402 - Standardizing the Declaration of Death Process in a Pediatric Emergency Department: A Case Series

Publication Number: 4394.402

Michael T. Stratton, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Archit Sahai, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; James M. Gray, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Mary E. Frey, ENA Cincinnati Children's Hosptial Medical Center, Cincinnati, OH, United States; Gina L. Klein, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Kelsey Feldmann, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Benjamin T. Kerrey, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States

Background: The declaration of death (DOD) in a pediatric emergency department (PED) is emotionally and psychologically challenging for care teams and families. Its goals are to confirm that resuscitation should not continue and to detect any signs of life to avoid the Lazarus effect. Despite its critical nature, limited evidence guides pediatric DOD practices.

Objective: This project aimed to standardize the Declaration of Death process in an academic Pediatric Emergency Department.

Design/Methods: A multidisciplinary team developed a DOD algorithm using expert consensus, in situ simulation, and literature on termination of resuscitation criteria. All patients undergoing CPR without sustained return of spontaneous circulation were eligible. The DOD process was defined as the time from cessation of chest compressions to either verbal declaration of death or detection of signs of life prompting resuscitation. Video review was used to collect data on resuscitation, DOD process, clinical signs, and objective findings. Descriptive analyses focused on team preparation, clinical assessments, and patient outcomes.

Results: .The revised algorithm was developed between January 2023 and August 2024 and implemented in August 2024. We reviewed 33 cases from August 2024 to August 2025. Death was declared in 31 cases; 2 showed signs of life during DOD, prompting continued resuscitation and PICU admission (table 1). All patients were assessed for signs of life either before or during the DOD process, though variability existed in timing and type of assessments.
Key assessments included: shared mental model prior to DOD (100%), cessation of compressions before declaration (97%), pulse palpation (82%, with detection in 9%), pupil assessment (58%), heart and lung auscultation (76%), and cardiac POCUS (52%) (table 2). In cases where death was not declared, assessments indicating cardiac output (e.g., pulses, heart sounds, pulsatile SpO₂ tracing, ETCO₂ waveform, cardiac POCUS) prompted resumption of resuscitation (table 3).

Conclusion(s): Significant variability exists in clinical assessments during DOD. While essential assessments remain undefined, our findings suggest that evaluating pulsatile blood flow may be most effective in identifying signs of life. Further research is needed to define critical assessments during pediatric DOD.

Table 1. Demographics
Demographics of case series including age in years, outcome of Declaration of Death (DOD) process and disposition from the emergency department.

Table 2. Declaration of Death Criteria Completion
Performance of components of the standardized Declaration of Death (DOD) process in a pediatric emergency department, including resuscitation, process adherence, clinical assessments, and objective findings (N = 33).

Table 3. Clinical Assessments Observed When Death Not Declared.
Characteristics of two cases in which signs of life were detected during the Declaration of Death (DOD) process, prompting resumption of resuscitation and PICU admission.