death and life sustaining treatments and complete detail about brain death and udda act made by uniform law commission and the whole presentation is based on united states medical system and government.
Death and life sustaining treatments AND MEDICAL AND LEGAL ETHICAL VIEW OVER IT.
Defining death in the law
Medical defination of death
Legal defination of death
Determination of death
American Academy of Neurology Guidelines for Brain Death
Biological death and signs of biological death
Quality Care at the End of Life
LIFE SUSTAINING TREATMENT
Decisions regarding life-sustaining treatment
Autonomy, obligation to treat, and medical futility
Specific treatment guidelines ICU admission
Defining Death in the Law.
The law recognizes different forms of death, not all of them
meaning the end of physical life.
Natural death- It is death by action of natural causes without the aid or
inducement of any intervening instrumentality.
It is used in some states to describe the circumstance of an
individual who has been convicted of a serious crime or sentenced to life
imprisonment. Such an individual forfeits his or her Civil Rights, including the ability
to marry, the capacity to own property, and the right to contract.
Legal death- It is a presumption by law that a person has died. It arises
following a prolonged absence, generally for a prescribed number of years, during
which no one has seen or heard from the person and there is no known reason for
the person's disappearance that would be incompatible with a finding that the
individual is dead (e.g., the individual had not planned to move to another place).
Violent death- It is death caused or accelerated by the application
of extreme or excessive force.
It is a medical term first used in the late 1960s, is the
cessation of all functions of the whole brain.
It is the end of life through a willful or negligent
Medical definition of Death
Death the cessation of life i.e. permanent cessation of all vital
For legal and medical purposes, the following definition of death has
been proposed-the irreversible cessation of all of the following:
(1) total cerebral function, usually assessed by EEG as flat-line.
(2) spontaneous function of the respiratory system.
(3) spontaneous function of the circulatory system.
Brain death- Irreversible brain damage as manifested by absolute
unresponsiveness to all stimuli, absence of all spontaneous muscle
activity, including respiration, shivering, etc., and an isoelectric
electroencephalogram for 30 minutes, all in the absence of
hypothermia or intoxication by central nervous system depressants.
Called also irreversible coma and cerebral death.―
N.B- Electroencephalography (EEG) is the recording of electrical
activity along the scalp
Legal Definition Of Death
An individual, who has sustained irreversible
cessation of all functions of the entire brain,
including the brainstem, is dead
(a) In the absence of artificial means of
cardiopulmonary support, death (the irreversible
cessation of all brain functions) may be
deter-mined by the prolonged absence of
spontaneous circulatory and respiratory
(b) In the presence of artificial means of
cardiopulmonary support, death (the irreversible
cessation of all brain functions) must be
deter-mined by tests of brain function.
Determination Of Death
In an era of rapid technological change, it is not unusual
for technology to overcome medical, social and legal
commonplaces. One instance of this is the legal
standard for determining biological death. Advances in
medical techniques and equipment have made it
necessary to re-evaluate traditional legal standards for
declaring a human being dead.
Such standards are necessary not because of death
itself, but because of the effect in the law of the
biological fact of death. Determinations of death are also
important in establishing the property relationships that
arise through inheritance and devise. They are important
in tort law to actions in wrongful death and survivor's
action. The standards for determining death are not
The Uniform Law Commissioners (ULC) created the Uniform Brain
Death Act in 1978 in an effort to clear up the legal ambiguity that had
arisen over the question of determining death. It was plain that legal
recognition only of traditional criteria—which rely on measuring
cessation of respiration and circulation—would no longer suffice.
Clearly the brain, as the center of the human body, is its most important
organ. Its irreversible functioning should be accepted as death. Direct
detection of loss of brain function is a product of very modern
The Uniform Brain Death Act simply established that the "irreversible
cessation of all functioning of the brain, including the brain stem" is
death. It then prescribed that determination of death be made in
accordance with "reasonable medical standards." The ULC assumed
that the traditional criteria would stand automatically alongside the
brain-death standard described in the uniform act, and so did not
mention those criteria in the act itself. But this omission proved
confusing for states trying to adopt comprehensive legislation on the
The ULC corrected the situation in 1980 by replacing the act with the
Uniform Determination of Death Act (UDDA).
