The cardiopulmonary criterion of death is the classical criterion of death before 1968: irreversible cessation of heartbeat and respiration. For centuries it was the only operationalized criterion of medical determination of death.
With the introduction of mechanical ventilation in the course of the Copenhagen polio epidemic of 1952, the separation of brain function and cardiovascular function became medically relevant: patients could now be kept alive without their own respiration. In 1968 the Harvard Ad Hoc Committee established the neurological path (brain-based criterion of death) as an equal alternative.
Significance today
The cardiopulmonary criterion remains the dominant path outside the transplantation context. When a person dies at home or in a care facility, his death is for the most part determined cardiopulmonarily — through the cessation of heartbeat, respiration, and reflexes.
In the transplantation context the criterion is the basis of the permanence stipulation in organ donation after circulatory arrest (organ donation after circulatory arrest): after observed asystole, permanence is established via the five-minute observation — and on this basis the diagnosis of death is made.
Clinical determination
The medical determination of cardiopulmonary death follows a classical course of examination:
- Respiratory arrest: no thoracic movements, no breath sounds on auscultation, possibly the mirror test (no fogging of a mirror held before mouth and nose), no CO₂ in the exhaled air (capnography, where available).
- Circulatory arrest: no palpable carotid or femoral pulse, no heart sounds on auscultation, asystole on the ECG, no arterial pressure.
- Accompanying signs: wide, light-fixed pupils, complete areflexia, cessation of all spontaneous movements.
- Observation time: in routine, 5–10 minutes of continuous observation; in the context of organ donation after circulatory arrest, exactly 5 minutes (no-touch period).
- Differential-diagnostic exclusion of confounders: deep hypothermia, severe poisoning, deep sedation — states that can feign a reversible quasi-arrest.
Certain and uncertain signs of death
Forensic medicine draws a strict distinction:
Uncertain signs of death (possible also in apparent death / vita minima): respiratory and cardiac arrest, pupillary rigidity, areflexia, pallor of the skin.
Certain signs of death (counted as conclusive only then):
- Livores (livor mortis / post-mortem lividity) — from about 20–30 minutes, fully developed after 6–12 hours.
- Rigor mortis — from 1–2 hours, full after 6–8 hours, resolves after 24–48 hours.
- Algor mortis (cooling of the corpse) — about 0.5–1 °C per hour.
- Putrefaction (decomposition) — visible from 24–72 hours (greenish discoloration of the abdominal wall, gas formation, odor of decay).
- Injuries incompatible with life (e.g., decapitation, brain extrusion, complete incineration).
In Germany, the physician may certify death on the death certificate only when at least one certain sign of death is present — the uncertain ones do not suffice.
Decomposition as the last certain sign of death
Of the five certain signs, decomposition is the only one that dissolves the anatomical substance itself. Post-mortem lividity, rigidity, and cooling indicate the cessation of function; decomposition indicates the perishing of the form. In Hartmann’s modal language: only decomposition is the completed actuality of death — the space of possibility is not merely unused, but materially consumed.
Thereby decomposition is the only undisputed example of ontological irreversibility in the context of death: no medical measure — not even NRP, not ECMO — can revive a decomposing body. Here permanence, medically diagnosed irreversibility, and ontological irreversibility coincide.
It is precisely here that the tragic dilemma of transplantation medicine lies: organs are no longer transplantable long after 24–72 hours. Practice is structurally dependent on removing organs before the last certain sign of death — and operates in the time window between uncertain signs and early permanence (asystole + 5 min). The precautionary principle of Benedict XVI addresses precisely this tension: the most honest reading of the requirement of certainty would be to wait for decomposition — practice chooses the permanence stipulation as a surrogate.
Difference from irreversibility
The international practice of organ donation after circulatory arrest bases the determination of death on permanence, not on irreversibility in the strict sense: after five minutes of observed asystole without resuscitation attempt, the circulatory arrest counts as permanent. The autoresuscitation findings (Dhanani et al., NEJM 2021) secure the interval empirically, if narrowly.
Substance-ontological position
From the position represented here, the permanence stipulation is not sufficient for identification with certain death. Sufficient would be only anatomical irreversibility — and this is not reached after five minutes of asystole, as NRP practice empirically shows. The precautionary principle therefore requires that, in doubt, the stricter interpretation be adopted.
Ontological classification
Superclass: criterion of death
Connected with: permanence, five-minute observation, asystole, organ donation after circulatory arrest
Sources
- Uniform Determination of Death Act (UDDA) (1981). https://en.wikipedia.org/wiki/Uniform_Determination_of_Death_Act
- Bernat, James L. (2010): How the Distinction between ‘Irreversible’ and ‘Permanent’ Illuminates Circulatory-Respiratory Death Determination. Journal of Medicine and Philosophy 35(3): 242–255. https://pubmed.ncbi.nlm.nih.gov/20439357/
- Dhanani, Sonny et al. (2021): Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures. NEJM 384(4): 345–352. https://www.nejm.org/doi/full/10.1056/NEJMoa2022713
- Hornby, Krista L. et al. (2023): Autoresuscitation after circulatory arrest: an updated systematic review. Canadian Journal of Anesthesia 70(4): 699–712. https://link.springer.com/article/10.1007/s12630-023-02411-8
- Madea, Burkhard (ed.) (2015): Rechtsmedizin. Befunderhebung – Rekonstruktion – Begutachtung. 3rd ed. Berlin/Heidelberg: Springer. — Standard work on the differentiation of certain and uncertain signs of death, clinical examination, and post-mortem examination.
- Brinkmann, Bernd; Madea, Burkhard (eds.) (2004): Handbuch gerichtliche Medizin. Berlin/Heidelberg: Springer. — Classic German-language reference work; chapter on putrefaction and post-mortem changes.
- Bundesärztekammer (2013): Empfehlungen zur Durchführung der ärztlichen Leichenschau. Deutsches Ärzteblatt 110(33–34): A-1547.
- Henßge, Claus; Madea, Burkhard (2007): Estimation of the time since death. Forensic Science International 165(2–3): 182–184. — Methodology of estimating the time of death via algor mortis and post-mortem courses.
- Vass, Arpad A. (2001): Beyond the grave – understanding human decomposition. Microbiology Today 28: 190–192. — Microbiological foundations of putrefaction and its temporal courses.
Generated by querying the Personhood ontology.