When Is Death
When Is Death
I was only 24 years old the first time I was called upon to pronounce a person dead. It was during my fourth year in medical school and it was 3:00 a.m. Because all the physicians were in surgery, a nurse called me, an on-call medical student, to come to the bedside and make official what she had already diagnosed.
Arriving at the bedside, I listened for heart sounds with my stethoscope but heard nothing. I watched for signs of breathing and saw none. I felt for pulses, but could not perceive any sign of life.
Still insecure, I asked the nurse to get an electrocardiogram machine so I could make absolutely sure. I saw her roll her eyes upward as she left to comply with my request. I knew I was showing my inexperience, but I was worried that if I made a mistake and this man awoke in the morgue, I would never be able to forgive myself.
So, I attached the EKG machine, checked the leads twice, and after seeing the persistent flat-line, finally wrote a brief note in the patients chart stating that he was indeed dead.
Pronouncing that man dead over thirty years ago was not easy for me, and it seems little has changed. Today our society is still having a tough time defining death. For centuries death was defined by the cessation of breathing and heart beat. But in the 1950s modern medicine provided us with machines that take over these functions,and the old definition was no longer useful. This left us with a group of patients who were kept alive, yet considered brain dead.
This is a serious problem. In this country there are, at any one time, approximately 10,000 individuals in comas or a persistent vegetative state. These individuals can remain in such a state for a long time before dying. The longest ever recorded was Elaine Esposito, who lapsed into a coma after surgery in 1941 and stayed that way until her death 37 years later. Other famous, but less lengthy examples include Karen Quinlan, Nancy Cruzan, and Sonny Von Bulow.
In 1983, the president's commission for the study of problems in medicine adopted the definition of death known as whole brain death. The entire brain includes the upper portion (the cerebral cortex), that controls consciousness, and the lower brain (the brain stem), that controls breathing and heart beat.
To be considered dead, both upper and lower brain activity must cease. Irreversible coma patients are individuals who have suffered only upper brain death while maintaining their lower brain function. This allows them to breath and have a sustained heart beat, yet rendering them in a persistent vegetative state the remainder of their lives.
The strict definition of death has created serious legal problems such as with babies born without brains, individuals whose family can not let go, and organ transplantation cases.
But it also protects us. There is the unusual and dramatic case of coma reversal such as the one in High Point, N.C. In 1991, a man regained consciousness after eight years of being in a persistent vegetative state. Anecdotal cases like this probably give hope to families of the 10,000 people in this country who are in the deep sleep of coma.
Are they dead? Not legally if their brain stem still functions! But with so many individuals in a persistent vegetative state, costing our society billions of dollars, we need a definitive, yet workable definition of death that allows for an element of medical wisdom and action based on individual circumstances.
Just like I needed over 30 years ago.