In 2008 the Academy of Medical Royal Colleges published a code of practice for confirmation of death.1
There is some evidence to suggest that these guidelines are not followed.2 We decided to find out whether GPs were aware of these guidelines and used them in clinical practice.
An e-mail was sent to 277 GPs in Dumfries and Galloway inviting them to participate in an online questionnaire regarding death confirmation. The questionnaire described a clinical scenario followed by questions on how death was confirmed. The survey also asked whether they were aware of the guidelines.
Eighty-six GPs responded: a response rate of 31%. Only 12 (14%) were aware of the guidelines.
The guidelines recommend assessing for the absence of a circulation for 5 minutes. Twenty-two (26%) responders said that they would assess for the absence of a circulation for 5 minutes or more and 42 (49%) would only assess for 1 minute.
Following 5 minutes of cardiorespiratory arrest, the guidelines recommend assessing the pupillary response to light, the corneal reflex, and the motor response to supra-orbital pressure. Eighty-three (97%) of responders said they would assess the pupils but only 14 (16%) checked the corneal reflex and 14 (16%) checked the response to supra-orbital pressure.
Prior to the publication of the 2008 guidelines, there was no formal guidance on how to confirm death following cardiorespiratory arrest. Practice varied from confirming death as soon as the heart stops to waiting 10 minutes or more.1 Many textbooks do not describe how to confirm death3 and The Oxford Handbook of Clinical Medicine published in 2010 describes the diagnosis of death in the following way: ‘Apnoea with no pulse and no heart sounds and fixed pupils’.4
It is apparent that GPs in Dumfries and Galloway are not following these guidelines. Indeed the vast majority are unaware of this guidance. Does this matter? Diagnosis of death requires ‘confirmation that there has been irreversible damage to the brain-stem, due to the length of time in which the circulation is absent’1 and an assessment for only 1 minute is likely to be inadequate.
How could this be improved? These guidelines were distributed to medical directors of NHS trusts/boards for dissemination to relevant personnel. It is recognised that passive dissemination is ineffective and multifaceted approaches may be required to change practice.5
- © British Journal of General Practice 2012
