KY Paramedic Determination of Death

Kentucky Prehospital Determination of Death: 

Kentucky Prehospital Determination of Death KRS 311A.185

Introduction: 

Introduction Purpose of Training Review of KRS 311A.185 (Handout copy)

Definition of Death: 

Definition of Death Kentucky Revised Statutes KRS 446.400 defines death (Handout copy) House Bill 285 originally granted the authority for Paramedics to pronounce death.

Protocols for Pronouncement of Death: 

Protocols for Pronouncement of Death 202 KAR 7:401 Handout copy Patients encountered by Kentucky Licensed Paramedics, who have been trained in accordance with KRS 311A.185 that appear to have expired will not be resuscitated or transported if all five (KY definition) signs of death are present and at least one of the associated factors of death can be identified on the patient.

Protocols for Pronouncement of Death: 

Protocols for Pronouncement of Death The five signs of death that must be present are: Unresponsiveness , and Apnea , and The absence of a palpable pulse, determined to be absent at the carotid and the radial or femoral sites , and Bilaterally fixed, dilated pupils , and The absence of audible heart sounds

Protocols for Pronouncement of Death: 

Protocols for Pronouncement of Death In addition to the five signs of death, at least one of the associated factors of death must be present.

Protocols for Pronouncement of Death: 

Protocols for Pronouncement of Death Associated Factors Lividity (Livor Mortis) of any degree and/or generalized cyanosis , or Rigor Mortis of any degree , or The presence of venous pooling in the body , or Damage or destruction of the body which is incompatible with life (further detailed on next slide)

Protocols for Pronouncement of Death: 

Protocols for Pronouncement of Death Damage or Destruction further defined: Decomposition , or Incineration , or Decapitation , or Total separation of the heart or brain , or Any combination of the above

Protocols – Blunt or Penetrating Trauma: 

Protocols – Blunt or Penetrating Trauma The patient that is in arrest prior to or on arrival must: Have a present history of blunt/penetrating trauma , and Have met all of the aforementioned five signs of death , or Have failed to respond to 20 minutes of ALS treatment

Protocols – Blunt or Penetrating Trauma: 

Protocols – Blunt or Penetrating Trauma The patient arrests after your arrival but prior to transport from the scene must: Have a present history of blunt/penetrating trauma , and Have met all of the five signs of death as aforementioned , or Have failed to respond 20 minutes of ALS treatment

Protocols – Blunt or Penetrating Trauma: 

Protocols – Blunt or Penetrating Trauma The total extrication time for the patient exceeds twenty minutes: During which no resuscitative measures can be carried out prior to extrication , or Due to the size of the patient, there is insufficient manpower to facilitate the safe movement of the victim to a transport vehicle and during the 20 minute time frame the victim does not respond to ALS treatment , and The patient meets all five of the aforementioned signs of death

Termination of Efforts – Medical Condition: 

Termination of Efforts – Medical Condition Resuscitative efforts for a patient who suffers a cardiac arrest as a result of medical conditions or for a patient of advanced age, with evidence of severe wasting from chronic disease may be terminated in the field when three circumstances have occurred.

Termination of Efforts – Medical Condition: 

Termination of Efforts – Medical Condition Termination circumstances – Medical conditions: An ET tube has been placed & patient is being ventilated with 100% oxygen An IV line has been established & one dose of epinephrine & other initial cardiac drugs have been administered for the dysrhythmia Presenting rhythm is Asystole or PEA & Medical Control concurs with termination of efforts after consult with the paramedic at the scene

Termination of Efforts in the Field: 

Termination of Efforts in the Field 202 KAR 7:401 (Handout copy) Resuscitation initiated by the on scene Kentucky Licensed Paramedic may not be terminated without consultation with and the approval of on line physician medical control

Termination of Efforts in the Field: 

Termination of Efforts in the Field A Kentucky Licensed Paramedic is not obligated to continue resuscitation efforts that have been initiated inappropriately by other persons on the scene, including telephone CPR initiated by EMD or EMS dispatchers

