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Death

Last updated: April 29, 2026

Summarytoggle arrow icon

Death is the cessation of life, but where life ends and death begins is not always clear. In medical contexts, a distinction is drawn between cardiopulmonary death (irreversible cessation of heartbeat and respiration) and brain death (irreversible cessation of all brain and brainstem function). Considering that pronouncing death is usually a physician's responsibility, it is important to know the signs of death and the differences between reversible and irreversible clinical death. If there is a delay before death has been pronounced or the events leading up to death are unclear, knowing irreversible postmortem changes also helps in determining both the manner and time of death. These changes may be of medical and/or legal interest and include rigor mortis, livor mortis, Tardieu spots, and decomposition. When pronouncing death, it is important to understand the events leading up to death, if it was expected or not, and to conduct a careful examination before declaring the death and its time. Since addressing family and friends after death is a very emotional and vital responsibility, clinicians should be prepared by having a clear approach for dealing with this situation. In addition, special documentation must be handled, including writing a death note, death summary, and death certificate. Important steps should also be considered if the patient is a potential donor candidate or if a medical examiner/coroner should be notified for further investigation and possibly an autopsy. Clinical autopsies are performed for the purpose of medical diagnosis and research, while forensic (i.e., medicolegal) autopsies are performed for the purpose of establishing the cause and manner of death, especially if there is evidence of foul play.

Overviewtoggle arrow icon

  • A number of ethically challenging scenarios may arise in the context of end-of-life care.
  • At the end of life (as throughout life), the core ethical principles of medicine should be upheld and the physician should act in the best interest of the patient.
  • Proper knowledge of the legal and ethical aspects of end-of-life care allows the physician to practice efficient and evidence-based medicine while respecting the patient's wishes.
  • In disputes over end-of-life issues, the physician plays a key role in facilitating communication and emphasizing the importance of focusing on what patients themselves would have preferred.

Definitionstoggle arrow icon

  • Death: : An ambiguous term referring to the cessation of life. Death can be diagnosed if a patient meets the criteria for brain death or cardiopulmonary death.
  • Apparent death
    • Reduction of vital function to a minimum, creating the appearance of death without signs of certain death
    • Misdiagnosing apparent death as clinical death can have grave consequences such as postponing vital care, false alarms for organ donation, and unnecessary emotional stress for family members.
  • Clinical death (somatic/systemic death): a term for the cessation of respiration and circulation
    • May be reversible
    • Some descriptions may also consider the loss of brain activity as a component of clinical death.
  • Cardiopulmonary death: irreversible cessation of circulatory and respiratory functions
  • Brain death: irreversible, complete loss of function of the entire brain (including the brainstem), even if cardiopulmonary functions can be upheld by artificial life support
    • Two physicians are required to make the legal diagnosis of brain death.
    • See “Requirements for the diagnosis of brain death” for more information.
  • Intermediary life: the period of time between irreversible cardiopulmonary death and biological death
  • Biological death (molecular/cellular death)
    • Permanent and irreversible cellular damage with complete cessation of metabolic cell function
    • Tissue that has undergone biological death is unsuitable for transplantation.
  • Legal death
    • Recognition of a person's death under the law
    • Legal death comprises medically determined death (e.g., via a doctor's declaration of death) as well as the presumption under the law that a person is dead after a prolonged and unexplained absence with no signs of life (declaration of death in absentia).
  • Uniform determination of death act
    • In the US, legal provisions regarding death and the clinical examinations or legal investigations it may entail vary from state to state.
    • However, all states have adopted the “Uniform determination of death act” (1981), which specifies that the determination of death must be made in accordance with accepted medical standards and depends on either cardiopulmonary death or brain death.

Signs of deathtoggle arrow icon

  • Understanding the signs of clinical death is important for correctly declaring death.
  • Prematurely pronouncing death can have grave consequences, including neglecting potentially vital care, giving false alarms for organ donation, and unnecessary emotional stress for family members.
  • Uncertain signs of death must be considered in relation to certain and irreversible signs of death, such as cardiopulmonary and brain death.
  • If there is a delay before death has been pronounced or the events leading up to death are unclear, irreversible postmortem changes can help also in determining both the manner and time of death.

