral arrangements.
A registered nurse assessing the extinction of life shall make a full report of the assessment (including the time of assessment) in the deceased person's health care record.
- Medical and nursing staff need to be informed of their responsibilities relating to the Coroner’s Act 1996 and Health Act 1911 (see Circulars IC 0008/07 Coroner’s Act 1996, IC 0133/13 Notification of deaths, OP 0713/96 Perinatal Deaths: Registration and Disposal of Body).
- Where the death is a Coroner's case, and there is no medical practitioner available on site to attend the deceased, a registered nurse may assess the extinction of life and give preliminary notification to the police.† The considerations in paragraph 4 above as to whether a registered nurse should undertake the assessment also apply in this situation. †Nevertheless in Coroner's cases, a medical practitioner should formally pronounce life extinct for the purposes of the inquiry or inquest, confirm that the death is a Coroner's case and ensure that the police have been notified as required by the Coroners Act 1996.
- Certification of brain death for the purposes of organ donation can only be made by two medical practitioners. Hospitals and health services should have regard for the requirements of the Human Tissue and Transplant Act 1982. (Refer to Operational Circular OP 1577/02 †Human Tissue and Transplant Act 1982 - Non-Coronial Post-Mortem Examinations Code of Practice 2002.
- Certification of cardiac death for the purpose of organ donation should be by an intensivist (intensive care specialist or other specialist with rostered responsibility for patients in the ICU) or other nominated doctor who is not a member of the organ retrieval or transplantation teams. (refer to the document ‘National Protocol for Donation after Cardiac Death’).
- Appropriate education in the necessary clinical assessment skills and the requirements of the legislation in this area should be made available to all relevant clinical staff.
The attached flow charts are designed to assist hospitals and health services in the implementation of this policy to take into account the local conditions, locations and relationships with medical officers.
Assessment of Extinction of Life in the Home
Remote health services may choose to allow assessment of the extinction of life in home settings by registered nurses where this is rendered necessary by the scarcity of medical practitioners in the area, and on occasion if the body is severely damaged and clearly dead, by a police officer.† They should take into account the guidelines in this Circular insofar as they are applicable to the home setting, and in particular, paragraphs 1, 2, 5, 6 and 8.
Professor Bryant Stokes
DEPARTMENT OF HEALTH WA