UNIFORM DETERMINATION OF
This Act provides comprehensive bases for
determining death in all situations.
"Uniform Determination of Death Act" developed
jointly by the National Conference on
Commissioners of Uniform State Law, the
American Medical Association and the American
Bar Association, approved October 19, 1980 and
February 10, 1981.
DEATH AS PER UDDA
An individual who has sustain -either irreversible
cessation of circulatory and respiratory- functions,
or irreversible cessation of all function of the
entire brain, including the brain stem, are dead.
A determination of death must be made in
accordance with accepted medical standards.
Brain death is the irreversible end of all brain
activity (including involuntary activity necessary to
sustain life) due to total necrosis of the cerebral
neurons following loss of brain oxygenation. It
should not be confused with a persistent
Even after brain death, the working of the heart
might continue at a slow pace, but there will be
no respiratory effort.
Brain death, either of the whole brain or the brain
stem, is used as a legal indicator of death in
American Academy of Neurology
Guidelines for Brain Death
Establish irreversible and proximate cause of coma.
Achieve normal systolic blood pressure.
Perform 2 neurologic examinations
Absence of brainstem reflexes.
1. The death caused by degeneration of tissues
in brain and other part is called biological death.
2. Most organs become dead after biological
3. These organs can not be used for organ
Signs of biological death
Cessation of breathing
Cardiac arrest (no pulse)
Pallor mortis, paleness which happens in the 15–120
minutes after death
Livor mortis, a settling of the blood in the lower
(dependent) portion of the body
Algor mortis, the reduction in body temperature
following death. This is generally a steady decline
until matching ambient temperature
Rigor mortis, the limbs of the corpse become stiff
(Latin rigor) and difficult to move or manipulate
Decomposition, the reduction into simpler forms of
matter, accompanied by a strong, unpleasant odor.
“Quality care at the end of life is what we wish for”
A guiding philosophy of medicine is that the health and well being of
the individual patient is of paramount consideration.
There is a long-standing tradition in medicine that physicians must
do everything medically possible to keep a patient alive.
It is important that physicians understand and personally
acknowledge that death is an acceptable outcome of care in certain
circumstances, and that in many situations treatment cannot
Physicians should aim to provide their patients with care that fulfills
the goals identified above, is compassionate and respectful, and
allows patients to experience as dignified a death as possible.
Dying patients may have last wishes relating to many issues other
than treatment. Physicians should endeavour to honour the last
wishes of patients wherever it is possible to do so, as respect for
the autonomy of the patient must continue, to the extent clinically,
physically, and legally possible, to the end of life.
Quality Care at the End of Life
Research and experience show that patient goals for
quality end-of-life care generally include the
Management of pain and other distressing
2. Avoidance of unnecessary prolongation of dying;
3. Facilitation of clear decision-making and
Treatment with respect and compassion;
Preservation of dignity;
Affirmation of the whole person;
Opportunity to address personal concerns;
Achievement of a sense of preparedness, control
Preparation for death;
Achievement of closure.
Strengthening of relationships with loved ones;
Relief of unnecessary burdens on others;
Contribution to others and continued participation
and active involvement in social interactions, to the
Life-sustaining treatment is any medical intervention,
technology, procedure, or medication that forestalls
the moment of death, whether or not the treatment
affects the underlying life-threatening diseases or
Examples include mechanical ventilation, dialysis,
cardiopulmonary resuscitation (CPR), antibiotics,
transfusions, nutrition, and hydration.
Discussions about forgoing life-sustaining treatment
will often be raised when death is the predictable or
unavoidable outcome of the patient's underlying
medical condition. However, a patient need not be
terminally ill or imminently dying for these discussions
to be held.