Uncertain signs of deathtoggle arrow icon

Cardiopulmonary deathtoggle arrow icon

Cardiopulmonary death is the irreversible cessation of circulatory and respiratory functions. The following factors must be considered before making this determination:

  • Monitoring of the patient for a specific period of time to confirm continuous apnea, unconsciousness, and lack of circulation
  • Exclusion of factors that may be the cause of the cardiorespiratory arrest, such as:
  • No intention of beginning or continuing cardiopulmonary resuscitation (CPR); prohibition of any intervention that might restore cerebral blood flow [1]
  • Often synonymous with clinical death, but it is important to understand that clinical death is usually considered to be reversible

Brain deathtoggle arrow icon

Definition

  • The irreversible, complete loss of function of the entire brain (including the brainstem), even if cardiopulmonary functions can be upheld by artificial life support. [2]
  • Differs from persistent vegetative state, in which brainstem functions are preserved

Declaring brain death

Declaring brain death requires all of the following:

  • Establish irreversible coma and the possible cause (e.g., acute severe damage to the CNS consistent with brain death as established by clinical or radiologic evidence).
  • Brain death may not be established if one of the following is present in the patient:

Neurological examination

Confirms coma, brainstem areflexia, and apnea.

Ancillary brain death tests

Confounding conditions

Ethical issues concerning brain death [3][4]

  • If a patient has been declared to have brain death, no consent is needed to withdraw life-sustaining therapy.
  • The patient's family should be informed that the patient is being assessed for brain death as soon as the evaluation has started.
  • The patient's family should be given a reasonable amount of time to visit the patient and accept the diagnosis before discontinuation of life-sustaining treatment. [5]
  • If the patient's family disagrees with a diagnosis of brain death:
    • Discuss the family members' concerns with them; express empathy and respect for their position and provide additional information to eliminate any misunderstandings regarding the diagnosis. [3]
    • Involving a hospital ethical committee may be helpful in resolving disagreements. [3]
    • If the disagreement stems from religious or cultural beliefs, consider involving chaplains and/or local cultural leaders in the discussion. [6]

If spontaneous breathing is present, the medulla is intact. If the corneal reflex is present, the pons is intact. If the pupillary light reflex is present, the midbrain is intact.

Postmortem changestoggle arrow icon

The postmortem period is divided into the supravital period, early postmortem changes, and late postmortem changes (decomposition). For more information, see "Supravital period", "Early postmortem changes", and "Late postmortem changes" in "Autopsy and thanatology."

End-of-life issuestoggle arrow icon

End-of-life issues are diverse and affect patients, their loved ones, and treating teams in significant and varying ways.

Clinical care

Ethical and medicolegal issues

Communication skills, counseling, and wellness

Medical aid in dyingtoggle arrow icon

  • Physician-assisted dying [7][8]
    • Physician provision of medication, intervention, or information to a patient to enable or accelerate their death
    • Illegal in most states
    • The U.S. Supreme Court has ruled three times that the laws of physician-assisted death are to be decided on a state-by-state basis.
  • Euthanasia
    • Active and intentional termination of a patient's life, usually by sedative or paralytic, performed by the physician at the explicit request of the patient
    • Requires the full process of informed consent before initiation
    • Currently illegal in the U.S.
  • Terminal sedation [9]
    • The administration of sedative medication to a terminally ill patient to relieve intractable end-of-life pain
    • Legal and distinct from euthanasia
    • The intent must be to relieve pain rather than bring about death, even though doing so may hasten the dying process.
    • Not an appropriate means of addressing suffering that is primarily existential (e.g., death anxiety). [10]
    • Relies on the principle of double effect
      • An ethical principle that legitimizes an act of good intent despite causing serious harm
      • An act may be justified when the positive effects outweigh the negative ones (e.g., administering large amounts of opioids to relieve pain despite causing respiratory depression).

Pronouncing deathtoggle arrow icon

  • Laws regarding who is authorized to pronounce a person clinically and/or legally dead as well as who is authorized to order an investigation into the circumstances of death vary from state to state.
  • If a patient dies while under care, it is generally the physician's responsibility to examine the body to pronounce the death and record the time. Clinicians may also be called to the bedside for declaration of death.
  • In some states, registered nurses (especially in hospice settings) are authorized to pronounce death.
  • If no physician or registered nurse is readily available, a medical examiner or coroner is called to the scene to declare death.
  • Emergency response teams may pronounce a person “Dead on Arrival” (DOA) if certain criteria are met (e.g., obvious postmortem changes or injuries that are incompatible with life such as decapitation or evisceration of thoracic contents).
  • The specific procedures vary depending on the clinical scenario (e.g., cardiac death vs. brain death). Signs of death aid in diagnosing certain death and determining the time of death.

Approach

  • If called to declare death, determine:
    • If it was expected or not
      • If it was unexpected, efforts should be made to go immediately to the patient for assessment.
    • Who has already been informed
    • If family members are present
  • Assess the patient [11][12][13]
  • Pronounce the time of death
    • The official time of death is the time at which the examination confirms death.
    • If family or friends are present, determining the time of death via phone should be avoided. Instead, a watch or wall clock should be used.
  • Determine further information
  • Communicate with loved ones: See “Addressing family and friends after death.”
  • Complete documentation: See “Documentation of death.”

