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The waiting game

The stormy night that shaped my views on death verification

Dr David Church writes about a visit to verify death

There has been recent debate regarding who can verify life extinct in cases of expected death, polarised between some coroners who are keen to have confirmation from a suitably trained (and registered) professional on the one hand; and GP representatives on the other who quite naturally wish to avoid taking on this role, as this is time-consuming, especially in the current pandemic.

One of the questions around the new regulations – brought in during the pandemic - is whether a qualified person must be present ‘in person’ for deaths in the home, or can diagnose life extinct remotely by video-link or telephone, or via and with assistance of an untrained lay person. It may be an unpopular opinion, but I think a GP, and preferably one who knows the patient, should be making this diagnosis.

This is partly shaped by my own experience. Some years ago, as a GP trainee in fact, I was phoned one awful stormy winter night by a farmer’s wife, who reported his death when they had found him slumped unresponsive and not breathing or beating at the living room table.

I followed her directions to a meeting with her son at a junction on a rural road, from where I followed him in the farm Land Rover through a very dark night with thick wind and rain; then along a very wet and muddy path to the farmhouse. This was no emergency response (she would have used 999 for that!), so we carefully wiped our feet, etc, and the farmer’s wife matter-of-factly introduced themselves and gave an account of the evening’s events so far.

To the surprise of myself and the wife, he started to breathe again

I found the farmer sat in upright chair at the table, dressed as farmers do in every layer you can think of, and completely unresponsive, deathly pale, with no pulse. However, remembering that to follow correct procedure I would need to put my stethoscope on his bare chest, but conscious of the time and difficulty that would accompany taking off the jacket, waistcoat, jumper, shirt, woolly layer and vest, I took a slight short-cut in grabbing a handful of all said layers just above his loosened belt, and lifting them all at once.

To the surprise of myself and the wife, he started to breathe again, irregularly at first, and listening to his chest revealed heart sounds.

The son, who had deferently left the room while we ‘confirmed death’ was called back again and sent immediately out to meet the ambulance which we summoned at the same time. Unfortunately, being unprepared when he returned with the ambulance crew, he received quite a shock when they did return, to find me arguing with his father about whether his current condition was enough to mandate a hospital admission. I suspect his reaction supported my side of the discussion, and with help of the ambulance crew the farmer was persuaded to accept admission to the town’s cottage hospital, as a compromise - there was no way he was willing to go to the district general hospital in the Big Town.

Tests, as could be done in the cottage hospital next morning, confirmed that he had perfect physical condition (for an elderly farmer), memory (except for a short period of the previous evening), and ECG, and as he appeared to have suffered no ill effects, I was persuaded to allow him to go back home. He would have it no other way. So far as I know he lived for at least several years more, although having moved overseas, I lost track of him.

In short, this was a routine call to ‘confirm death’, to which a non-emergency response was made, given the impossibility of getting there within 10 minutes and this was before bystander CPR was routinely available, and in a situation where decease was, to the family, an acceptable fact of life. However, check by a ‘competent person’ revealed he was actually not ready for the undertaker to visit.

Only in some hospital specialties do medics find themselves at a significant number of acute successful resuscitations. I have attended a few, but a greater number which were not. Successful CPR outside hospital is still rare, but to achieve it without actually doing any of it seems impossible. I can only assume that I had somehow opened the airway and jolted the heart by my pull on his clothing.

Anyway, I think it has forestalled any tendency on my part to take short-cuts in death verification.

Dr David Church is a locum GP in Aberystwyth, and South Gwynedd

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Readers' comments (20)

  • I agree ; it may be unpopular but there are big problems with asking families to verify death. Definitely GPs not needed if experienced nurse, paramedic etc, but I think I many cases it would not be right to expect families to verify Historically there have been cases of people being taken to the mortuary and even buried alive

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  • All about context: elderly frail with end stage dementia not breathing pretty likely to be deceased with 'expert' attendance unnecessary which constitutes the bulk of our verification cohort. Youngster found lifeless in a cold river, unexpected death probably a different matter.

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  • ONCE SAW A PATIENT I THOUGHT WAS DEAD.
    NEARLY SENT HIM OFF TO THE MORGUE
    IN FACT HE HAD PROFOUND HYPOTHERMIA

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  • Dear All,
    so if a person falls to the ground and we suspect an arrest, what do we do before starting CPR. confirm death, ooops that'll be another 15 minutes before anyone who can do it properly arrives, so they'll sit by and wait......

    What on earth is the logic in having a higher threshold for verifying death than the one you expect every citizen to exercise to start life saving CPR?


    No matter how you cook this it just never adds up.

    If you want to verify every death in person by all means do so. Get your colleagues to cover you whilst you are away, wear a mask, use a face shield and don't touch anything.

    Meanwhile i'll get on with caring for those who can benefit from it.
    Regards
    Paul C

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  • I've been asked by nurses in hospitals to verify death in two patients who were indeed very close to death but not actually dead. One had even been washed and laid out!

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  • Didn’t a doctor get struck off a few years ago for certifying death in what urned out to be a severely hypogycaemic patient. So it can be difficult for a doctor, let alone a relative or carer.

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  • I saw a resurrection a long time ago when I was a house officer. Had been pronounced dead by a medical registrar- clearly us Drs ain't perfect either!
    Dr Cundy spot on given circumstances and for the vast majority of cases I think.

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  • While it is a nice story it does not make a case for changing the law which currently allows any competent adult to confirm death. Incidentally, any other person attending to confirm death - like a funeral director - would have had the same response on moving the patient. This article is positively dangerous, pushing Doctors onto a guilt trip making them put themselves at risk of contracting Covid19 by unnecessarily assuming sole responsibility for all death verifications. I totally disagree with the author.

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  • These are anecdotes and somewhat dodgy ones at that. Does the author suggest we drop everything for a death in case the patient is alive? That is undesirable and based on very shaky evidence. That said it hasn't stopped our response to COVID!

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  • Are you educated, intelligent, discriminative Professionals, or a bunch of people making up rules and processes based on anecdotal stories and ancient myths. Gads, your like a bunch of charletans creating a time of reasons why the people need your magic otherwise they will be engulfed by a wave of death and misery if the Medical Mages don’t confirm the living. Grow up, and let the people grow up and stop being afraid of the one thing everyone will encounter. Death is not a medical diagnosis, other than its 100% prevalence- it is a normal fact of every single life. Stop medicalising normality, and you might just find the public stop trying to get us to medicalise their lives.

    Undertakers are the experts in management and care after death- they are best placed to train to confirm death in the community. After all, they’re the most likely to pick up our mistakes when we incorrectly ‘diagnose’ death

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