2 high-profile cases this summer beg the question: Should pediatric death pronouncement require another safeguard?
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The reality of the Lazarus Phenomenon can be hard to swallow for emergency medical professionals who terminate resuscitation efforts all too often during their careers. While civilians often see the line between life and death as black and white, there are obviously a few shades of gray.
—Alexandra Jabr, PhD, EMT-P, Emergency Resilience
Two extraordinary pediatric cases this summer has the medical community asking: Are current protocols for declaring death in infants and toddlers robust enough—or should they include additional safeguards?
The first case involved an Arizona toddler who was declared dead after drowning, transferred to a hospital morgue, and later discovered to be alive. Police records suggest that concerns about possible signs of life were raised before the child was pronounced deceased, prompting investigations into both clinical decision-making and hospital processes.[]
The second involves a Texas legal battle over a child who nearly drowned and whose family sued to stop a hospital from testing for brain death, highlighting ongoing public confusion over the distinction between neurological and circulatory criteria for death.[]
While the circumstances are entirely different from the Arizona case, both are placing pediatric death determination in the spotlight.
Two pathways to determining death
Modern medicine recognizes two separate pathways:
Death by neurologic criteria (brain death)—the irreversible cessation of all functions of the entire brain, including the brainstem.[]
Death by circulatory and respiratory criteria—the irreversible cessation of circulation and breathing.[]
Although both are legally accepted definitions of death in the US, they are established differently and require different examinations.
The recently updated practice guideline from the American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine standardizes brain death evaluation across adults and children.[] The guideline emphasizes prerequisites before testing, standardized neurologic examination, apnea testing, and ancillary studies when appropriate. It also stresses avoiding confounders such as hypothermia, high levels of sedatives, metabolic derangements, or shock that could invalidate an examination.
Brain death determination is highly protocolized, but circulatory death is different.
Circulatory death is common—but less standardized in pediatrics
Most deaths outside discussions of organ donation are declared using circulatory criteria: no pulse, no spontaneous respirations, and no evidence of circulation after appropriate assessment.[]
The challenge is that, compared with brain death, there has historically been less pediatric-specific guidance on exactly how long clinicians should observe for autoresuscitation or what additional safeguards should be routine in young children following prolonged resuscitation.
Autoresuscitation, the spontaneous return of circulation after CPR has stopped, also called the Lazarus phenomenon, is exceptionally rare but well documented in the medical literature. Most reported cases occur within 10 minutes after resuscitation efforts cease, although reports are heterogeneous and often involve adults.[]
“The reality of the Lazarus Phenomenon can be hard to swallow for emergency medical professionals who terminate resuscitation efforts all too often during their careers. While civilians often see the line between life and death as black and white, there are obviously a few shades of gray,” wrote Alexandra Jabr, PhD, EMT-P.[]
Young children present unique physiologic considerations. Hypothermia after drowning, immature cardiovascular physiology, medications administered during resuscitation, and prolonged low-flow states can all complicate assessment of irreversible circulatory arrest.
That does not mean current pediatric declarations are unsafe. Millions of deaths have been appropriately determined using existing standards. But unlike neurologic determination of death, circulatory determination relies more heavily on bedside clinical assessment and institutional policy than on a universally standardized pediatric protocol.
Why these two cases matter
Neither of this summer’s stories should prompt clinicians to distrust established standards. Instead, they highlight different vulnerabilities.
The Arizona case appears to raise questions about whether signs of life were recognized, communicated, and acted upon before the child was transferred to a hospital morgue. Investigators are examining whether there were opportunities to reassess the patient after concerns were voiced.
The Texas case underscores a different issue: the persistent public misunderstanding of brain death vs severe neurologic injury. Families frequently equate a heartbeat maintained through intensive care with ongoing life, while physicians understand that neurologic death and circulatory death are separate medical and legal determinations.
Those are fundamentally different conversations—but both require extraordinary clarity.
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Whether these cases ultimately lead to formal guideline revisions remains to be seen. Some experts may argue for additional procedural safeguards in very young children before declaring circulatory death after prolonged resuscitation, such as:
A mandatory observation period before transfer after death is pronounced.
Explicit documentation of repeat examinations.
Confirmation of absent cardiac activity with bedside ultrasound when appropriate.
Standardized team “pause” checklists before transfer to the morgue.
Clear escalation pathways if any member of the care team believes signs of life may still be present.
None of these measures would replace clinical judgment. Rather, they would function much like surgical safety checklists—guardrails for extraordinarily rare but high-consequence events.
Whether evidence ultimately supports these changes is an open question. The Arizona investigation may provide important lessons about system failures vs failures to follow existing protocols.
Related: The $5.6M lesson in escalation protocol failure every physician should read