Mode of dying Human beings have a deep-seated belief that a person’s mode of dying is an important part of the totality that is his or her life. The moment of passing on from this world is, therefore, a very important point in the human life story.
History of death Before 1816, physicians were not well trusted in their ability to diagnose death Fear of being buried alive
In ancient Rome Call out deceased person’s name 3 times If no response-- finger amputated If no bleeding– declared deceased
Fear to be buried aliveIn 14th century Duke of Lancaster left instructions to keep his body in bed for 40 days If doctors still believed he was dead then to be buried
Magic words (1790) “I am dead”written on mirrors in invisible ink (silver nitrate)Decomposed body produced hydrogen sulfide, writing became visible as silver sulfide was produced
Patented Coffin to alert (1897)If death was misdiagnosed If presumed deceased awoke from sleep beneath the ground A device was rigged to light a lantern, raise a flag and ring a bell
Clawed forceps By French physician Designed to clamp around the nipple of the presumed corpse to confirm death No response---dead
“…I know when one is dead, and when one lives. She is dead as earth. Lend me a looking glass. If that her breath will mist or stain the stone, why then she lives” King Lear; Act V, Scene III William Shakespeare
Invention of stethoscope (1816) Physician were began to be trusted in their ability to diagnose death
Primary modes of confirming death Respiration Heart sound pulse
Death criteriaIn beginning of 20th century Cardiorespiratory criteriaClinical Death Cessation of blood circulation and breathing
Change MECH ANICAL VENTILATION Change started in 1952 with an outbreak of polio in Copenhagen, 12 year old girl under went tracheostomy & put on ventilator Pierre Mollaret (French) in 1957 reported on patients who had developed brain injury and were on mechanical ventilation No brainstem reflexes were present and post mortem examination revealed brain liquefaction
Factors for change Increasing availability of mechanical ventilation—legal implications of disconnection Rapidly advancing field of organ transplantation
If we have a human body being ventilated on a respirator, but in which there is no sign of brain activity, ought we to regard that person dead or alive?
A new diagnosis of death In 1968 Harvard Brain Death Committee published report on how to diagnose death on new criteria Criteria proposed that patient could have no brainstem or spinal cord reflexes. A confirmatory test was also required i.e. EEG, absence of circulation to brain In essence, committee said a person is dead if the brain is dead
Clinical DeathCessation of blood circulation and breathing When the heart stops beating in a regular rhythm. Condition is called cardiac arrest The absence of blood circulation and vital functions related to blood circulation was considered to be the definition of death
“Clinical death is now seen as a medical condition that Precedes death rather than actually being death”
During clinical death, all tissues and organs in the body steadily accumulate a type of injury called Ischemic injury
Death Permanent and irreversible cessation of vital functions of heart, brain and lungs (C.K. Parikh; Text book of forensic medicine and toxicology)
How should we regard a person in permanent coma? When should we cease to persist with life prolonging treatment? Under what circumstances can patients decline life-saving measures?
TYPES OF BRAIN INJURY Coma Brain death Vegetative state Locked-in state Minimally conscious state
Coma Prolonged state of unconsciousness, in which patient is alive, but unable to move or respond to environment.
ComaMost serious brain injuries begin with a coma “Eyes-closed unconsciousness.” It is as if the patient is sleeping but cannot be aroused. Coma is usually not permanent. Some patients go on to become brain dead; others enter the vegetative stage, become “locked in,” or enter the minimally conscious state; still others recover completely
Brain deathIrreversible loss of the clinical function of the whole brain: The cortex (responsible for motor and cognitive function) The midbrain (which might be thought of as integrating higher and lower centers in the brain) Brain stem (responsible for vegetative functions such as sleep-wake cycles and breathing).
Brain death is a product of modern technology, made possible by mechanical ventilators and cardiopulmonary resuscitation
Brain death criteria Absence of eye opening Absence of verbal or motor response to pain Loss of brain stem reflexes (such as pupil response, corneal reflexes, caloric response to vestibular stimulation, cough reflexes and hypercapnia)
Brain death criteria cont; Total unresponsiveness to these tests, combined with good evidence that it is caused by irreversible structural damage to the brain means that person will never regain consciousness
Vegetative State: Refers to plant life i.e. without locomotion) It is a brain injury resulting from Trauma or Diseases, where higher functions of brain are lost while the non-cognitive functions, like breathing and heart beating are retained.
Vegetative state “Eyes-opened unconsciousness” There is a disassociation between wakefulness and awareness. While patients may appear awake, there is a lack of evidence that the upper brain receives or projects information. The upper brain and the midbrain are not integrated in function with the brain stem or the rest of the body, although the brain stem continues to manage the vegetative functions.
Vegetative state “Sustained and reproducible voluntary response” is important in the diagnosisPrognosis is determined by the Cause of the injury Length of time the patient has been in the vegetative state Comorbid conditions.
Duration of the vegetative state also affects nomenclature A duration >1 month is said to be persistent. When the cause of the vegetative state is nontraumatic —such as an anoxic injury after cardiopulmonary resuscitation a duration >3 months is said to be permanent BUT When the cause of the vegetative state is traumatic a patient must remain vegetative for >12 months before the condition is defined as permanent.
Locked-in state Consciousness is preserved but the patient is paralyzed except for eye movement and blinking.
Locked in Syndrome Paralyzed from head to toe, the patient, his mind intact, is imprisoned inside his own body, but unable to move or speak. “In my case blinking my left eyelid is my only means of communication….My heel hurt, my head weighs a ton, and something like a giant invisible diving-bell holds my hole body prisoner”Jean-Dominique Bauby describing his experience in The Diving Bell and the Butterfly, a book dictated entirely by eye movements
Minimally conscious state Sleep-wake cycles exist, just as in the vegetative state. Arousal levels range from obtundation to normal arousal. There is reproducible but inconsistent evidence of perception, communication ability, and/or purposeful motor activity. Visual tracking is often intact but typically inconsistent. Communication ranges from none to unreliable, with inconsistent yes-no responses, verbalizations (typically fewer than six words), and gestures
Can we cease our medical efforts tokeep alive some one who is braindead?
Islamic perspective Unanimous approval of whole brain death criterion and its permissibility within Islam (Acdemy of Islamic jurisprudence, Jordan1986}
PAKISTAN Brain death is widely accepted Legislation?
Famous cases for legal Battles Karen Quinlan 1975----- 1986 Nancy Cruzan 1983----- 1990 Theresa Marie Schiavo 1990 -----2005
Readings Bioethics for clinicians: 24 Brain death by Neil M. Lazar et al The final diagnosis of brain death: David C. Kaufman www.sccm.org Ethical & social dimensions of brain death. F.Moazam. Pakistan journal of neurological sciences