​​​​​​​Calling Time of Death: How to Reduce Risk Factors for EMS and Patients

The news that a 20-year-old woman was found alive by funeral home personnel just prior to being embalmed—after being declared dead “based on real-time medical data, including heartbeat and breathing, that was provided by responding authorities and EMS personnel,” said People Magazine—has been ringing the globe in cyberspace. (The last-minute discovery saved her life.)

Not surprisingly, this story has cast multiple medical providers in a bad light. But it has also spotlighted an ongoing concern for everyone concerned with emergency care: namely, how can EMS professionals call patients’ time of death as reliably and safely as possible when the data needed to make this decision may be limited and difficult to assess?

Dustin Calhoun, MD, is an associate professor of emergency medicine at the University of Cincinnati and someone who has given this issue very serious thought. EMS World picked his brain on the subject.

EMS World: Television makes it look like it’s really easy to pronounce whether someone is dead or not. In reality, what challenges do EMTs and paramedics run up against when they’re trying to decide?

Calhoun: Well, much like all the other things that EMS does, they’re doing the same kind of work that other people do in very controlled environments [but] in a very uncontrolled environment. This means all the things that influence the ability to use one’s senses—such as noise, heat, or cold—can negatively affect paramedics’ ability to do what they’re trying to do. It makes the tough job of accurately determining if someone is alive or not much tougher.

What are some of the things that can lead to errors, and how can an EMS professional prepare themselves to avoid them?

One factor that can make the process very difficult is a patient’s body type. For instance, a patient who is morbidly obese is difficult to treat when it comes to pretty much everything in healthcare, but things such as palpation of pulses become much more difficult in this situation. If a morbidly obese patient is in cardiac arrest, it is very difficult for an EMT or paramedic to find their pulse through a large amount of adipose tissue, even if the pulse is there.

Some hospitals are using ultrasound to detect heartbeats in clinical settings. But in many prehospital settings in states such as my own, EMS is not allowed to use ultrasound in the field. This means the ability to look at the heart and see if there is movement is often not available to EMTs and paramedics.

Instead, EMS professionals are using secondary measures such as CO₂ measurements. Having a patient who has a particularly low CO₂ reading can support the decision that they are deceased.

That said, today’s automated CPR devices are so good that you can have a patient with a reasonable CO₂ level who is not still salvageable. So the absence of a particularly low CO₂ is not an absolute contraindication for terminating a code.

What about seeking a heartbeat with a stethoscope? Is that a reliable way to determine life or death?

It is possible the patient may not have a heartbeat you can hear with a stethoscope. Then, as the paramedic decides to terminate the code, the patient’s heartbeat converts spontaneously to a perfusing rhythm. It is rare, but it does happen.

Given these factors, what can EMTs and paramedics do to improve the accuracy of their calls?

The situation is very much like what we do when we intubate a patient, which is a very high-risk procedure. This is why we use multiple methods to verify we have the tube in the right place.

The same approach is necessary for a termination of resuscitation. We need to use multiple modalities and an appropriate amount of time to look for any signs the patient is not appropriate for termination. To do this we have to use all the things we have at our disposal, recognizing the limitations the environment can place on us.

Sometimes it may be necessary to move a patient from the site at which you’ve been running their cardiac arrest to an area where you’re less hindered by the environment in order to get a better view. You also need to recognize that there are some patients for whom, due to a combination of all the factors I mentioned earlier, it may be impossible to be 100% sure about making the call in the field.

What role should hospitals and other care facilities play in backing up EMTs and paramedics who may not be in the position to make accurate calls in the field?

This is where the healthcare system you report to needs to be supportive of decisions such as transporting that patient to hospital when you are uncertain as to your ability to determine their particular cardiac status.

In a lot of places—my area included—EMTs and paramedics are required to make a medical control call to an emergency department physician to terminate resuscitation. This being the case, these physicians need to have adequate understanding of the prehospital environment to identify some of those limitations the EMS crew is dealing with and to determine whether it is reasonable to make the decision that the patient is or is not appropriate for termination.

Having that level of training among the physicians backing up EMS is important. So is having a good relationship between the hospital systems and the EMS personnel, so that if there is a question, EMS feels comfortable pointing out the concerns they have about the limitations I’ve noted. The crew also needs to feel comfortable transporting a patient they might not otherwise transport because they’re not convinced they’re able to tell for sure that this patient should be terminated.

Is there any sort of rule of thumb you could recommend to EMTs and paramedics when it comes to reducing the risks associated with making the call? Or is that not doable?

I don’t know that it’s doable. I think there are too many variables.

Now, there are certainly standards out there. Obviously you would never terminate without having an electrocardiogram. You would never terminate a patient if you had been unable to determine where their pulses should be during CPR. It is very hard to know whether you’re missing pulses because you’re not looking in the right place, because of the anatomical specifics associated with each patient. So anytime there are pieces of the puzzle not fitting together, I suggest you pause, take a step back, and ask yourself, “Do we have evidence that the patient is truly not salvageable, or do we just have a lack of evidence?” As with most things in medicine, being able to distinguish between negative evidence versus lack of evidence is very, very important.

Reference

1. DeSantis R. Woman Declared Dead Was About to Be Embalmed When Funeral Home Saw Her Breathing, Attorney Says. People, 2020 Aug 25; https://people.com/human-interest/woman-declared-dead-found-alive-about-to-be-embalmed/.

James Careless is a freelance writer and frequent contributor to EMS World.