Patient safety

Progressing towards guidance for the determination of death

The determination of death

Death is the inevitable end of life. The determination of death has been performed over the world for millennia. In health care, death is an irreversible terminal event. Advancing medical technologies and interventions, in particular the ability to substitute vital functions such as breathing, have enabled the better recognition of death at an earlier stage in its process.

The necessity to determine death

The diagnosis of death is crucial in justifying the cessation of purposeless care. For instance, in intensive care, keeping a cadaver on a ventilator is a clear situation of overtreatment which cannot bring back life and engages unnecessary expense. Indeed, in order to provide equitable access to health services, the infrastructures, human and financial resources should always be used for a patient who can actually be saved. In the context of organ donation, the “dead donor rule” states that “ a patient may only become a donor after death and the recovery of organs must not cause a donor’s death”. Professional and public confidence in the diagnosis of death is therefore essential. The practical criteria for the determination of death depend on the clinical expertise and available technologies, whilst the legal requirements vary across countries. Nevertheless, from a scientific standpoint, the diagnosis of death as a biological event is the same for all humans.

Towards global guidance for the determination of death

In order to standardize practice globally, the international scientific experience must be thoroughly examined and carefully considered, taking into account the different traditions, cultures, and levels of education in various countries. Additionally, the progress in technology and practice demands such guidelines to be regularly reviewed. The World Health Organization, following requests from some Member States and professional scientific societies, is facilitating the development of international guidelines on the determination of death. In December 2010, an exploratory meeting was held at its headquarters in Geneva, Switzerland.

A collaborative effort: The Montreal Meeting

Further momentum was gained at a subsequent meeting, held in collaboration with Canadian Blood Services, in Montreal, Canada, in May 2012. This constituted Phase 1 in the process of the development of guidelines for the determination of death. An “operational definition” of human death was developed and stated as ‘the permanent loss of capacity for consciousness and loss of all brainstem functions, as a consequence of permanent cessation of circulation and/or catastrophic brain injury’. In this context, ‘permanent’ refers to loss of function that could not resume spontaneously and would not be restored through intervention.

Onwards and beyond

On this basis, the next phase of the development includes a systematic review of the scientific literature and regional-based consultations with medical experts and policy-makers.