Diagnosis of death using neurological criteria - guidance regarding not performing the Apnoea Test in the context of evidence of high cervical spinal cord injury

In 2022 a diagnosis of death using neurological criteria was made in a child which had to be reversed later when the patient had return of spontaneous albeit abnormal breathing. An expert group reviewed this case in detail. This guidance summarises the essential immediate implications arising from that review for the clinical community.

Publication date: 16 February 2023

Background: the diagnosis and confirmation of death in the UK

A code of practice for the diagnosis and confirmation of death, published by the Academy of the Medical Royal Colleges (AoMRC) in 2008, sets out guidance for the diagnosis and confirmation of death. Death entails the "irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breathe".

For children aged 2 months to 18 years, the 2008 AoMRC code of practice applies.

For infants between 37 weeks corrected gestation (post menstrual) and 2 months (post term), the RCPCH has issued additional guidance
The process for testing a patient’s capacity to breath is known as the ‘apnoea test’. However, it is a precondition that ‘potentially reversible causes of apnoea’ be excluded before the ‘apnoea test’ is conducted.

Specifically, the Code states at 5.3 (bold text our emphasis): "When coma follows a head injury, the presence of a cervical spine injury must be excluded in the usual way using clinical criteria, plain X-rays, CT, and MRI scans as indicated. If there are reasons to suspect that an underlying high cervical spine injury and associated cord injury are causing the apnoea, then the apnoea test becomes invalid."

Guidance to clinicians

  1. All necessary pre-conditions must be met prior to the diagnosis of death using neurological criteria being made.
  2. In the context of head injury, it is possible that upper cervical spinal cord injury alone may cause apnoea. The AoMRC is clear that a) the presence of cervical cord injury must be excluded where trauma is the mechanism of injury, and b) where evidence of cervical cord injury is found, clinicians do not proceed to conduct the apnoea test since the cervical cord injury renders its interpretation invalid.
  3. In this rare scenario irreversible cessation of brain stem function can be only established by confirming the absence of other brain-stem reflexes and by using ancillary investigations.
  4. In adults cerebral CT angiography (CTA) is the standard ancillary investigation of choice in the UK for supporting the diagnosis of death using neurological criteria. Recently a consensus group has established a standardised protocol for CTA (PDF).
  5. In children under 16 years of age there is a paucity of evidence regarding the use of cerebral CTA, and currently it is not possible to make consensus recommendations for the use of ancillary investigations in the paediatric population. In clinical situations where ancillary investigations are considered necessary, there should be a local case-by-case discussion. The use of ancillary investigations to support a clinical diagnosis of death using neurological criteria is not recommended in neonates less than 2 months corrected gestational age. A Paediatric Critical Care Society working group is currently developing guidance for ancillary investigation in children.
  6. If irreversible cessation of brain stem function cannot be established, this should lead the clinical team to pause and re-consider. One course of action might be to limit life sustaining treatment on a best interest’s basis (see RCPCH Framework for Practice (PDF).

The current guidelines are being updated and can be accessed at: