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Archive for April, 2010

Death and Why It Matters

Posted by MDViews on April 3, 2010

Death is a universal experience through which we all must pass. In The Pilgrim’s Progress by John Bunyan, death is seen as a river with the celestial city on the other side. But to go through the river takes faith that one will get to the other side. Regardless of the metaphor, we all will pass through death.

So what makes us dead? How is death defined from a medical standpoint? And why would that even be important?

Traditionally, death occurs when the heart stops and breathing stops. These two parameters defined death and served mankind well for millennia. But with modern medical technology, the definition has been expanded to included brain death—death defined as the total cessation of all brain activity. Total cessation of brain activity means no EEG evidence of brain function including the brain stem which controls many basic functions of the body. According to one article, all religious groups have acknowledged brain death as legitimate death, even if the heart still beats. A ventilator necessarily sustains bodily functions when brain death occurs.

The transplant industry, however, is extremely interested in the definition of death. If a dead person previously agreed to organ transplantation or if the next of kin gives permission for transplantation of the decedent’s organs, the organs may be harvested. The advent of new, powerful and effective anti-rejection medicines has caused the transplant industry to greatly expand. Transplants now include kidneys, heart, livers, pancreas, corneas, lungs and other body parts. Even a face has been transplanted. These transplants allow recipients to continue their lives, lives which would have been lost without a transplant. But the number of needed organs exceeds the number of available organs for transplantation. On this shortage stands the definition of death. Liberalize the definition of death—increase the available organs.

With brain death, the body essentially becomes a corpse, even though the heart beats. Not many object to transplant in those circumstances. However, total brain death is not that common. Strict criteria must be met to declare a person brain dead.

The desire for more transplantable organs has resulted in a new definition of death based on cardiac death, even if the brain has some function. This type of death is more “problematic,” as they say in medical circles. Problematic because fresher organs are better organs for transplant and it’s hard to get fresh organs if you have to wait for the heart to quit pumping.

A heart stopped for 5 minutes defines cardiac death for transplant in most circumstances. Some places use 2 minutes of no cardiac function to declare death. In Colorado, some pediatric transplant doctors were only waiting 75 seconds. In addition, with cardiac death transplant, the patient must die within 30 minutes of stopping mechanical ventilation or the patient is returned to the hospital room and the transplant attempt aborted.

Can one declare death after the heart has stopped for only 75 seconds? Is the heart really dead if it can be restarted in another person?

Cardiac death results in clotted blood in blood vessels, a major problem. Clotted vessels make revascularization of organs nearly impossible. The solution to this dilemma is a solution—literally. If a solution of heparin and another preservative are injected into a big vessel, even a day before, the blood doesn’t clot, making transplant more successful. But, injecting the solution pretty much guarantees death, again “problematic” as they say.

Abuses occur. Death must be determined by a doctor not involved with the transplant at all. Two doctors must each declare a patient brain dead. In one circumstance, an attending declared a patient brain dead and asked an ER doctor to confirm the diagnosis—which he did with a very cursory exam. Fortunately, a nurse documented a gag reflex and a response to pain, both indications of brain function. She called in a third doctor who confirmed brain activity and the transplant was aborted.

One family told of the transplant doctors calling her twice a day to see if she would consent to use of her child’s organs for transplant. (How do you define pressure?)

I fully recognize the benefit of transplantation and the great good to prolong life. But tenuous life must be protected or more people will see the transplant doctors as vultures circling the patients’ with serious illness and injuries.

Examples of liberal definitions of death are not hard to find. Many European countries now have an opt-out law instead of an opt-in law, which means organs are deemed available without consent—unless the decedent or the decedent’s family specifically denies permission. Some countries call the persistent vegetative state death, a disturbing development.

Our zeal for prolonging life with transplants should not result in the premature dispatch of the living.

In the old movie, The Princess Bride, Farm Boy was thought to be dead and was brought to Miracle Max (Billy Crystal) for help. Enigo Montoya (Mandy Patinkin) asks if Farm Boy is dead. “He’s not dead,” Miracle Max replies. “He’s just mostly dead. If he were completely dead, we’d go through his pockets and look for loose change.”

Let’s hope those donating their organs are not just “mostly dead.”

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