# Paramedic's can not pronounce someone DOA?



## EMTCop86 (Nov 23, 2008)

I have always thought that paramedics were able to pronounce someone DOA but I have been recently told differently. Only a MD can pronounce someone DOA. Paramedic's can "refuse" treatment in certain cases when they know someone is dead but have to call an MD to officially pronounce it, but as far as paramedics actually pronouncing them DOA they are forbidden. Is this correct?


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## akflightmedic (Nov 23, 2008)

No this is not entirely correct.

You will find it varies from state to state, possibly even system to system as with everything else in EMS.

In Alaska, we had the authority to pronounce dead as medics and EMT Basics were allowed to do it under extreme situations which were clearly defined so there was no misinterpretation.


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## Melbourne MICA (Nov 23, 2008)

EMTCop86 said:


> I have always thought that paramedics were able to pronounce someone DOA but I have been recently told differently. Only a MD can pronounce someone DOA. Paramedic's can "refuse" treatment in certain cases when they know someone is dead but have to call an MD to officially pronounce it, but as far as paramedics actually pronouncing them DOA they are forbidden. Is this correct?



That sounds right to me. Under licensure with the state, mandate for responsibility in all matters medical is assigned to the medical profession - that's not us. 

In aussie land determination of death is the province of the pts doctor or coronial office in his/her absence. The "State" takes a statutory interest in the death of every citizen (and their "life") but delegates responsibility to the "professional" most likely to make a judgement in keeping with medical practice, the views of the "state" - another way of saying the society taking into account minority religious and other interest groups needs - but the state still has privy over this issue. For example, the "state" may order an autopsy against the wishes of individuals or groups if believed warranted.

Believe it or not their is even a stipulation as to what are the "absolute indicators" of death written into legislation -  a kind of "death act". This is now being challenged by interpretations from many parties as to what constitutes death - you know the "brain dead" person etc and interestingly this parallels with how we view what constitutes "life" - when in starts etc.

Previously the "absolute indicators" of death (here in Australia) were;

1. Decapitation
2. Significant visceral trans-section
3. Putrefaction

All other indicators are not so clear cut (pardon the pun) as they may mimic death and so do not fall into the first category. The waters get muddier the more equivocal indicators are that's why there is just one person making the final judgement at the behest of the "state".

Fortunately for us, the state, through the decision makers of the medical profession have given us a much broader scope of decision making ability (within reason and often strict criteria) to make determinations of death - up to a point.

This is all about what is "reasonable" to expect from a person with a certain level of medical training such as we Paras without fear of common law challenge. Most ambos who have served for a few years would be a better judge of when someone has died than most GP's - personally I've seen hundreds of very dead people.

Unfortunately there are medico-legal and insurance factors (and economic costs as well) taken into account.

The problem is less about when someone is dead and more about providing or withholding treatment (resus). The vast majority of court cases against ambos would certainly have been involving these issues.

Still, it's a very sensitive issue with many stakeholders needs that have to be met.

So in short - the chain of ultimate responsibility starts with the state and ends with the state or its delegated representative - the Doctor.

It's actually a very interesting area of medicine -the whole death thing if I can so crudely put it.

MM


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## Sapphyre (Nov 23, 2008)

I'll pull out the regs later if you want.  Paramedics, and in some cases EMTs can presume death in my system in cases of extremely obvious death (decapitation being one of them).  The medics still have to call med control to make it official.

/rocking the parking lot, til 0700


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## fortsmithman (Nov 23, 2008)

Here in the NWT to the best of my knowledge if the death is in a hospital or nursing home setting the MD can pronounce, but outside of those two settings the Coroner pronounces.


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## Ridryder911 (Nov 23, 2008)

Usually pronouncement of death is only made by a licensed medical physician. This is the one signing the Death Certificate. Some areas still use elected officials with NO medical training called County Coroner. 

Paramedics and EMT's usually can _*declare death *_which is stating someone is dead. This is not the same legal term as pronounce of death. The same effect though. 

R/r 911


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## fortsmithman (Nov 23, 2008)

Ridryder911 said:


> Usually pronouncement of death is only made by a licensed medical physician. This is the one signing the Death Certificate. Some areas still use elected officials with NO medical training called County Coroner.
> 
> Paramedics and EMT's usually can _*declare death *_which is stating someone is dead. This is not the same legal term as pronounce of death. The same effect though.
> 
> R/r 911


Most of our Coroners here in the NWT don't have any formal medical training.  Our Coroner's are appointed.


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## EMTCop86 (Nov 23, 2008)

Thanks for the answers guys clears things up quite a bit.


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## akflightmedic (Nov 23, 2008)

In Alaska, a medic CAN sign the death certificate.

My name is on one of these, my first and presumably the last one I will ever do.

Typically, the doctor is willing to sign for your decision, however on occasion, they may ask the medic to do so. I imagine this procedure exists due to the remoteness of many of the villages. 

Usually when we pronounced in a remote village, if there were no suspicions to transport the body back to a larger town, we just left the body with the family so they could bury it and called in the death to the state police and the medical director. And this is how and why sometimes the medic had to sign the death certificate.