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Patients who have suffered from Immersion Hypothermia for a confirmed period of greater than two hours may be pronounced by the paramedic

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Patients that present in arrest suspected to be hypothermic or have suffered immersion hypothermia for a confirmed period of less than two hours should receive full BLS & ALS care as deemed appropriate by local protocols

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Children 18 years and younger are specifically excluded from this policy unless the patient meets the criteria established under the aforementioned “Protocols for Pronouncement of Death” and on line physician medical control approves the pronouncement after consultation with the Kentucky Licensed Paramedic on the scene with the patient

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Multicasualty incidents are an exception to this policy The administration of CPR or other BLS measures or placement of an AED or other cardiac monitor , for the purpose of determining the presence or absence of viable cardiac activity, to an apparently dead person prior to or after the arrival of the Kentucky Licensed Paramedic, shall not preclude the pronouncement of death, in the field after complete assessment of the patient by the Kentucky Licensed Paramedic and after consultation with on line physician Medical Control, as may be required by this policy

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Nothing in this policy should be construed to prevent any EMS agency from withholding resuscitative for individuals that can produce a valid EMS DNR Form as addressed in KRS 311.623

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Special considerations for the transport of patients who may potentially be later pronounced dead: When in doubt as to whether resuscitation should be initiated, immediate efforts should be initiated at the highest level of care that can be provided by the caregiver. As quickly as a thorough patient assessment can be completed, immediate contact should be made with on line physician Medical Control to determine the need for transport or to terminate resuscitation efforts

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Special considerations for the transport of patients who may potentially be later pronounced dead (continued): Transport should not be delayed solely for the purpose of determining the efficacy of or response of the patient to ALS treatment. Transport should be initiated in a timely manner. Resuscitation may be terminated during transport if the patient meets the criteria for such. The time the resuscitation was terminated should be clearly noted on the ambulance service patient care report

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Special considerations for the transport of patients who may potentially be later pronounced dead (continued): Transport of the patient should be completed to the closest medical facility and the “Steps to Follow After Field Pronouncement of Death ” shall be followed

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Special considerations in the rendering of care for patients who may potentially be later pronounced dead: Avoid contamination of the scene. If circumstances require alteration of the scene for the purpose of aiding or assessing the patient, the Coroner’s office and Law Enforcement authorities must be notified. Avoid unnecessary contact with physical objects at the scene

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Special considerations in the rendering of care for patients who may potentially be later pronounced dead (continued): Anything carried into the scene in the way of dressings, wrappings or packages should NOT be removed by EMS personnel when leaving the scene. EMS personnel may be required to identify items that were utilized and/or then left at the scene. All sharps utilized by EMS personnel should be removed from the scene

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Special considerations in the rendering of care for patients who may potentially be later pronounced dead (continued): Avoid cutting through the clothing of the patient. If it is necessary to do so, avoid cutting through tears, bullet holes, or other damaged or stained areas of clothing In hangings or cases of asphyxiation, cutting through or untying knots in any material, unless necessary to free the airway

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Special considerations in the rendering of care for patients who may potentially be later pronounced dead (continued): In cases of penetrating trauma, objects should be left in place for medical reasons and for evidence collection purposes Do not wash or clean the hands of the victim or any other areas surrounding bullet wounds

Special Conditions, Considerations & Exclusions: 

Special Conditions, Considerations & Exclusions Special considerations in the rendering of care for patients who may potentially be later pronounced dead (continued): Be aware that you may find/encounter evidence entwined in the victims clothing. Be certain to check your stretcher and ambulance vehicle for the presence of any potential evidence (such as bullets that may fall out of heavy winter clothing) after each run. Any items of evidence should be turned over to the Coroner’s office or Law Enforcement agency. Clearly document in your run report what was found and wear it was found along with the name of the individual to whom the article(s) were released

The Patient is Pronounced Dead: Now what?: 

