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What is the way they determine someone died before declaring them dead?

There are stories I've heard of over the years, people who's heart stopped, were brain dead, fell under ice rivers for half an hour and miraculously survived. So there are many instances of unexplained recoveries.

How do the medical teams or doctors determine then that this person won't all of sudden get a heart beat back?

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    Much better but I edited your question to remove the news stories. They're just not necessary to understand your question and they tend to taint the question with sensationalism. If you disagree, you can revert my edits. – Carey Gregory Feb 24 '16 at 1:04
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You are correct that this happens. It is infrequent (there are not "many", as you say, compared to true deaths), but it occasionally happens that someone - even in a hospital - is thought to be dead when they are not actually dead. In one of your stories, the girl was presumed to be brain dead, not dead. So strike that one. Hypothermia is a beast all unto itself, and declaring a cold person dead is a bit tricky.*

Determining death is not simple. The International Guidelines for the Determination of Death – Phase I (May 30-31, 2012) Montreal Forum Report is 46 pages long and it still doesn't have a definitive conclusion.

For the most part (and to simplify a bit), death is determined to have occurred when someone is exceedingly unlikely (determined from experience of millions of deaths) to regain function of their heart. It can be from a very wide variety of causes, but basically it follows cardiac arrest or respiratory arrest leading to cardiac arrest.

The procedure is to observe the patient carefully. In hospital, that usually includes electronic monitors of one sort or another. Out of hospital it's by observation. When there is no evidence of cardiac electrical activity capable of generating a pulse, the patient has not been breathing for some time, oxygenation of blood has fallen to beyond critical levels, and there is no neurological activity, they are pronounced dead.**

How do the medical teams or doctors determine then that this person won't all of sudden get a heart beat back?

They "know" because of the combined observations of millions of deaths before that one. Since it has happened, clearly it might happen, but once all the criteria are met, it means they are clinically dead. The exceedingly vast majority of people observed to be clinically dead are, indeed, dead (no possibility to regain function.) There's nothing else to do.

It is roughly estimated from the WHO that about 56 million people die every year. Yet it is not every day that someone who was thought to be dead is not, or it wouldn't make the news. Lets be really generous and say it happens once a month somewhere in the world - 12 times a year - and I think this is very, very generous (there is no known number. I'm guessing it's less in industrialized nations.)

That would mean a death diagnostic accuracy rate of at least 99.9999786% (55,999,988 true deaths in 56,000,000 diagnosed deaths.) That is very, very accurate. It is incredibly difficult and expensive to improve on 99.9999786% of anything for a very small return numerically speaking. It sounds harsh, but it's not. It's what society accepts, including you. If you don't believe me, try to get someone to pass a law changing that.

A better question might be why does this happen? It happens because sometimes a heartbeat is so weak as to be imperceptible to the touch, to sound, and even electronically. The person does not appear to be breathing at all. They have no reflexes to demonstrate neuronal activity (for example, the pupil size doesn't change on shining a light into their eyes.) In the days before burial, that doesn't change 99.9999786% of the time. But if someone's metabolic rate is low enough, they might just survive (being cold increases the chances of this*) and the heart might just start getting stronger and they might just wake up. But the odds of that are so extraordinarily low that the increased expense of storing the body, and checking it again in a more advanced state of decomposition, in addition to the increased risk of contagion... it just doesn't happen, because when someone is declared dead, they are dead 99.9999+% of the time.

The whole situation is frightening to some people. But it's really an irrational fear.

To put the "risk" in more understandable terms - because the difference between life and death are pretty important - in 2013 in the US, there were 16,121 homicides. About 20% of those are stranger on stranger homicides (that is, not domestic violence, gang related, etc.). That means of 316,000,000 people in the US that year, about 3,225 people were killed by someone unknown to them, or one in 97,984. That's much higher than 12 in 56 million (which is roughly one in 4,670,000). Yet, though it's more common, you probably still leave your house most days not worrying that you'll be killed in that year. It's an acceptable risk, though death by firearm at a stranger's hand is never acceptable.

If this is an unacceptable risk to you (I'm not being sarcastic; it is an acceptable risk for me personally), you should stipulate in your will your wishes to be kept in storage and reexamined intermittently over a period of several days longer than usual for signs of life, and include the funds to do this.

*In medicine, we have a saying, "They aren't dead until they're warm and dead." It may seem callous to a reader, but it is precisely to avoid the scenario of which you speak, because someone with a decreased temperature can survive anoxic injury better. In fact, cooling someone down who is in cardiac arrest is not uncommon, and cooling after resuscitation is common.

**Often it is a nurse who discovers someone has died, but in many states, only a doctor, paramedic, or a coroner can declare someone dead. Nurses are often allowed to declare someone dead who is in a nursing home, hospice or a home care patient. Usually (but there is no law) we feel for pulses at various points on the body, we listen for heart sounds with a stethoscope, we listen for breath sounds, we look for chest movement, and I shine a light in the person's eyes looking for a neurological response. If after a few minutes of observation, nothing has been found, the patient is then pronounced.

