Confirming death in general practice

Kelso et al from Dumfries & Galloway raise the issue of ‘confirming death in general practice’.¹ This is an area that is inadequately addressed in undergraduate and postgraduate training. Similarly the certification process following confirmation of death is similarly neglected. There is often a difference between confirming death at a patient’s home and in a hospital as a hospital doctor is working in an acute setting where death may be sudden, with the need for a decision whether or not resuscitation is required and appropriate. Furthermore, in general practice, nurses are being trained in some parts of the UK to confirm death out-of-hours.

Every few months there is a global report in a newspaper of a patient ‘waking up’ in a mortuary where death has been mistakenly confirmed in circumstances of conditions that can induce coma. This led to my writing an editorial in the BMJ in 1996 on the subject of ‘diagnosing death’ and similarly concluded that this is a subject rarely mentioned in modern textbooks, although much is written about pronouncing brain death. In this editorial I provided guidelines for practitioners, as for many this process has fallen into a ‘commonplace formality’.^2,3 In my days as a hospital doctor and a GP there was often considerable doubt about the actual moment of death, particularly for those witnessing the process of dying, as the warmth of the body and the long unnerving intervals between respiratory gasps can be misleading.

The authors ask how the process may be improved. Perhaps consideration could be made for this to be a mandatory Direct Observation of Procedural Skills (DOPS) for both Foundation Doctors and Associates in Training for General Practice based on the 2008 Academy of Royal Colleges code of practice for confirmation of death.⁴