Verifying and certifying death
Observe for 5 minutes, check pupils, response, heart sounds, breathing and pulse, record the time, then write the cause in a logical sequence.
A 78-year-old man with metastatic lung cancer, for comfort care only, has died. The nurse asks you to verify death. His sons are at the bedside and want to take him home tonight for burial tomorrow morning.
In the emergency department, a 25-year-old brought in after a road traffic accident has died despite resuscitation.
How do you verify death, what do you write for the first man, and why is the second one different?
- Verify deathNo central pulse, no heart sounds and no breath sounds for at least 1 minute each, after at least 5 minutes of observation.
- Pupils and responseFixed and dilated, no response to pain (supraorbital pressure).
- DocumentTime of verification, findings, who was present, implanted devices.
- Cause of deathThe disease process in order (WHO format). Not "cardiac arrest" alone.
- Medicolegal case?Trauma, poisoning, burns, suspicious, custody, unknown cause: inform police, no routine certificate.
- Speak to the familyPrivately, simply, with time for questions.
- Religious and practical needsMuslim burial is often within 24 hours: help with paperwork promptly.
- Unexplained or unnatural death
- Death in custody or after assault
- Concerns about care
- Family disputes the cause
- Possible organ or tissue donation
- A medicolegal case treated as natural
- Implanted device (pacemaker) not noted
- Wrong patient or time
- Writing a mode of death instead of a cause
- Possible infectious disease needing notification
| Observation | At least 5 minutes to confirm irreversible cardiorespiratory arrest |
| Heart and breath sounds | None for 1 minute each |
| Central pulse | None for 1 minute |
| Part I | Ia immediate cause, Ib due to, Ic due to (underlying cause) |
| Part II | Other conditions that contributed but didn't cause it |
| Medicolegal | Unnatural death, injury, poisoning, burns, custody, unknown cause: police and MLC process |
Check every dose against a current drug reference and your hospital protocol.
On this page
Verifying death
- Identify the patientWristband against notes.
- ObserveAt least 5 minutes for absence of breathing and circulation.
- Central pulseCarotid or femoral: none for 1 minute.
- Heart soundsNone for 1 minute.
- Breath soundsNone for 1 minute.
- Pupils and responseFixed and dilated, no response to supraorbital pressure.
Document: date and time of verification, the findings above, who was present, any implanted device (pacemakers must be removed before cremation; note them anyway), and that the family were informed.
Writing the cause of death (WHO format)
| Part | Meaning | Example |
|---|---|---|
| Ia | Disease or condition directly leading to death | Bronchopneumonia |
| Ib | Due to (or as a consequence of) | Metastatic carcinoma of the lung |
| Ic | Due to | Smoking-related (or blank if not needed) |
| II | Other significant conditions contributing to death but not causing it | COPD, type 2 diabetes |
- Write the disease, not the mode of dying. "Cardiac arrest", "cardiorespiratory failure", "respiratory arrest" alone are not acceptable.
- Avoid abbreviations.
- The underlying cause goes on the lowest line used in Part I.
- If unsure, ask your senior.
Medicolegal cases in Pakistan
Routine death certificate
- Medicolegal: inform police and the MLC officer
- no routine certificate
- post-mortem decision by the authorities
Discuss with your senior before writing anything
- Record injuries clearly and objectively.
- Preserve samples (blood, urine, gastric contents) if poisoning is suspected.
- Keep clothing and items as evidence where relevant.
- A dying declaration (a statement by a dying patient about the cause of their injuries) should be recorded properly, ideally before a magistrate; if not possible, by the doctor with witnesses, in the patient's words.
Talking to the family
- A quiet, private space. Sit down. Introduce yourself.
- Say clearly that the person has died; use the word "died".
- Allow silence and emotion. Answer questions honestly.
- Explain the next steps: paperwork, release of the body, and if medicolegal, why the police are involved.
- Respect religious practices (washing, prayers, early burial).
Common mistakes
- Writing "cardiac arrest" as the cause of death.
- Issuing a routine certificate for a road accident or poisoning death.
- Not documenting the time of verification.
- Delaying paperwork when the family needs to bury quickly.
- Breaking the news in a corridor.
Frequently asked questions
How do you verify death?
Confirm absence of a central pulse, heart sounds and breath sounds for at least 1 minute each after 5 minutes of observation, fixed dilated pupils and no response to pain, and record the time.
What should not be written as a cause of death?
Modes of dying such as "cardiac arrest" or "cardiorespiratory failure" alone. Write the disease that caused the death.
