Apparently flatlining is a myth. What really happens?

I’ve read recently that the long continuous tone and the flat line of a heart monitor when you die is a Hollywood fabrication.

So what really happens on a heart monitor when someone dies?

Here’s a strip chart from a heart going into ventricular fibrillation:

Normal rhythm is at the top. At the end of the second line is where the heart goes into fibrillation. Hollywood would show the bottom half of that as a flatline.

When my mother died, the lines on her monitor didn’t suddenly go flat; they just got progressively weaker and weaker. And there was a lot of dying down, almost to zero, then kind of slightly fluttering back to life, then down again. After a while the peaks were pretty much nonexistent, and the doctor simply turned off the monitor. It wasn’t like TV at all.

News to me, I’ve seen plenty of flat lines. Hollywood mostly just compresses the time span and skips over the agonal rhythms.

We usually try to collect asystole rhythm strips in 3 leads before we declare a time of death.

I think it is the perfectly flat line that signifies death that Hollywood has wrong.

Asystole (no electrical activity) means the heart isn’t functioning- this gives a flatline, but the line won’t be ruler straight in most cases, it might be a little wavy.

It is also possible to have a cardiac arrest where the ECG montor picks up a near normal looking trace but the heart isn’t working enough to give a pulse- so called Pulseless Electrical Activity. This becomes asystole and death pretty rapidly if left alone.
The truth is, if death is expected, you disconnect someone from the monitors- there simply isn’t a reason to monitor the heart rate and rhythm of someone who is going to die peacefully in the near future. They’ll die, and you’ll stand back and watch without intervening, so really, the monitor is useless.

If death isn’t expected or someone is for full resuscitation- THEN sure, you monitor, because you plan to jump up and down on their chest and shock them if something bad happens.

It is perfectly possible to decide someone is dead without the help of an ECG.
I would sometimes be called to verify deaths, either in the community or in hospital when a resuscitation attempt has not been made .TOD is called by whoever leads the resus attempt, and you won’t call it if the person is shockable, so that’s when you want your asystolic ECG.

One documents verification of a death thusly:

Absent heart sounds (1 minute)
Absent breath sounds (1 minute)
Absent carotid pulse (1 minute)
Absent corneal reflex
No response to pain
Pupils fixed and dilated
No evidence of a pacemaker/Pacemaker in situ*
Life extinct at XXh DD/MM/YY

It is easier if the body is blue, cold and stiff, but no sophisticated equipment other than a stethoscope, a torch and a pen is required.

*Pacemakers may explode when heated up. This is relevant if the body is for cremation.

[quote=“irishgirl, post:5, topic:574763”]

I think it is the perfectly flat line that signifies death that Hollywood has wrong.

Asystole (no electrical activity) means the heart isn’t functioning- this gives a flatline, but the line won’t be ruler straight in most cases, it might be a little wavy.

Well, there’s your answer. If Hollywood were to depict the line as “a little wavy,” there are going to be audience members who think the person is still alive because the line isn’t perfectly flat. It’s easier for many people to learn, as they have from TV and movies, that wavy=life, flat=death than it is that peaks and valleys=life, subtle hills=death.

Plus it’s more dramatic.:slight_smile:

Cool. Now I think I understand. It seems Hollywood isn’t wrong so much as exaggerated, which is SOP for them in everything anyway.


Is it really a normal rhythm? It looks plenty irregular to me, but I’m not a specialist.

No, it’s not a normal rhythm. It’s only one lead so I can’t make a definitive diagnosis, but I see what looks like AV dissociation with a wandering ventricular pacemaker. Or possibly atrial fibrillation with aberrantly conducted ventricular contractions. Not a good rhythm either way. It then deteriorates into Ventricular tachycardia first before degenerating into ventricular fibrillation.

As a biomedical technician, what really annoys me are the sounds Hollywood has them make. Of the dozens and dozens of makes and models of patient monitors I have worked with, not a single one makes a long, steady “beep” during asystole. Generally, if the monitor is set up to actually make a tone for each beat (which is rarely the case,) it does so during the QRS complex, and so obviously during asystole there is no QRS complex, so no regular beep. What almost always DOES happen, however, is when it detects aystole it alarms, which is also not a long, continuous beep, but a unique series of beeps and bloops.

It’s really annoying when they actually have real machines (well, I’m sure they’re props, but modeled to look like real brands and models,) but the sounds are just generic “beep.” It doesn’t make me as annoyed as when I see a modern day video game making Atari-era noises, but it’s close.

I understand that they are for entertainment, but my wife and I can’t watch any medical dramas because they’re just so ridiculous. Breaking news everyone, people die in real life! As soon as the average American comes to grips with that we can stop wasting all this money on prolonging people’s death.