Marek Vácha2011

Death

The end of life, but also relief from the earthly pains ...

Once a central ritual of social and religious life, death has been privatized, desacralized, hidden behind institutional walls, and implicitly made taboo.

(Singer, P.A., Viens, A.M., (eds.) (2008) The Cambridge Textbook of Bioethics. Cambridge University Press, p.67)

AutopsyThailand

Nedherlands, around 1460

1470

Until the invention of the stethoscope and the acquisition of knowledge about human anatomy in the early nineteenth century, physicians were unable to diagnose death with precision. the ability to do so provided them with great

credibility from a public that had, until then been concerned about premature burial

Premature Burial

Count Karnice-Karnicki, chamberlain to the Tsar of Russia, patented and marketed a device to prevent premature burial in 1896 (see panel). The apparatus allowed the buried to signal that he or she was still alive by activating a flag and ringing a bell.

Premature Burial

It could be rented for a small amount of money and, after a length of time, when there was no chance of revival, the tube could be pulled up and used in another coffin. There is no record of what the success rate of these devices might have been.

In the modern ICU, physicians are able to break down the dying process, teasing apart each of its component parts and supporting some functions while providing technological replacement for others. the cascade of events that previously led to death

is no longer inevitable. Before, if one vital function ceased, the others quickly followed

once thought to be in the hands of God or fate, the time of death is now most often a matter of deliberate human decision

The Criteria for Death

serious controversies over formally defining death began with the invention of the positive pressure mechanical ventilator in the 1950s. prior to the development of mechanical ventilators,

brain injuries severe enough to induce apnea quickly progressed to cardiac arrest from hypoxemia.

before the 1950s, the loss of spontaneous breathing ond heartbeat ("vital function") were perfect predictors of death because the functioning of the brain and of all other organs ceased rapidly and nearly simultaneously thereafter, producing a unitary death phenomenon. it all happened at once

The Criteria for Death

with the advent of mechanical support of ventilation, the previous unitary determination of death became ambiguous

now patients were encountered in whom some vital organ functions (brain) had ceased totally and irreversibly, while other vital organ functions (such as ventilation and circulation) could be maintained, albeit mechanically.

The Criteria for Death

these patients resembled dead patients in that they could not move or breathe, were utterly unresponsive to any stimuli, ad had lost brain stem reflex activity.

but they also resembled living patients in that they had maintained heartbeat, circulation and intact visceral organ functioning.

Were these unfortunate patients in fact alive or dead?

Bernat, J.L., The Whole-Brain Concept of Death Remains Optimum Public Policy. Journal of Law, Medicine and Ethics 34, no. I (2006):35-43.

Death

a higher vertebrate organism can reside in only one of two states, alive or dead: no organism can be in both states or in neither simply because we currently lack the technical

ability to always accurately identigy an organism´s state oes not necessitate postulating an in-between state.

death must be an event and not a process. if there are only two exclusive underlying states of

an organism, the transition from one state to the other, at least in theory, must be sudden and instantaneous, because of the absence of an intervening state.

Death as a process

too early too late

taking organsethically impossible

taking organsmedically impossible

+ donor is certainly dead

+ organs are in good physiological condition

Without the pressing need for organs, the definition of death would remained on the back shelf, the conversation of a few interested philosophers or theologians

Mr. Smith is walking down the street and hs a massive heart attack resulting in cardiopulmonary arrest and loss of consciousness at time T1. Four minutes later, at T2, he is discovered lying on the sidewalk, is not breathing, and has no pulse. CPR is begun and a 911 call is placed. The EMS squad arrives and continues the resuscitation efforts as they transport the patient to the emergency room, where it is continued for a total of forty-five minutes following T2 when the patient was found on the street. After forty-five minutes of resuscitation, there is no resumption of spontaneous heartbeat so the emergency room physicians stop and declare the patient dead at T4. Since there is no good data on how long resusscitative efforts must continue before declaring them a failure, it is likely that the situation became hopeless sometime earlier, between T2 and T4. Let us call this time T3.

Steinbock, B., (2009) The Oxford Handbook of Bioethics. Oxford University Press, Oxford. p. 295)

T1 ...lying on the sidewalk T2 ...found on the street T3 ....Mr. Smith is dead T4 ...the physicians declare patient dead

The Definition of Death

definition what functions are so essential that its

irreversible loss signifies the death of human being?

criterion determining that the definition has been

fulfilled

Death

death is irreversible by its nature, if the event of death were

reversible it would not be death but rather part of the process of dying that was interrupted and reversed

The Definition of Death

by "death" it is not required the cesation of functioning of every cell in the body, because some integument cells that require

little oxygen or blood flow continue to function temporarily after death is customarily declared

"death" is not the cessation of heartbeat and respiration

The Definition of Death

Rober Veatch: "the irreversible loss of that which is considered to

be essentially significant to the nature of man" his project attempted not to reject brain death, but

to refine the intuitive thinking underlying the brain death concept by emphasizing that it was the cerebral cortex that acounted in a brain death concept and not the more primitive integrating brain structures

BUT that a higher-brain formulation of death would count PVS patients as dead...

