VERIFICATION OF LIFE EXTINCT (VLE)
This guidance is intended to assist healthcare staff who are trained in the verification of life extinct (VLE) with those aspects which vary from the non-pandemic situation. The procedure and a model adult form are included as aids. This guidance is not all inclusive, it is intended to give staff additional guidance during the COVID-19 pandemic; for more detail please consult Guidance surrounding Death .
VLE during the COVID-19 pandemic
An efficient and safe VLE procedure is important for ensuring that the sequence from death to last offices and burial or cremation is timely and as seamless as possible. Once the verification of life extinct procedure has been performed, the body can be moved from the place of death to a mortuary, the premises of a funeral director or other temporary resting facility.
In a pandemic, the major problems that arise do so as a result of the,
volume of deceased patients, both in hospital and in the community;
reduction in numbers of staff trained in the VLE procedure; and
iii. risk of infection to the staff performing the VLE procedure.
i. In a pandemic, the numbers of patients dying might result in a significant delay between the actual time of death and performance of VLE. It is expected that with the addition of more nursing staff to perform this role, delays should be prevented. The date/time of VLE determines the official date of death.
Those professions trained in the VLE procedure include medical practitioners, nurses and ambulance clinicians. In a pandemic situation, there will be fewer numbers of trained staff. As all doctors and the appropriate grade of ambulance clinicians are already trained, it would be crucial that some of the nurses who are not trained to verify life extinct, receive the appropriate training so that they can consider themselves competent to perform this role.
In this COVID-19 pandemic there is a risk of transmission of the infective agent unless it is clear, from recent testing, that the deceased is coronavirus free. This risk may arise from the patient or from their environment; this guidance applies to hospital and community deaths. Otherwise, staff need to take precautions when performing the VLE procedure for COVID-19 and suspected patients. This will include the wearing of suitable PPE (disposable gloves, disposable plastic apron, fluid resistant surgical face mask, disposable eye protection).
WHO CAN VERIFY LIFE EXTINCT (VLE)?
All doctors registered with the General Medical Council can verify life extinct and must be professional and compassionate when confirming and pronouncing death and must follow the law, and statutory codes of practice, governing completion of death and cremation certificates.
VLE can also be undertaken by an experienced registered nurse2 who has received training and is deemed competent in the procedure, in any health care setting; in the HSC or independent sector. Their employers must have policies and their associated protocols in place, detailing the local workplace agreements setting out clearly the circumstances in which nurses can undertake VLE. These should contain specific details applicable to the workplace in question (particularly in the case of unexpected deaths, although see below for pandemic situation).
Education and training must be made available and nurses should ensure they have enough confidence, competence, knowledge and skills to equip them for undertaking this role.
Appropriately trained and registered nurses may, during this COVID-19 pandemic, continue to verify life extinct; the process is not limited to those deaths occurring as a result of coronavirus (SARS-CoV-2).
If VLE is performed by a nurse, they must contact the Doctor/GP/Healthcare centre and inform them of the end of life event and advise that they have completed a VLE. They must record on the VLE record sheet the name of the doctor informed.
VLE in pandemic circumstances
Due to the possibility that medical practitioners or ambulance clinicians may not be able to respond promptly during a pandemic surge, a nurse may need to perform the VLE procedure in circumstances which, in the past, they would not have done so.
These circumstances include the following,
- sudden death which is unexpected, unforeseen and not predictable2;
- when the cause of death is uncertain;
- the verifying nurse feels that there may be suspicious circumstances;
- death as a result of untoward incident e.g. fall or drug error;
- if the deceased is to undergo a Coroner’s or a consented hospital post-mortem examination.
In such circumstances, the nurse should still perform the VLE. When that is complete, they must then make every effort to inform a medical practitioner, so that the deceased can be attended, or the circumstances of the death reported to the Coroner.
If it is not possible to make contact with a medical practitioner within an acceptable time period the nurse must contact the Coroner Service for Northern Ireland and report the death to their Death Reporting Team. This team will then take over any further inquiries.
If there has been no explicit advance decision for a ‘do not resuscitate’ order prior to collapse and the wishes of the patient and/or family are unknown, there is a presumption that every reasonable effort will be made to resuscitate, unless the fact of death is unmistakable.
If a patient experiences a completely unexpected and unpredictable cardiac arrest (with no DNACPR form available), then CPR should be attempted.
However, if a patient experiences a cardiac arrest that,
- is the end result of a known and terminal illness; and
- it is not unexpected & could be predicted, although it may occur suddenly; and
the wishes of the patient and/or family (acting for the patient’s best interests) were known, then the wishes of the patient and/or family should be followed.
COVID-19 is a notifiable disease to the Public Health Agency. The presence of a notifiable disease, as defined in the relevant public health legislation, does not preclude VLE by a suitably trained individual who is not a registered medical practitioner. Also, a death from notifiable COVID-19 does not require the death to be reported to the Coroner, unless other circumstances surrounding the death e.g. unnatural cause of death, require it to be reported.
Ambulance Clinicians, when responding on behalf of the Northern Ireland Ambulance Service, can verify that death has occurred in accordance with the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Practice Guideline for the Recognition of Life Extinct (ROLE). Ambulance Clinicians include Emergency Medical Technicians and Paramedics in training who possess the relevant ASA/IHCD professional qualification, and Paramedics registered with the Health Professions Council.
Training and competence requirements
All staff whose role it is to verify life extinct should have education and training in this area.
In addition, nurses2 and ambulance clinicians should ensure they have enough confidence, competence2 knowledge and skills to equip them for undertaking this role. Specific topics that may be included are,
- aspects of accountability;
- current legislation;
- record keeping and documentation;
- Ethics and Legislative aspects;
- Skills and knowledge to determine the physiological signs of death;
- Process for pronouncing life extinct including documentation;
- Professional responsibilities;
- Awareness of the role of PSNI and Coroner’s Service.
Documentation and Informing Medical Practitioner
The documentation (including VLE record sheet) for recording the examination undertaken and verifying life extinct must be completed and put in the patient’s notes.
Nurses should record their decision-making process, leading to them performing VLE, including the rationale and circumstances.
The date and time of verification should be recorded.
N.B This applies whether a doctor or nurse verifies death.
A suggested model form (Adult) is available.