Documentation of deathtoggle arrow icon

Physicians should follow local institutional protocols. They generally include:

Death certificatetoggle arrow icon

  • In the US, the authority to sign death certificates varies from state to state.
  • Generally, physicians are authorized to sign death certificates when the manner of death is natural, whereas in, e.g., violent or suspicious deaths, the authority lies with a coroner or medical examiner.
  • The U.S. Standard Certificate of Death provided by the CDC's National Center for Health Statistics (NCHS) records the following information:
    • To be provided/verified by the funeral director
      • Decedent's personal information (name, address, relations, race, education, occupation, etc.)
      • Place of death
      • Method and place of disposition
      • Funeral facility information
    • To be provided by the medical certifier

Investigation of deathtoggle arrow icon

Reportable types of death

The initial postmortem examination may not provide conclusive information regarding the manner, cause, mechanism, or mode of death. In certain types of death, an investigation is required by law. The specific characteristics of death that require an investigation vary from state to state. Below is a selection of the types of death that most commonly require reporting:

  • Undetermined death
  • Suspicious/unusual/unnatural circumstances
  • Accident/casualty
  • Suicide
  • Violence
  • Homicide
  • Fetal/infant death
  • Sudden death when in apparent good health
  • Abortion/criminal abortion (maternal or fetal)
  • Death from injury
  • Therapeutic death or circumstances suggesting gross negligence in a healthcare setting
  • Death that may constitute threat to public health
  • Death in jail/police custody
  • Drug and/or chemical overdose or poisoning

Professionals involved in the investigation of death

  • Physician
    • Conducts postmortem examination
    • Determines the cause, time, and manner of deaths that occurred under natural circumstances; declares death; issues death certificates
    • Notifies local death investigation office if the type of death requires reporting (e.g., if it occurs under unnatural circumstances)
  • Coroner
    • Elected government official tasked with running the investigation to determine the cause, time, and manner of deaths that occurred under unexpected, violent, and suspicious circumstances or in the absence of a physician
    • Declares death; issues death certificates; initiates inquests; requests autopsies; qualifications, functions, and authority vary from state to state; does not require medical training
  • Medical examiner: medically trained government official qualified to perform autopsies; otherwise similar functions and authority as coroner
  • Forensic pathologist: establishes cause of death and performs autopsy upon the request of the medical examiner or coroner
  • Death investigator: assists the medical examiner/coroner in investigating deaths, focusing on the collection of information on the decedent and guiding the investigation process.

Inquest

  • A legal inquiry before a coroner or medical examiner to establish the identity of the decedent and the time, place, cause, and manner of death.
  • Often involves a jury; inquiries are conducted almost exclusively in the event of deaths taking place under unexpected, violent, or mysterious circumstances.

Manner of deathtoggle arrow icon

The first step in investigating a death is determining the manner by which a person died. If the manner of death is determined to be natural, a further investigation is not legally obligatory, while unnatural manners of death elicit an inquiry into the precise circumstances. The manner of death is distinct from the mode, cause, and mechanism of death in so far as the manner is the root cause of how the death occurred (e.g., “homicide” involving an axe attack), while the cause is the disease or injury that causes death (e.g., an “axe wound”), the mechanism is the physiological derangement that causes death (e.g., “exsanguination” due to an axe wound), and mode is the abnormal physiological state in an individual at the time of death (coma = failure of brain function, syncope = failure of heart function, asphyxia = failure of respiratory system; e.g., “coma” from axe wound). The manner of death is of particular importance because of the legal consequences that inevitably follow any unnatural manner of death.

  • Natural manner of death
    • Due (nearly) exclusively to disease and/or age
    • Patient history characteristic of a specific cause of death
    • Clear and objectifiable findings characteristic of underlying disease
    • No evidence of third-party interference in the course of the disease
  • Unnatural manners of death: death caused by external events or a third party
    • Accident: death from injury or poisoning without evidence of third party intent to kill or cause harm
    • Suicide: death from intentional, self-inflicted injury or poisoning for the purpose of causing self-harm or death
    • Homicide: death from intentional injury or poisoning committed by another person for the purpose of causing fear, harm, or death. Intent is a common element, but it is not required for classification.
  • Could not be determined: applied to deaths in which the manner could not be determined even after consideration of all information available
  • Pending investigation: if determination of the manner of death depends on further information

Autopsytoggle arrow icon

An autopsy is the close examination of a body to determine the cause of death. It typically involves the dissection of the body. Many states require that a pathologist performs the autopsy. However, in some states, autopsies may also be performed by medical examiners without a degree in pathology.

