Introduction
Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and
Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence. The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment (https://criticalcare.org.za/resource/death-determination-checklists/).
Key points
- Brain death and circulatory death are the accepted terms for defining death in the hospital context.
- Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met.
- The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks’ corrected gestation.
- Brain-death testing while on extra-corporeal membrane oxygenation is outlined.
- Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation.
- The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.
Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation. [1] There is no documented case of a person who fulfils the preconditions and criteria for brain death ever subsequently developing any return of brain function. [2,3]
Clear medical standards for death certification augment the quality and rigor of death determination. [4-6] Currently there are no clinical guidelines on death determination in South Africa (SA), with clinicians using available international guidelines, which vary markedly and are not always applicable to the SA context. [7-10] The World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM) recently published a document, based on current literature, aiming to standardise terminology and establish minimum testing standards across the world. [5] In order to be applicable over a range of legal jurisdictions, some sections of this document are necessarily broad, making application to the local context challenging. There is therefore a need to align the WFSICCM document with the SA context and legal system, and to provide clear guidance to SA practitioners and the public.
The aims of this document are to provide guidelines for healthcare providers for the testing process, and to answer key questions that commonly arise when medical professionals are called upon to determine death in SA. The objectives are to:
- provide clear medical standards for healthcare providers in the determination of death, in order to promote safe practice and avoid diagnostic errors in the determination of death
- provide assurance to patients, their families and the SA public that determination of death is undertaken with diligence, integrity, respect and compassion and in accordance with accepted medical standards and societal expectations
- create a checklist for brain death and circulatory death determination.
Critical Care Society of Southern Africa: South African Guidelines on the Determination of Death_SAMJ/SAJCC_March 2021, Vol. 37, No. 1 (Part 2)