Letter to the Editor
Thank you to Kimberly Chernoby, MD, JD, for her poignant and well-written article on time of death in the ED. (“Change the Way Time of Death is Called,” EMN. 2019;41:4; http://bit.ly/2FL6GxP.) She did not address some legal, logistical, and ethical issues, however.
Most states in the United States utilize an ancient form of certifying death. Someone is required by law to certify time of death, and that time is when the pronouncement is made. You are not legally held to the instant moment of death in pronouncement notifications, and that's where physicians come in for hospital patients.
Does it matter if the death occurred at 1:23 a.m., 45 minutes earlier when CPR first started, or when the patient was found pulseless? I don't think so, and neither do the courts or other relevant agencies unless there is a criminal or suspicious cause of death. For every person who might have died minutes before he arrived at our doors, several have return of spontaneous circulation and continued to live. We cannot have uniform and consistent rules that say people who died prehospital at time x are the same as those who died at time x but are now alive.
Dying is a process, and death is an event. Are we certain those prehospital deaths are truly deaths? Do we not successfully resuscitate many of them? Dr. Chernoby also cited the Uniform Declaration of Death Act, but did not mention the legal standard for death, the whole brain death criteria. Focusing on a time misses a lot of the complexities of death and adds unnecessary distress for a time to note the end of efforts. It is just part of the necessary processes to ensure a person is truly dead.
As far as well-being, Dr. Chernoby is absolutely right that in our debriefs we should remind all involved that these people were unable to be resuscitated and their deaths were unavoidable. Focusing on time of death for paperwork is missing the real issue at hand.
Al O. Giwa, MD, MBA
New York City