The International Guidelines for the Determination of Death – Phase I May 30-31, 2012 Montreal Forum Report available in full online in PDF
"I Pronounce This Patient Dead" shows that it's not easy even for doctors
Cooling the body after resuscitation following cardiac arrest
All homicides CDC

  • My father woke up in a pre-morgue cold storage room after going into anaphylactic shock. This was just a few years ago. To our knowledge, the hospital's reporting mechanisms made no accommodation for the incident. Failure to report "bizarre" incidents such as this one and the high frequency of organ donations from still-living bodies no doubt skews your estimate of the accuracy as possibly several orders of magnitude too high. 99.9% would not, for instance, be an acceptable level of accuracy. Our process for determination of death and its application are far from where they should be. – pygosceles Sep 4 at 13:25
  • @pygosceles - Your father's experience is without a doubt horrifying. However, my answer still stands. The organ donation from "still living" bodies is common, as they are usually on life support but are brain dead. Several orders of magnitude? Given 99.9%, just one order of magnitude would mean that only 100 people of 1000 declared dead were actually dead. Two orders of magnitude would mean that only 10 of 1000 people declared dead were actually dead. This statement that we are orders of magnitude off is ridiculous, sorry. As I said, my answer stands. Horrifying, but correct. – anongoodnurse Sep 4 at 14:44
  • You misunderstood the "orders of magnitude" argument by looking only at the correct classification rate instead of the misclassification rate. It is correct to say that "one in a million patients deemed dead is actually alive" is orders of magnitude off from "ten thousand out of a million patients deemed dead are actually alive". Those are the ones it makes the biggest difference for--those who are falsely presumed dead. Given that brain death is incorrectly taken as total death, we curtail our figures on the misclassification rate, potentially by many orders of magnitude. – pygosceles Sep 5 at 17:06
  • A false positive classification of "death" is vastly more tragic than a false negative. In the latter case, inexpensive and repeated re-trials will divulge the true result in pretty good time. In the former case, there is no re-trial and the outcome is catastrophically bad for the victim and his family and for society generally. That's why I focus on the misclassification rate and in particular the false positive rate of determination of death. It does indeed have many indications of being orders of magnitude off from your estimate, based on experience and aggressive organ harvesting policies. – pygosceles Sep 5 at 17:12
  • @pygosceles - "no doubt skews your estimate of the accuracy as possibly several orders of magnitude too high." I misunderstood nothing. You may have written something that you didn't mean. "It does indeed have many indications of being orders of magnitude off from your estimate, based on experience..." Have you seen more than one rare erroneous pronouncement of death? How much experience with death do you have? Organ harvesting while alive is common, as I stated, and cannot be classified as an error in pronouncing someone dead. ... – anongoodnurse Sep 5 at 23:06
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Disclaimer

anongoodnurse has provided an excellent answer mostly based on the U.S. I will focus on Germany and European countries to provide you with a broader view of the topic.
If you should live in the U.S., this will still matter to you as the medical aspects behind my answer remain the same in the U.S.

Obligatory Disclaimer: I am not a lawyer!

Obligatory Disclaimer No. 2: I have a rather dark sense of humour and tried to hold it back as to not offend anyone. Feel free to point out parts that you are uncomfortable with in a comment.


Legal Aspects

You're not dead (yet) when you decease. It is only when a doctor declares you dead that you have officially died. In Germany, only a professional doctor (1) may fill out a death certificate and pronounce you dead.

These are well trained physicians (2) and hardly make any mistakes, especially if it comes to something as important as declaring someone dead.

Unexperienced physicians or similar are not allowed to fill out death certificates for exactly this reason: To prevent living people from being declared dead (3). Also, any doctor making a mistake will probably lose their Approbation (license to be a doctor) and no one really wants to declare a person dead even though they aren't. The doctor will be extra cautious.

Declaring Someone Dead

In Germany, additional to the rather obvious check for respiratory arrest, cardiac arrest the doctor has to check for the following three signs of death:

  1. Rigor Mortis (Stiffness of Death):
    This is stiffness of the corpse due to post-mortem muscle contraction. The normal reaction between adenosine triphosphate and adenosine diphosphate (ATP and ADP) within the muscle fibres ceases after death and the ATP level in the muscle progressively diminishes. This is accompanied by accumulation of lactic acid and a fall of pH (increase in acidity), which leads to stiffening and firmness. (4)(5)(6)
  2. Livor Mortes (The blue color of death):
    Once the heart stops beating, blood collects in the most dependent parts of the body as it is not pumped around by the heart, usually the buttocks and back when a corpse is supine. The skin, normally pink-colored because of the oxygen-laden blood in the capillaries, becomes pale as the blood drains into the larger veins. Within minutes to hours after death, the skin is discolored by livor mortis, or what embalmers call "postmortem stain," the purple-red discoloration from blood accumulating in the lowermost (dependent) blood vessels. (5)(6)
  3. Decomposition:
    Yeah, let's actually not get into that too much... Basically, there is autolysis (aseptic breakdown of tissues due to the release of intracellular enzymes) and putrefaction (breakdown of tissue due to bacteria). Both are usually accompanied with a very strong odor. It's hard to be overlooked by anyone! (6)

What if I'm not sure why this person died?

