Healthy Living: The Diagnosis of Death
By- Dr. Jonathan Wood
When is someone dead? It seems simple, but clearly it is not.
This is the question circulating the country right now around the case of an unfortunate young girl in California who was declared “brain dead”, but whose family insists that she is not dead. This case is sad and unfortunate, perhaps made more tragic by the girl’s age and by the fact that her brain injury resulted from complications of a seemingly “routine” operation. Unfortunately, the situation has become even more tragic because of the confusion around understanding her death. This confusion is very important to discuss because this type of misunderstanding is more common than many people realize.
How is someone declared dead in the United States in 2014?
There are two pathways to making the diagnosis of death:
- Death by cardiorespiratory criteria – This is when the lungs and heart stop and is the “usual” way for declaring someone dead. If the heart cannot spontaneously pump blood (and oxygen) around to the rest of the body, the body stops working. If the heart stops, then the person will soon stop breathing and the person will be declared dead. Similarly, if the lungs don’t function or the drive to breathe is irreparably impaired, then no oxygen will enter the blood and eventually the heart itself will stop working. Again, the lungs and the heart stop and the person is declared dead.
- Death by neurologic criteria – Just as the body cannot function without the heart and lungs, the body cannot function without a brain. Some severe brain injuries leave a person devastated, but the most primitive parts of the brain can remain intact. Although they may never think and function normally again, their heart and lungs and other integrated functions of the body continue. This person is devastated, but not dead. However, sometimes a brain injury is so devastating that both the thinking part of the brain and the primitive “body controlling” part (brainstem) stop working. When these parts of the brain are permanently destroyed, the person is declared dead by neurologic criteria. Our medical community, our legal institutions, and our society define these patients as dead.
So why the confusion?
With machines and medicines, doctors and hospitals are able to keep a heart beating and lungs functioning in the setting of devastating illness or injury. Often, these patients can eventually recover. However, if the brain function is completely destroyed, no recovery is possible. In these cases, the person is declared dead by neurologic criteria. The person is appropriately declared dead, even though the heart continues to beat with medicines and the chest continue to go up and down with a machine. This is “body support”, not “life support”, because the patient is no longer alive.
Confusing terms that should be eliminated:
- “Brain death” – This term arose in the 1960’s. It was meant to describe “Death by Neurologic Criteria”, but is understandably confusing. It suggests that though the brain is dead, the rest of the person is alive. It ignores the reality that a person cannot be alive if the brain is completely and irreversibly damaged. Just as a person whose heart has stopped is dead (not “heart dead”), a person whose brain has stopped is dead. Some families want to honor their loved one by offering organs for donation after being declared dead by neurologic criteria. In this case, the machines and medicines can be continued until that wish is fulfilled, sometimes for a day or two. Otherwise the machines are stopped when death by neurologic criteria is determined. The term “brain dead” needs to be abolished and replaced universally with “dead by neurologic criteria.”
- “Life support” – The machines and medicines we have in ICU’s are amazing and invaluable. They can support a person’s bodily functions during extreme illness and often make recovery possible. But they are not “life support.” They are organ support: lung support, heart support, kidney support, etc. When we refer to these machines and medicines collectively as “life support” in a patient who has been declared dead by neurologic criteria, we create confusion. How can “life support” be withdrawn from someone who is already dead? This term need to be abolished from our vocabulary.
The story of the young California girl who died from a devastating brain injury is tragic. It is made even more tragic by the confusion that has been allowed to arise and persist around her death.