The Patient is Pronounced Dead: Now what? The death is a Coroner’s case: Coroner’s cases are defined in KRS 72.025 (Handout copy). KRS 72.020 (handout copy) requires the reporting of deaths which meet the criteria of KRS 72.025 to the Coroner and Law Enforcement agencies KRS 72.445 (Handout copy) Once appropriate agencies are notified, comply with “Scene Security”

The Patient is Pronounced Dead: Now what?: 

The Patient is Pronounced Dead: Now what? The death is not a Coroner’s case: Contact the Coroner for courtesy and confirmation that the death is not a Coroner’s case Assist family in contacting the funeral home Complete your paperwork and have family sign where/when appropriate Stand by, if possible, until funeral home personnel have arrived

The Patient is Pronounced Dead: Now what?: 

The Patient is Pronounced Dead: Now what? KRS 311.247 (Handout copy) This statute requires EMS, Law Enforcement and medical personnel to make a reasonable effort to determine if the victim is an organ donor and to make notifications as appropriate This is obviously preempted in Coroner’s cases until such time that the Coroner has completed his investigation and releases the body of the decedent for such purposes

Scene Security: 

Scene Security Once it has been determined the patient will be pronounced or resuscitative efforts will be halted, the body SHOULD NOT be covered. If it is necessary to cover the body, a new sheet, taken directly from factory packaging should be used due to the risk of contaminating the scene with trace evidence form a laundered or dirty sheet. You may close doors, hang sheets over windows or take whatever actions are prudent and appropriate to prevent the view of the body by the media or the general public. Personnel should secure the scene, remove all people from the scene, and withdraw from the immediate area, making certain that nothing is allowed to be removed from the scene, until appropriate authorities arrive at the scene.

Scene Security: 

Scene Security Pursuant to Kentucky Revised Statutes ( KRS ), the county Coroner and the police agency having jurisdiction over the scene shall be notified Once appropriate authorities arrive at the scene, the ambulance crew may be released to respond to other ambulance calls. The ambulance company is obligated to provide their staff to the Coroner or investigating law enforcement agency for interview purposes

Scene Security: 

Scene Security Under no circumstances should a scene be left unsecured prior to the arrival of the Coroner, Deputy Coroner or law enforcement agency. Likewise, a body should not be left in the possession of anyone prior to the arrival of the Coroner, Deputy Coroner or law enforcement agency representative Do not remove any item(s) from the body or the scene for any purpose

Scene Security: 

Scene Security If resuscitation is not to be attempted, do not move the victim without direction from the Coroner’s office unless the body has to be moved to allow for adequate assessment or the body must be moved to protect it’s integrity

Scene Security: 

Scene Security Begin immediate, thorough documentation of your findings of the scene on arrival. Use drawings or sketches to clearly show all pertinent details of the scene on your arrival. Remember that your observations may be the first observations of a crime scene or death investigation. Be detailed. Copies of the ambulance report shall be shared with the Coroner or the responding law enforcement agency pursuant to KRS 72.410 – 72.470

Scene Security: 

Scene Security Documentation within the report should include: Lists of all persons present when you arrived Any changes that were made at the scene as a result of your action Note as many facts about the scene on your arrival as possible including a sketch of the scene as you first saw it Note any comments that may have been made by people on the scene when you arrived. Be specific if possible about who made the comments Be sure to diagram on your sketch, the path(s) of entry and exit you followed at the scene

Closing Comments: 

Closing Comments These guidelines are applicable to KENTUCKY only. Be sure to operate under the guidelines of the State authority in which you are dealing with a decedent. State laws, statutes and regulations vary dramatically on these issues.

Questions?: 

Questions? Keith Widmeier NREMT-P, CCEMT-P, EMSI, AAS Wayne County EMS Training Officer 111 Jim Hill Service Rd Monticello, KY 42633 Phone-606-348-3303 Email- WayneCountyEMSTraining@gmail.com

Reference: 

Reference This PowerPoint was produced using the House Bill 285 – KRS 311A.185 Instructional Curriculum (designed by Charles M. O’Neal, Certified KY Master Coroner) as a reference.