Training healthcare providers on deceased patientstoggle arrow icon

  • Performing procedures on newly deceased patients can provide valuable hands-on training for inexperienced health care providers.
  • Training procedures may be performed if the deceased patient has consented through advanced directives.
    • In the absence of an advanced directive, consent may be obtained from the next-of-kin.
  • If the deceased patient's identity is unknown, health care providers may search through the patient's belongings and share the patient's personal information (e.g., social security number) with authorities to determine their identity and contact next-of-kin. [16]
  • Performing any kind of unnecessary procedure on a deceased person's body without written consent from the patient or the next-of-kin is unethical, regardless of the procedure's degree of invasiveness.
  • If consent is obtained, the patient's body should be treated with respect, and the educational/research procedures should be conducted according to a plan and under direct supervision of an expert.
  • All procedures undertaken on the cadaver should be documented in the patient's medical record.

Referencestoggle arrow icon

  1. International Guidelines for the Determination of Death. https://www.who.int/patientsafety/montreal-forum-report.pdf. Updated: October 1, 2012. Accessed: April 14, 2021.
  2. Greer DM, Shemie SD, Lewis A, et al. Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project.. JAMA. 2020; 324 (11): p.1078-1097.doi: 10.1001/jama.2020.11586 . | Open in Read by QxMD
  3. Nikas NT, Bordlee DC, Moreira M. Determination of Death and the Dead Donor Rule: A Survey of the Current Law on Brain Death. J Med Philos. 2016; 41 (3): p.237-256.doi: 10.1093/jmp/jhw002 . | Open in Read by QxMD
  4. Gardiner D, Shemie S, Manara A, Opdam H. International perspective on the diagnosis of death. Br J Anaesth. 2012; 108: p.i14-i28.doi: 10.1093/bja/aer397 . | Open in Read by QxMD
  5. Wijdicks EF, Varelas PN, Gronseth GS, Greer DM, American Academy of Neurology. Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010; 74 (23): p.1911-1918.doi: 10.1212/WNL.0b013e3181e242a8 . | Open in Read by QxMD
  6. $Sample Brain Death Policy for Hospital Adaptation.
  7. Schofield GM, Urch CE, Stebbing J, Giamas G. When does a human being die?. QJM. 2014; 108 (8): p.605-609.doi: 10.1093/qjmed/hcu239 . | Open in Read by QxMD
  8. Friedrich AB. More Than “Spending Time with the Body”: The Role of a Family’s Grief in Determinations of Brain Death. J Bioeth Inq. 2019; 16 (4): p.489-499.doi: 10.1007/s11673-019-09943-z . | Open in Read by QxMD
  9. Weiner J. How Should Clinicians Respond When Patients' Loved Ones Do Not See “Brain Death” as Death?. AMA Journal of Ethics. 2020; 22 (12): p.E995-1003.doi: 10.1001/amajethics.2020.995 . | Open in Read by QxMD
  10. Annas GJ. Congress, Controlled Substances, and Physician-Assisted Suicide — Elephants in Mouseholes. N Engl J Med. 2006; 354 (10): p.1079-1084.doi: 10.1056/nejmlim060731 . | Open in Read by QxMD
  11. Code of Medical Ethics Opinion 5.7: Physician Assisted Suicide. https://www.ama-assn.org/delivering-care/ethics/physician-assisted-suicide. . Accessed: March 16, 2023.
  12. AMA Code of Medical Ethics. http://journalofethics.ama-assn.org/2013/05/pdf/coet1-1305.pdf. Virtual Mentor. 2013; 15 (5): p.428-429.
  13. AMA Council on Ethical and Judicial Affairs. AMA Code of Medical Ethics' Opinions on Sedation at the End of Life. AMA Journal of Ethics. 2013; 15 (5): p.428-429.doi: 10.1001/virtualmentor.2013.15.5.coet1-1305 . | Open in Read by QxMD
  14. Council on Ethical and Judicial Affairs of the American Medical Association.. Performing procedures on the newly deceased.. Acad Med. 2002; 77 (12 Pt 1): p.1212-6.
  15. Performing Procedures on the Newly Deceased. https://www.ama-assn.org/delivering-care/ethics/performing-procedures-newly-deceased. . Accessed: April 23, 2023.
  16. Anatomical Gifts Act (2006). https://www.uniformlaws.org/viewdocument/final-act-19. Updated: August 26, 2009. Accessed: November 2, 2021.
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