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## KEVD18 (Nov 23, 2008)

as R/r mentioned, the big diff is *declare v. pronounce.* we can declare them dead, and call the doc to pronounce. in some areas, you dont call olmc but go direct to the me/coroner and they do the pronouncement.


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## tydek07 (Nov 23, 2008)

Ridryder911 said:


> Usually pronouncement of death is only made by a licensed medical physician. This is the one signing the Death Certificate. Some areas still use elected officials with NO medical training called County Coroner.
> 
> Paramedics and EMT's usually can _*declare death *_which is stating someone is dead. This is not the same legal term as pronounce of death. The same effect though.
> 
> R/r 911




Ridryder hit it right on the nose!

Take Care,


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## Melbourne MICA (Nov 23, 2008)

Ridryder911 said:


> Usually pronouncement of death is only made by a licensed medical physician. This is the one signing the Death Certificate. Some areas still use elected officials with NO medical training called County Coroner.
> 
> Paramedics and EMT's usually can _*declare death *_which is stating someone is dead. This is not the same legal term as pronounce of death. The same effect though.
> 
> R/r 911



A nice clarification Ridders. Thank goodness the days of transporting and doing pointless resus on obviously dead people are (almost?) gone for Paramedics. 

Paramedics with years of experience and degree level university training should surely be able to make a reasoned and sensitive judegment over such things providing process is carefully followed and those "not absolute" indicators" of death I mentioned previously have been clincially addressed through thorough assessment.

In the end its a kind of bureaucratic necessity that a licensed physician signs the paperwork to close the file if you like.

In Aussie Land we can withhold resus on a number of types of cases and frequently do without problems from aggrieved relatives or bystanders.

I would say our biggest problems come with NFR orders or lack thereof.

Still, there hasn't been a civil suit against an ambo over a death/lack of resus dispute over here in years. And good thing too. 

MM


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## ErinCooley (Nov 23, 2008)

I'm pretty sure here in Ga, at least in my company, a paramedic can declare someone DOA however we cant call the coroner.  Only the police can do that... figure that one out.


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## Hal9000 (Nov 23, 2008)

We can declare someone dead, as Rid says.  We have a "County Coroner" (Not elected and does have medical training.) that allows us to bypass going to an MD.  We just used that avenue today with a patient, per request of medical control. The CC came, inspected, signed off, and then we made a stop by the funeral home on the way back to putting the rig in service.


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## medicdan (Nov 23, 2008)

Hal9000 said:


> We can declare someone dead, as Rid says.  We have a "County Coroner" (Not elected and does have medical training.) that allows us to bypass going to an MD.  We just used that avenue today with a patient, per request of medical control. The CC came, inspected, signed off, and then we made a stop by the funeral home on the way back to putting the rig in service.



Isn't it illegal (or wasn't it at some point) for ambulance to transport dead bodies (outside of extreme need like MCIs)? Do you just turn up the AC in the back?


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## ffemt8978 (Nov 23, 2008)

emt-student said:


> Isn't it illegal (or wasn't it at some point) for ambulance to transport dead bodies (outside of extreme need like MCIs)? Do you just turn up the AC in the back?



I would say that would vary by region.  In some areas, it is the ambulance companies that transport corpses to the morgue for autopsy.  In others, it is a funeral home or the county coroner.


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## Ridryder911 (Nov 23, 2008)

emt-student said:


> Isn't it illegal (or wasn't it at some point) for ambulance to transport dead bodies (outside of extreme need like MCIs)? Do you just turn up the AC in the back?



No, in fact I know of EMS that loves to transport because they get a guaranteed amount of money. As we also charge for declaration of death (if they have insurance). 
Turn the A/C ? How cold do you think your unit will get? 

R/r 911


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## Hal9000 (Nov 23, 2008)

*And*

I think Rid is correct.  In this case, the doctor "called it" while he was in the rig...we couldn't just chuck him once he was "dead."  And when we parked for the coroner, we couldn't leave just him on the curb.  We actually cut down on the time he would have been in there by taking him to the home.


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## fortsmithman (Nov 23, 2008)

emt-student said:


> Isn't it illegal (or wasn't it at some point) for ambulance to transport dead bodies (outside of extreme need like MCIs)? Do you just turn up the AC in the back?



Here in Fort Smith the town's ambulance service picks up the bodies and transports to the morgue.


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## Grady_emt (Nov 23, 2008)

ErinCooley said:


> I'm pretty sure here in Ga, at least in my company, a paramedic can declare someone DOA however we cant call the coroner.  Only the police can do that... figure that one out.



Actually Erin, it varies by region within the state. Here in the Metro Area and other urban counties we have Medical Examiners not Coroners.  As for who to call, that is agency dependent. Here we call APD who may call the ME, or we may also call the ME if APD has and extended ETA to the scene.  Either way, for all field deaths the ME must be notified. The on call examiner takes a report from EMS and determines if they need to respond to the scene or not.