...despite their profound and tragic disability. all societies, cultures, and laws consider PVS patients as alive

The Criterion of Death

the whole-brain formulation USA and most parts of the world

cessation of all brain clinical functions including those of the cerebral hemispheres, diencephalon (thalamus and hypothalamus) and brain stem

it does not require the loss og all neuronal actibities. Some neurons may strvive and contribute to recordable brain activities by an electroencephalogram, f.e. but not to clinical functions

the higher-brain formulation, popular in the academy but accepted in no jursdictions anywhere

the brain stem formulation accepted in the United Kingdom

the cardiac option some religious communities

The Criterion of Death

the brain has two major function: the integrative functions of the brain stem

brain stem capacity for consciousness and cognition

cerebral hemispheres

Another Approach

loss of vital fluid flow circulation of blood and oxygen throughout the

body

loss of functioning of the organism as a whole

irreversible loss of all brain function, including that of brain stem

Brain Death

Brain-dead patients´ hearts continue to beat spontaneously they breath with the aid of a ventilator the kidneys produce urine their pancreas produce insulin their livers metabolize waste products in the blood

In the early stages of pregnancy. such "dead" patients can gestate fetuses for months until they are capable of living ex utero

Although initially considered very unstable, better technology, persistence, and demands of family members have kept some brain-dead patients "alive" for up to ten years

Steinbock, B., (2009) The Oxford Handbook of Bioethics. Oxford University Press, Oxford. p. 288)

Brain Death

Brain-dead patients will never wake up and they will never breathe on their own.

Steinbock, B., (2009) The Oxford Handbook of Bioethics. Oxford University Press, Oxford. p. 290)

The Criteria for Brain Death

...given by the Harvard Medical School Ad Hoc Committee, 1968: "total and irreversible loss of functioning of the whole brain" unreceptivity and unresponsiveness no movements or breathing no reflexes flat E.E.G of confirmatory value

The Criteria for Brain Death

Demonstration of coma Evidence for the cause of coma Absence of confounding factors, including

hypothermia, drugs, and electrolyte and endocrine disturbances

Irreversibility

1. a lost function cannot be restored by anyone under any circumstances at any time now or in the future

2. loss of function cannot be reversed by those present

1. this construal would preclude taking organs in DCD (Donation after Cardiac Death) protocols after two to five minutes because electric shock could restore heartbeat

3. a function is reversibly lost if a morally defensible decision has been made not to try to reverse lost

The Criteria for Brain Death

Brain death cases are often very problematic to families, as the patient appears to have natural warmth and color, the EKG may be in sinus rhythm, and the chest rises and falls with each cycle of the ventilator.

Families views these as signs of life and need time to be brought to an understanding of the true condition.

Edge, R.S., Groves, J.R., (2006) Ethics of Health care. Thomson Delmar Reading, New York. p. 203

Diagnostic criteria for brain death (American Academy of Neurology guidelines, 1995)

Demonstration of coma Evidence for the cause of coma  Absence of confounding factors (hypothermia,

drugs, electrolyte, and endocrine disturbances)  Absence of brainstem reflexes  Absent motor responses  Apnea  A repeat evaluation in 6h  Confirmatory laboratory (when specific

components of the clinical testing cannot be reliably evaluated)

Coma

= a state of unarousable unresponsiveness in which the patient lies with the eye closed and has no awareness of self and surroundings (Posner et al., 2007).

These patients will never open their eyes even when intensively stimulated.

coma must persist for at least one hour. In general, comatose patients who survive begin

to awaken and recover within 2 to 4 weeks. This recovery may sometimes go no further than

the vegetative state or the minimally conscious state. 

Diagnostic Criteria for Coma

Absence of eye opening even with intense stimulation

 No evidence of awareness of self and their environment

 Duration: at least one hour

Differences in brain metabolism measured in brain death and the vegetative state, compared with healthy subjects. Patients in brain death show an ‘empty-skull sign’, clearly different from what is seen in vegetative patients, in whom brain metabolism is massively and globally decreased (to 40-50% of normal values) but not absent.

The Test of Death

Brain death tests must be used to determine death ony in the unusual case in which a patient´s ventilation is being supported

traditional examinations for death, in addition to testing for heartbeat and breathing, always included tests for responsiveness and pupillary reflexes that directly measure brain function

Bernat, J.L., The Whole-Brain Concept of Death Remains Optimum Public Policy. Journal of Law, Medicine and Ethics 34, no. I (2006):35-43.

how can we measure that the brain has been irreversibly destroyed (that it has "died")?

ought we as a society or as individuals to treat an individual with a dead brain as a dead person? this question is clearly not something about which

the neurological community can claim expertise this is a religious, philosophical, ethical or public

policy question, not one of neurological science

Donation after Cardiac DeathOpinion

"In the current practice of organ donation after cardiac death (formerly known as non -heart-beating organ donation), I and others raised the question of whether the organ donor patients were truly dead after only five minutes of asystole. The five-minute rule was accepted by the Instutue of Medicine as the point at which death could be declared and the organs procured. Ours was a biologically valid criticism because, at least in theory, some such patients could be resusucitated after five minutes of asystole and still retain measurable brain function. If that was true, they were not yet dead at that point so their death declaraltion was premature.

