A Test For Death / A Test For Life
By Mike Wolffram
Introduction:This paper has been prepared with the point of raising discussion in the industry around this subject. The writer remains aware that the issue of legal responsibility must always be the major consideration and does not intend to convey an impression that there should be any change in this area. The matter of professional responsibility however derives from the public's view of our ethical responsibilities, our individual and personal professionalism, our duty of care and the expectations of our client families.
Background:
Embalmers through their training generally form the habit of making a "Test for Death".1 It is acknowledged at the beginning of this discussion that although this long-standing practice has not been thought of as a legal responsibility of the embalmer, it has been seen as a professional responsibility. Funeral Directors and Embalmers understand that while it is the legal responsibility of the attendant medical practitioner to certify death, there have always been occasions when the medical practitioner does not physically see the body prior to signing the medical Certificate of Causes of Death (BDM 50). In certain instances there exists no legal compulsion for them to do so - and so they don't!2 Anecdotal reports from different areas of the country indicate a growing practice amongst GP's servicing Rest homes, not to sign certificates after hours or on weekends. Whatever the resolution of the legal issues involved may prove to be, Funeral Directors, under pressure from mourning families, do embalm on the promise of the certificate, perhaps from the Rest home manager, sometimes from the GP. Although this is in no way condoned by industry codes of practice, the practical, though somewhat dangerous choice to embalm a body when a certificate has not yet been issued, does occur from time to time. It is in such circumstances, (together with those instances of non-institutional deaths where Burial is the means of disposal) that the funeral Director needs to have heightened awareness around the so-called Test For Death. Most institutions, Rest homes, Hospitals, Hospice, will have protocols that require the attendant GP to sight the deceased body prior to release. We can take it that 'sight' means a professional medical evaluation to make confirmation of the absence of life and to positively identify the patient. There remain many occasions where for expediency; such practices are adapted to local arrangements, to meet family requests for early release or because of the GP's temporary absence.
If we consider the recommendations of the Wellington Coroner following a well-documented Lower Hutt incident, Funeral Directors and Embalmers have been challenged to build their own protocols. These he suggests should include a time lag between death and embalming and the issuing of the correct documentation. He has further made recommendations around the requirement of professional training of those involved with the preparation of deceased human beings.
Industry has reacted to this with a range of responses, including further approaches to Government for recognition of professionalism through registration.
For most of the cases we receive into our funeral homes we can be reasonably assured that there have been some either expert or inexpert tests for signs of death prior to our receipt of the deceased person, however with home deaths it is possible that no test for signs of death have occurred at all.
The expert and inexpert tests for signs of death:3
Definition: A test for death is any procedure used to prove a sign of death
A properly trained individual usually administers an expert test for death. eg. Doctor
- Stethoscope - used to detect sounds of circulation or breathing.
- Ophthalmoscope - used to examine the eye to detect circulation in the capillaries.
- Electroencephalogram (EEG) - used to detect brain activity.
- Electrocardiogram (EKG, ECG) - used to detect heart activity.
An inexpert test for death can be as simple as placing a saucer of water on the chest to detect any ripples that might suggest cardiac or respiratory activity.
- Ligature Test - ligate a finger with ligature or a rubber band. If the finger becomes swollen and discoloured this indicates a sign of circulation.
- The eye check for fixed dilated pupils
- Pulse - Digital pressure can be applied on the radial or the common carotid artery to feel for a pulse beat.
- Placing the testers ear over the chest cavity - heart or respiratory sounds may be able to be heard in this manner. Or Stethoscope - used to detect sounds of circulation or breathing.
- Ammonia Test -a small amount of ammonia is injected subcutaneously. If there is a reddish reaction this indicates life is present.
Timing:
This is a crucial point that goes to the heart of the Funeral Director's professional responsibilities. t is noted that in many practices the test for death is timed to coincide with the beginning of the embalming process. The Embalmer, as part of the routine pre-embalming case analysis carries it out. In our busy mortuaries deceased persons are frequently transferred from the place of death and are then transported to the funeral home mortuary room, where they may be placed on a table and dealt with at once, left on a stretcher for some indeterminate amount of time, or perhaps placed in a holding room or low temperature environment for a period of time. The timing of the next step is dependant upon the availability of certification, permission to embalm, the expression of family needs and the availability of the embalmer. We can see in practice that the test for death routinely applied by the embalmer may occasionally occur close to arrival of the deceased at the funeral home but equally may not occur for between several and many hours following receipt into the funeral home.
Renaming the test:
The problem here is; if such a test is to have validity in relation to the assurances the Coroners recommendations indicate are necessary, for professional trust issues to be met, the timing of the test needs to be much closer to the point of arrival in the funeral home, rather than 'several to many' hours. One way to achieve a new sense of awareness in the industry around this issue and to give the public the assurance they need in our professional responsibilities is to re name the test to a "Test For Life".
Test for Life:
Using this terminology puts a somewhat different connotation upon the existing practice. For those who do not presently employ a routine practice of testing for signs of death this might afford an ideal opportunity to consider instigating one. There should be no need to change the standard practices, except for their timing. Tests that indicate signs of life are sufficient to involve an expert at once (call an ambulance!) Tests that indicate signs of death obviously require no further action.
Practical application:
The resolve to change would simply see a standard practice instituted in each funeral home that all bodies arriving, receive a test for life. (There are obviously a large number of exceptions to such a rule, including the arrival of autopsied cases, decomposed cases etc) However, one must also consider the practice of medical practitioners in Coroners cases. Police Doctors will often provide their own reassurance of the absence of life by checking the pupils, taking a pulse and using the stethoscope, even in cases where injuries are so severe that these tests seem superfluous, professional responsibility is only discharged when the tests are complete.
In Summary:
¥ The responsibility for deciding that life is no longer present is generally not that of the Funeral Director.
¥ The legal responsibility clearly lies with the Rest home or institution, the GP, or those professionals attendant upon the dying person
¥ There are some circumstances where the Funeral Director/Embalmer may be the only person who makes physical appraisal of the deceased with a view to ensuring the absence of life, prior to the embalming procedure.
¥ There is a long-standing practice in Embalming to provide a test for signs of death prior to the commencement of an operation.
¥ A change in timing of the Tests for signs of death accompanied by an understanding that we are in fact testing for signs life needs to be considered.(the absence of such signs creates no action; the presence of such signs promotes immediate reaction)
¥ The adoption of this practice by the industry overall would be in accord with the spirit of the Wellington Coroner's recommendations.
¥ The adoption of this practice by the industry would enhance trust responsibility of the Professional Funeral Director in the community.
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