Which deaths are medicolegal?
Deaths from injury, road accidents, burns, poisoning, firearms, assault, drowning or hanging, deaths in custody, and deaths of unknown cause.
What goes in Part II of the death certificate?
Other significant conditions that contributed to death but didn't directly cause it.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. Which phrase should not be written as the underlying cause of death?
Answer: Cardiac arrest. Write the disease, not the mode of dying.
- Metastatic lung cancer: A disease.
- Myocardial infarction: A disease.
- Cirrhosis due to hepatitis C: A disease.
- Bronchopneumonia: A disease.
2. A man dies in hospital after a road traffic accident. What is required?
Answer: Inform the police as a medicolegal case. Deaths from injury are medicolegal; follow the MLC process.
- Issue a routine death certificate: Not for unnatural deaths.
- No action: No.
- Only inform family: Not enough.
- Release the body immediately: No.
3. How is death verified?
Answer: No pulse, heart or breath sounds. Confirm cardiorespiratory arrest and absent responses, record the time.
- Pupils only: Not enough.
- Cold skin: No.
- ECG for 10 seconds: Not enough.
- Absent radial pulse only: Not enough.
4. An elderly man dies at home. His doctor has treated him for heart failure and saw him a week ago. How should the cause of death be written on the certificate?
Answer: Ia immediate; underlying cause last. Medical certificates of cause of death follow the WHO format: Part I lists the chain from the immediate cause (Ia) back to the underlying cause (lowest line) — e.g. Ia congestive cardiac failure, Ib ischaemic heart disease. Part II lists other significant contributing conditions. Modes of death (cardiac arrest, respiratory arrest) alone should not be used. Unnatural, sudden unexplained or suspicious deaths must be reported to the police/medicolegal authorities instead.
- Ia "cardiac arrest" only: That is the mode of death, not the cause.
- Underlying cause in Part II only: Part II is for contributing conditions.
- Ia "heart failure"; rest left blank: The underlying cause must be recorded too.
5. At 2 a.m. an unconscious young man is brought to the emergency department smelling of pesticide. No police officer is present. What should the doctor do?
Answer: Treat, preserve samples, inform police. Medicolegal cases include suspected poisoning, injuries (assault, firearm, RTA, burns), sexual assault, unnatural or suspicious deaths, criminal abortion, unconscious patients without clear cause, and injuries in custody. The doctor’s first duty is to save life — emergency treatment must never be delayed for police or consent (implied consent/doctrine of necessity). Then: register in the medicolegal register, give accurate contemporaneous notes, preserve and label samples with chain of custody, inform the police (and a magistrate if a dying declaration is needed), and issue the medicolegal certificate (MLC). Refusing or delaying emergency care is a breach of duty.
- Wait for police before treating: Treatment cannot wait for the police.
- Refer to another hospital: Emergency treatment must not be delayed by referral or police formalities.
- Treat but don’t document anything: Documentation is essential in a medicolegal case.
6. At autopsy of a woman who died suddenly 9 days after delivery, the pathologist must decide whether material in her pulmonary arteries is an embolus or a postmortem clot. Which feature indicates a postmortem clot?
Answer: Separate currant-jelly and chicken-fat layers. After death, blood clots in the vessels without flow, so the red cells settle by gravity. The result is a soft, rubbery, gelatinous clot with a dark red lower part (currant jelly) and a yellow upper part of plasma and fibrin (chicken fat), lying free and not attached to the wall. A thromboembolus is firm, dry and friable, may be coiled because it formed in a larger leg vein, and shows lines of Zahn from formation in flowing blood.
- A firm, dry and friable texture throughout: Typical of an antemortem thrombus.
- A coiled shape that fits a larger vein: Suggests an embolus from a larger leg vein.
- Firm attachment to the vessel wall: Suggests a thrombus formed in life.
- Alternating pale and red laminations: Lines of Zahn indicate formation in flowing blood.
7. What causes rigor mortis after death?
Answer: Lack of ATP to detach myosin. ATP is needed to release the myosin head from actin. After death, ATP runs out, so cross-bridges stay locked and muscles become stiff. Rigor starts at about 3 hours, peaks at 12 hours and passes off by about 36–48 hours as proteins break down.
- Excess ATP binding myosin: ATP actually releases the cross-bridges.
- Failure of calcium release: Calcium leaks out after death, allowing binding.
- Breakdown of troponin: Protein breakdown ends rigor rather than causing it.
- Loss of nerve supply: Denervation causes flaccidity, not rigidity.