Autonomy, Obligation to Treat, and
Patients have a right to control what happens to their bodies, so the
decision about whether to forgo life-sustaining treatment should, in
the final analysis, is theirs.
The physician has no obligation to render futile care and thereby
violate reasonable medical standards. Rather, physicians should
decide the extent of care in accordance with what they perceive is
medically appropriate for that patient and inform the patient about
In all circumstances continuity of the patient's care should be
assured. If the physician decides to forgo a non-beneficial treatment,
the patient should be informed.
Although patients do not have a right to insist on futile treatment,
circumstances can arise in which providing life-sustaining futile
treatment for a limited time is justifiable to achieve identified
Specific Treatment Termination
Intensive Care Unit Admission
The following types of patients are candidates for
admission to intensive care units when it is consistent
with their treatment preference and goals: critically ill
patients who require life support for organ system failure
that may be reversible; patients with irreversible organ
system failure who cannot be treated appropriately in
another setting; patients at risk of life-threatening
complications who require monitoring or treatment; and
patients who are receiving a trial period of monitoring or
treatment when the prognosis or the effectiveness of
therapy is in doubt.
A decision to forgo some forms of life-sustaining
treatment such as cardiopulmonary resuscitation should
not automatically preclude other forms of treatment and
Patients who generally should not be admitted
to the intensive care unit include
Patients with documented irreversible cessation of all
functions of the entire brain.
Patients who have been diagnosed as irreversibly
Patients with irreversible illness who are near death
Patients who, while capable of making decisions, have
requested that they not receive intensive care or its
Patients are entitled to refuse admission to an ICU, even
when doing so puts them at risk of death.
Patients should not, however, be able to demand
admission to an ICU. A request by a patient or a
surrogate for admission to an ICU may be denied if
admission would be medically inappropriate for the
patient, detrimental to patients already in the unit, or
contrary to the admission criteria.
These patients should be transferred from the ICU to
another setting within the hospital or to another
institution when intensive care will no longer benefit
them, either because they have improved to a point
where intensive care is no longer necessary, or
because they have deteriorated to a point where it no
longer offers reasonable promise of benefit.
Cardiopulmonary resuscitation (CPR) refers to those
measures used to restore ventilation and circulation in
patients in whom these functions have been interrupted.
Resuscitation techniques have no value in the
management of irreversible or terminal disease states.
They are intended to revive otherwise healthy individuals
who experience some reversible catastrophe that
interrupts breathing and circulation.
Because of the emergency character of CPR, a patient or
surrogate should ideally be consulted in advance about
whether to begin resuscitation in the event of cardiac or
respiratory arrest. Any patient who is at increased risk for
cardiopulmonary arrest should be given the opportunity to
In the absence of a Do Not Resuscitate (DNR) order,
resuscitation should be attempted, and if any doubt
exists as to whether a decision to forgo treatment has
been properly made, treatment to preserve life should
be given. Deceptive resuscitation efforts, known as
"slow codes" and "walk, don't run" codes are not
acceptable. Any code should be a full code unless a
partial code or limited resuscitation effort has been
consented to by an informed patient or surrogate. At the
time of cardiac or respiratory arrest, if the physician
summoned to direct resuscitation realizes that CPR
cannot restore cardiac and respiratory function, the
physician may call off the effort. If CPR is clearly futile
(i.e., does not achieve its physiological objectives, offers
no benefit to the patient, and violates reasonable
medical standards), there is no obligation to offer or
Guidelines for physician from AMA.
Guidelines by american academy of neurology for
Cleveland clinic of medicine and research article.
Yales university report.
Life sustaining treatment and tough decisions
article by James Bernard.
GUIDELINES FOR TERMINATING LIFE
SUSTAINING TREATMENT BY MICHIGAN
UNIFORM LAW COMISSION PROTOCOLS.