Paramedic Awareness: The risk of not adhering to procedures when determining life extinct

Paramedic Awareness: The risk of not adhering to procedures when determining life extinct

Currently, there is no legal definition of death, although it is generally taken to mean the ‘irreversible loss of capacity for consciousness combined with the irreversible loss of capacity to breathe.’[1] 

As determined by the British Medical Association, a Paramedic has the responsibility to confirm deaths within the community. The Recognition of Life Extinct (ROLE) protocol provides guidance for Paramedics on the holistic aspects of cardiac arrest management.   

There are three circumstances in which life extinct can be performed by ambulance clinicians[2]. All of the following criteria below must be confirmed independently and if possible, by two clinicians, before a formal determination that the patient is life extinct.

  • A condition unequivocally associated with death is observed. These are:

    • Decapitation
    • Massive cranial and cerebral destruction   
    • Hemicorporectomy or similar massive injury
    • Decomposition/putrefaction
    • Incineration
    • Hypostasis       
    • Rigor mortis       
  • A patient is in cardiac arrest with no evidence of CPR in the last 15 minutes AND no suspicion of drowning, hypothermia, poisoning/overdose, pregnancy AND an asystolic rhythm is observed for 30 seconds;   
  • If the patient is in asystole following 20 minutes of Advanced Life Support EXCEPT in cases of drowning, hypothermia, poisoning/overdose and pregnancy. 

If the criteria to determine life extinct is not met and there is no other logical reason to withhold resuscitation (for example, danger to the paramedic) then resuscitation should be commenced with a view to offering the patient the best possible chance of survival. 

As per the Ambulance Services Clinical Practice Guidelines, the ‘substantial chance’ and ‘real prospect’ of ‘avoiding death’ is to say that, had a full resuscitation protocol been followed, then the chance of survival; survival with a good neurological outcome and survival to discharge from hospital are significantly reduced the longer a person is in cardiac arrest and the longer it is before all the steps in the chance of survival are achieved.  

Ultimately, if clinicians can confidently adhere to JRCALC’s Recognition of Life Extinct, this will provide justification to determine when a resuscitation attempt is inappropriate.


  • [1] Murphy PG, Bodenham AR, Thompson JP; Diagnosis of death and organ donation in 2012. Br J Anaesth. 2012 Jan108 Suppl 1:I 1-2. doi: 10.1093/bja/aer409.
  • [2] Brown, S. N., Kumar, D. S., Millins, M., & Mark, J. (Eds.). (2016). UK Ambulance Services Clinical Practice Guidelines 2016. Bridgwater: Class Professional
  • Brown, S. N., Kumar, D. S., James, C., & Mark, J. (Eds.). (2019). JRCALC clinical guidelines 2019. Bridgwater: Class Professional.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact or call +44 (0) 203 355 9796.