[Music] foreign my name is Dr James Gill and you've joined me for another clinical skills lecture now today we're going to be doing a clinical skill an oscue station with a slightly different form and that requires a bit of a public health warning we're going to be looking at verification of death or confirming life is being extinguished in a patient thus if you're dealing with the death of a family member if this is a potential subject that's likely to upset you please skip this video and come back to this learning point when you're in a position that you can do so without unduly troubling yourself this is an important skill to be able to master at medical school but if you're not in a position to be able to a take in the information and be in a position that may result in anguish for yourself please look after yourself first and foremost and if need be discuss with your medical school they will be understanding about these things so with that bit of housekeeping in mind we need to think about verifying death let's just put in the context a few things certainly in UK law there is no requirement for a a doctor to be the one to verify death there are paramedics certain nurses and various Allied Healthcare professionals who are able to verify death there is also no requirement for a doctor to view the body after death nor for the doctor to report a death has occurred now the reporting uh that the death has occurred would fall to the family who will collect the death certificate now the doctor particularly the Doctor Who has last been involved in the patient's care will be the one who's required to provide that death certificate in the hospital that is often the the junior members of the team of the consultant who has provided the most recent care and in a general practice out in the community that will normally be done for the doctor that again has provided their last long-term care um whilst it's not an issue for the doctor to report a death it would be the responsibility of the doctor to report a death to the coroner and that would normally happen when the cause of death needs investigating I.E the doctor wasn't able to adequately provide a cause of death on the death certificate now it may be that that can be resolved with a discussion with the coroner about what the doctor wants to write but it may be that the coroner has to take over and organize for a post-mortem to be able to confirm the cause of death so with that in mind I suppose we need to get on with what it is that it means to verify death so if we're going to have to verify death we really need to be knowledgeable as to what death means so there are four features that a patient will have in order to be confirmed as dead life extinct they must be apneic I.E no longer breathing they must be unconscious I.E unresponsive they must have an absence of circulation and that must be irreversible in nature so as long as we've got all four of these features then we can verify that death and in the examination that we're going to go through now we will show how to demonstrate those features so whilst the verification of death is a clinical skill there may be a strong emphasis on your communication skills as well when you go to verify the death because it's quite likely if you've had a patient recently expire there will be family members present even more so if this was an expected death so whilst our approach to the verification of the death itself is obviously going to follow the Academy of Medical raw colleges we need to have a way of approaching those family members who may be in the room I go about that by introducing myself as Dr Gill and explaining that I'm there to verify the death and at this point I will offer those patients relatives to stay in the room if they wish to sometimes seeing the doctor work through the confirmation of death can be cathartic and it can help that family begin the process of acceptance and closure of that chapter of the patient's life conversely it may be something that patients family members don't want to be present for but they are more than happy for you to continue with them having left the room understanding what it is that you're there to do so make sure that you're discussing with anybody else who may be there at that time these are crucial communication skills facets that can take a simple clinical skill to a much more significant personal level so in this video athara has kindly agreed to provide his body once again for the examination but unlike the normal examination we can't introduce ourselves to the patient and ask them to confirm their name and date of birth instead assuming we're talking about a verification in the hospital we need to confirm with the ward staff the details of the patient that we've come to verify and make sure they agree with the person that we're there to see then we need to confirm the patient's identity on their body so looking at their wristband to confirm their name date of birth and Hospital ID now because we are there to verify and have not verified yet I actually approach all patients in this way by talking to them and that can be useful with regard to again if you have family members in the room bear in mind you are again there to verify the death it hasn't been confirmed until you have completed your assessment whether or not that's a doctor an a nurse a paramedic so personally I feel that going through these steps increases the respect you're showing to the person you're there to verify and any family members that may be there as well so with that in mind let's get on with the examination and verification of death hello Mr Johnson Mr Johnson can you hear me so we've got no response from the patient so we're going to confirm looking at the patient's ID bracelet that we've got the right patient and we confirm their name and date of birth we then need to confirm once again that there's no response to the voice Mr Johnson Mr Johnson can you hear us no so we're going to start off with the pen torch so we're going to check for people's response opening the people and we're checking the pupilla response and when a patient has died would expect the pupils to be fixed and dilated not responsive to the pen torch we then need to confirm negative stimuli so previously we used to do cernal rubs that is no longer the case now instead we're going to provide supraorbital pressure and again we've got no response to pain nor voice here so we definitely say that the patient is unconscious now we're going to check for one minute the absence of a pulse so you're going to use a large bore artery so that's either going to be the crotted or the femoral pulse and I like to do my 30 seconds on one side and then swap over to 30 seconds on the other that way I know that there's no issues with a blockage at the Carotid artery now it might seem a strange thing to say that there's no uh looking with for a blockage of the Carotid artery bear in mind we're verifying death so this is an individual who may have very well had significant pathology just making sure we've gone well over the 30 seconds and swapping over to continue on to make sure there's absolutely no pulse Okay so we've confirmed that there is no pulse we're then going to double check by using the stethoscope to listen for one minute for the lack of heart sounds so we've got no heart sounds at all then we want to listen for breath sounds and we're going to listen over both lungs listening for 30 seconds on each lung so no sounds on one's not lung and on the second so so again we've confirmed that there is no respiratory output either now we don't check for bowel sounds as those can continue even after death as the bowel gas settles the final thing that we do need to do is look visually over the clavicle and the top part of the chest and feel to make sure that there's no evidence that there may be a pacemaker in this area so with all of those checked and all coming back negative so we have confirmed absence of breath sounds so we have apnea we've got lack of circulation which is irreversible and we have the patient who is unconscious they're not responsive to verbal or pain thus we can verify this patient is life extinct and we need to document this in the notes confirming their name date of birth the time of death and the date of death as well as your details in case they need anybody needs to contact you afterwards so that completes our clinical examination verifying death we have confirmed the patient's apnic they're no longer breathing we've confirmed they are unconscious and unresponsive we've confirmed that their pupils are fixed and unreactive to light most likely dilated as well we've confirmed they have an absent pulse and there's no evidence of a functioning circulatory system and all of these are irreversible in nature we'd want to make sure we document such in the notes including the time of death and the date of death as well as making sure that we've documented our details and contact the number should anybody wish to contact us the person who's verified the death now I appreciate this has been a slightly unusual Examination for the channel but it is still important and something that can be requested of students during a medical Oscar it's definitely something that all doctors will have to do certainly in their Foundation years there are some additional skills that can be seen in the itu setting if you're required to confirm brain stem death that is far beyond the scope of this video so if you've got any questions or comments please put them down below and we'll try to answer those for you as ever if this has been useful please like the video and consider sharing it well thanks for watching this far take care and we'll see you in the next one cheerio [Music]