On a German death certificate, there are three types of death (7):

  1. Natural Death:
    If the person is 120 years old, has pulmonary embolism, cancer and multiple myocardial infarctions, their death is not too much of a surprise and can be considered natural. This is either the case if there are enough illnesses known to assume multiple organ failures or if all symptoms indicate a certain type of death (e.g. a myocardial infarction).

  2. Unnatural Death:
    First I thought he died due to stress, and then I noticed the knife in his back.
    If a person has multiple gunshots, is lacking a head or some limbs or alternatively has been cut into pieces, well, you're off safe to assume they have died an unnatural death. This triggers immediate call of the police and investigation by the prosecution.

  3. Unknown cause of death:
    If the physician has, simply put, no idea why this person could have died, they will tick the field with Ungeklärte Todesursache. This will usually lead to medical examinations by an official medical officer and sometimes autopsy if no cause for death can be found. (8)

Conclusion

In Germany, death certificates will only be filled out by highly trained physicians. If they have any doubt on how you have died, why or if you are actually dead, they are forced by law to escalate the problem to the next level (i.e. call the police and a medical officer).

Let's assume all eventualities and you actually are pronounced dead wrongly. What is the problem here? It's not like your being cremated the next day (9). Neither will you be killed to make sure that you are dead, but your body will either be left where it has been to allow relatives to have a last visit or stored somewhere. If you are not dead, you can come back to life and just joyfully announce this to your sobbing relatives. Or, in the most extreme cases, just climb out of the tomb ;).


References

(1): State Law Thuringen, §6 on Declaring Someone Dead [in German]

(2): In Germany, to be a professional physician one must study human medicine for 12 semesters and work 4 years as a assistant doctor before getting the Approbation (license to be a doctor). Only then after at least 10 years of study they are allowed to fill out death certificates.

(3): On a lighter note, just imagine all the bureaucratic effort to revert the death of a person. The word dead card gets a whole new meaning here.

(4): The Oxford Companion to the Body, hosted by encyclopaedia.com

(5): Macmillan Encyclopedia of Death and Dying, hosted by encyclopaedia.com

(6): Content Warning: Explicit Images of Corpses.
Forensic pathology - General Postmortem changes

(7): A template for the German death certificate [in German]

(8): An official guidance to doctors how to fill out a death certificate and what options there are by the state of Baden-Württemberg [in German].

(9) Interestingly enough, in the U.S. you can actually be cremated after a minimum waiting period of 24 hours or 48 hours (depending on state law).
In Germany, there has to be a second Leichenschau (basically going through the list and checking whether all signs of death are present) at least 48 hours after the official death time.

  • Some of the sources are in German. If someone is interested, tell me which parts you'd like to read and I shall translate them. – Narusan Apr 4 '17 at 15:24
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    In the US it's also true that only a doctor can declare you dead, but a paramedic can presume you dead. It's purely a legal distinction and the end result is exactly the same. That's true in most western countries so probably Germany as well. – Carey Gregory Apr 10 '17 at 18:00
  • Well, in Germany a doctor always has to do the checking, so the distinction is quite important as two people will be looking at you if a paramedic is involved. To be precise: if a paramedic presumes you dead, they will immediately call a doctor (Notarzt), which then has to examine you. – Narusan Apr 10 '17 at 19:11
  • But, to be honest, a paramedic can assess whether you have died as well as a doctor in my experience... False declarations of death are more current in hospitals where paramedics are generally not involved. That's what my answer was focussing on. – Narusan Apr 10 '17 at 19:25
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    It wasn't a criticism of your answer. The same formality of a doctor declaring death has to happen in the US, though it would be highly unusual to have a doctor actually come to the scene to do so. The death certificate is usually signed later by a coroner, although when the death is timely and not suspicious, that can usually be accomplished over the phone between paramedics, police and coroner. – Carey Gregory Apr 10 '17 at 20:40
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Through the collective experience of observing millions of deaths, we have arrived at the following indicators of irrecoverable death, each one a more final proof than the previous:

  1. Respiratory arrest (no breathing)
  2. Cardiac arrest (no pulse)
  3. Pallor mortis, paleness which happens in the 15–120 minutes after death
  4. Livor mortis, a settling of the blood in the lower (dependent) portion of the body
  5. Algor mortis, the reduction in body temperature following death. This is generally a steady decline until matching ambient temperature
  6. Rigor mortis, the limbs of the corpse become stiff (Latin rigor) and difficult to move or manipulate
  7. Decomposition, the reduction into simpler forms of matter, accompanied by a strong, unpleasant odor.

More Information: https://en.wikipedia.org/wiki/Death#Signs

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    Welcome to health SE :-). Since health is a very serious topic, we are looking for answers backed up with references more reliable than Wikipedia. For some ideas please take a look at this post: What are reliable sources?. Thanks! – Lucky Apr 4 '17 at 11:33
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    @Lucky Definitely needs another source simply because it is Wikipedia. However, this particular article is very accurate. – L.B. Apr 4 '17 at 13:43

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