R03: Recognition of Life Extinct

Clinical Medical Programs
Updated: June 3, 2025 Darrel Hunsbedt
Reviewed: June 3, 2025 Darrel Hunsbedt

Introduction

This guideline has been designed to provide information to paramedics and EMRs on the holistic aspects of cardiac arrest management: specifically, how to recognize life extinct, or confirm death.  It is to be used in conjunction with R02: Discontinuing Resuscitation.

Essentials:

Consultation with CliniCall must be made to confirm the discontinuation of resuscitation in all cases where CPR was commenced. The recognition of life extinct (ROLE) assessment occurs after the CliniCall consult and termination of resuscitation.

General

Unless the criteria for obvious death are met, all of the following elements must be satisfied and confirmed independently by at least two paramedics or EMRs following the discontinuation of resuscitation, and before a determination is made that life is extinct.

Paramedic/EMR (1) and (2) perform these tasks at the same time:

Paramedic/EMR (1) performs simultaneously: 

• No heart sounds heard for 90 seconds
• No breath sounds heard or respiratory effort observed for 90 seconds

Paramedic/EMR (2) performs: 

• No palpable carotid pulse for 90 seconds
• Making sure to reduce movement and noise

ACP and CCP only: when able, observe asystole, or pulseless electrical activity with a rate of 30 beats per minute or less, for over 60 seconds.

CCP only: Ultrasound may assist with the determination of ROLE with PEA with no mechanical activity.

In cases of environmentally caused hypothermia, the lack of signs of life is unreliable and cannot be used for recording life extinct.  These patients should be conveyed as soon as possible to a facility where aggressive rewarming during resuscitation is possible, preferably using extra-corporeal membrane oxygenation. Contact CliniCall (1-833-829-4099) to discuss options. 

In the event paramedics or EMRs are unsure or are concerned that the ROLE criteria have not been met, CliniCall must be consulted for further guidance.

Actions To Be Taken After Death Has Been Established

References

1. Grunau B, et al. Comparing the prognosis of those with initial shockable and non-shockable rhythms with increasing durations of CPR: Informing minimum durations of resuscitation. 2016. [Link]
2. Grunau B, et al. Gains of continuing resuscitation in refractory out-of-hospital cardiac arrest: A model-based analysis to identify deaths due to intra-arrest prognostication. 2017. [Link]
3. Grunau B, et al. External validation of the universal termination of resuscitation rule for out-of-hospital cardiac arrest in British Columbia. 2017. [Link]
4. Morrison LJ, et al. Validation of a rule for termination of resuscitation in out-of-hospital cardiac arrest. 2006. [Link]
5. Reynolds JC, et al. Association between duration of resuscitation and favorable outcome after out-of-hospital cardiac arrest: implications for prolonging or terminating resuscitation. 2016. [Link]