There are still a few rural counties in south GA that have coroners, and for all autopsies they send the body to GBI HQ in DeKalb County.


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## rhan101277 (Nov 24, 2008)

Here in Mississippi, you have to call the coroner.  You still have to make sure the person is dead, so that you don't have to provide medical interventions.  If someone dies at a car wreck, we call the coroner and then transport to the hospital in a body bag.  I have never put a dead body in a body bag yet, so I am not sure how tough that is going to be.  If they die at home, usually the family has the funeral home come get the body.


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## FF-EMT Diver (Nov 24, 2008)

Here in my area of GA we declare death in the field and call for coroner ( we can call)  our coroners go to coroner level 1 & 2, And are pretty medically inclined people.


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## pamedic983 (Nov 26, 2008)

*Call command*

In PA, we cannot pronounce, but if there are obvious signs of death in a trauma we don't need medical command. I've had two medical DOA's in the last three days. I get on scene, confirm aystole in three leads, get the history, check for rigor, check pupils, call command and he gives orders not to start working it. Then we call the coroner.


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## EMTinNEPA (Nov 26, 2008)

rhan101277 said:


> I have never put a dead body in a body bag yet, so I am not sure how tough that is going to be.



The first time is kinda freaky.  After the second or third, it's as routine as putting a patient on oxygen.


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## Melbourne MICA (Nov 27, 2008)

*Death in Melbourne*

We use to get tied up transporting deceased pts but no more. On rare occasions such as a traummatic paeds death in a public place we might take care of the body but even then only until the coroners wagon arrives. Deaths at home are never transported by Melbourne ambulance crews. 

We are allowed to make a determination of death following assessment including ECG and can withhold treatment/resus without any need to call command or anybody else if the pts situation meets certain criteria including obvious death, asystole with prolonged downtime and no CPR etc.

We arrange for a GP to do certification if at a residence or the coroners if out in public such as road deaths or if the pts GP or Locum is unavailable. 

The Police and their traffic investigation unit  take command at road deaths after we inform them of our findings.

We also have the option to consult with family about resus where exiting NFR orders are available at scene or in a nursing home situation - clear documentation is the best scenario for all of us in NFR type situations.

As for "rigor" - this doesn't happen till about the three hour mark after death so you will never see it in road trauma. Post mortem lividity is a better indicator for assessment of death and is easy to document in your paperwork. 

Its all about common sense and sticking to process so there are no unnecessary repercussions. Australia is somewhat less inclined to litigation than the US so I can understand stiffer controls over US ambos.

MM


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## ResTech (Nov 27, 2008)

In Pennsylvania, if the patient is of an older age and has a known medical history that appears to be a contributing factor in the death, we always attempt to contact the family physician first to ascertain if they are willing to sign the death certificate. If they are, then we coordinate and assist the family with contacting a funeral home and remain with the deceased until the funeral home takes possession.

If the family physician is not comfortable signing a death certificate, then we have to request the county coroner to respond. And in certain cases, its an automatic call for the coroner.. instances such as suicides, MVC, patients of a young age, etc. 

Technically speaking, we are not allowed to legally pronounce since we cant fill out and sign a death certificate, but in reality we do pronounce when we make the decision not to initiate resuscitation.


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## Melbourne MICA (Nov 28, 2008)

*Tying up ambos*



ResTech said:


> In Pennsylvania, if the patient is of an older age and has a known medical history that appears to be a contributing factor in the death, we always attempt to contact the family physician first to ascertain if they are willing to sign the death certificate. If they are, then we coordinate and assist the family with contacting a funeral home and remain with the deceased until the funeral home takes possession.
> 
> If the family physician is not comfortable signing a death certificate, then we have to request the county coroner to respond. And in certain cases, its an automatic call for the coroner.. instances such as suicides, MVC, patients of a young age, etc.
> 
> Technically speaking, we are not allowed to legally pronounce since we cant fill out and sign a death certificate, but in reality we do pronounce when we make the decision not to initiate resuscitation.



I think the situation is similar for most ambos no matter where given your last couple of paragraphs but how are your resourcing levels given you get tied up with the funeral home arrangements? That's must take hours on occasions. Doesn't seem like the best way to resource ambos but I can understand the sensitivities for families of the deceased.

MM


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## jochi1543 (Nov 28, 2008)

? Even EMRs (EMT-Bs) can do it here. Of course, that requires obvious signs of death or "injuries inconsistent with life" (decapitation, putrefaction, rigor mortis, and the like). I am not sure if EMTs (EMT-Is) can use other, less obvious signs, I'll ask my EMT-I partner at work.


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## ResTech (Nov 28, 2008)

> how are your resourcing levels given you get tied up with the funeral home arrangements?



Legally, in PA at least, we must remain with the body until it is transferred to the funeral home, coroner, or law enforcement takes custody of it (instance of a crime scene). So we aid the family in calling the funeral home since they usually have no idea of the process or what to say and it makes it easier on them. Its not a frequent occurrence so it doesn't effect out resources at all with having a second ambulance and mutual aid.


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