Donation after Cardiac DeathOpinion

But thereafter I changed my position to support programs of organ donation after cardiac death. I decided that it was justified to accept a compromise on this biological point when I realized that donor patients, if not already dead at five minutes of asysstole, were incipiently and irreversibly dying because they could not auto-resuscitate and no one would attempt their resuscitation. Because their loss of circulatory and respiratory functions was permanent if not yet irreversible, there would be no difference whatsoever in their outcomes if their death were declared after five minutes of asystole or after 60 minutes of asystole."

Bernat, J.L., The Whole-Brain Concept of Death Remains Optimum Public Policy. Journal of Law, Medicine and Ethics 34, no. I (2006):35-43.

After Death...

...in real sense the family become the patients with whom the health practitioners are involved. often the devices are turned down slowly so

that cardiac failure takes place to simulate death

A Jewish Approach

where there is breath, there is life

JP II

It needs to be determined whether the means of treatment available are objectively proportionate to the prospects for improvement. To forego extraordinary or disproportionate means is not the equivalent of suicide or euthansia; it rather expresses acceptance of the human conditions in the face of death.

Evangelium vitae, 1995 par. 65

Japaneses, influenced by Buddhist and Shinto belief system, see the presence of life in the whole body, not just in the brain

Definition of Death

Historically, death was considered to occur when the soul left the body, which might be determined by the cessation of breath and heartbeat.

Regardless of religious persuasion the traditional definition of death was cardiopulmonary – when the heart and lungs ceased to function. this definizion became increasingly problematic with the development of medical technology that enaabled physicians to prolong heartbeat and respiration after a person´s brain was no longer capable of doing so.

Three Deathsby Thomas Furlow

social life

intellectual life

biological life

biographical death social death intellectual death

biological death

Definition of Death

Advances in organ transplantation also fueled the controverses, because of increased interest in cadaveric organ procurement

(Pierce, J., Randels, G., (2010) Contemporary Bioethics. A Reader With Cases. Oxford University Press, Oxford and New York, p. 117)

Definition of Death

Acceptance is not universal. Japan, for example permits its citizens to choose between the brain standard and the traditional cardiopulmonary model

In USA, New Jersey state law provides an exemption frm the vrain standard in order to accommodate religious objections.

(Pierce, J., Randels, G., (2010) Contemporary Bioethics. A Reader With Cases. Oxford University Press, Oxford and New York, p. 117)

Definition of Death

Historically, death was considered to occur when the soul left the body, which might be determined by the cessation of breath and heartbeat.

Regardless of religious persuasion the traditional definition of death was cardiopulmonary – when the heart and lungs ceased to function. this definizion became increasingly problematic with the development of medical technology that enaabled physicians to prolong heartbeat and respiration after a person´s brain was no longer capable of doing so.

Definition of Death

Advances in organa transplantation also fueled the controverss, because of increased interest in cadaveric organ procurement

(Pierce, J., Randels, G., (2010) Contemporary Bioethics. A Reader With Cases. Oxford University Press, Oxford and New York, p. 117)

Definition of Death

Acceptance is not universal. Japan, for example permits its citizens to choose between the brain standard and the traditional cardiopulmonary model

In USA, New Jersey state law provides an exemption frm the vrain standard in order to accommodate religious objections.

(Pierce, J., Randels, G., (2010) Contemporary Bioethics. A Reader With Cases. Oxford University Press, Oxford and New York, p. 117)

RONALD RICHARD GILSON (November

17, 1963 – April 25, 2003) “Remember Me”

The day will come when my body will lie upon a white sheet,

Tucked neatly under the four corners of a mattress, located in a hospital busily occupied with the living and the dying . At  a certain moment a doctor will determine that my brain has ceased to function and that for all intents and purposes my life has stopped.

“When that happens, do not attempt to install artificial life into my body by the use of a machine and don’t call this my deathbed. Let it be called the bed of life and let my body be taken from it to help others lead fuller lives. 

RONALD RICHARD GILSON (November

17, 1963 – April 25, 2003) “Remember Me”

Give my sight to the man who has never seen a sunrise, a baby’s face or love in the eyes of a woman.

Give my heart to the person who has nothing but endless days of pain.

Give my blood to the teenager who was pulled from the wreckage of his car so that he may live to see his grandchildren play.

Give my kidneys to a person who depends upon a machine to exist from week to week. Take my bones. Every muscle fiber, every nerve and try to find a way to make a crippled child walk. Explore every corner of my brain, take my cells, if necessary, and let them grow so that someday a speechless boy will shout at the crack of a baseball bat or a deaf girl will hear the sound of rain against her window.

Burn the rest and scatter the ashes to the wind to help the flowers grow.

RONALD RICHARD GILSON (November

17, 1963 – April 25, 2003) “Remember Me”

If you must bury something, bury my faults, my weaknesses and my prejudices against my fellow man. Give my sins to the Devil, give my Soul to God.

If by chance you wish to remember me, do it with a kind deed or a word to someone who needs you. If you do all I have asked, I will live forever.