Dead or Alive?

It is not all that long ago that death arrived without too much fuss and its confirmation was accompanied without great medical expertise. One reliable test frequently advocated in the old textbooks was to place a mirror over the mouth of the patient; if no condensation appeared respirations were regarded as having ceased and death had occurred.

In The Quarterly ten years ago an editorial asserted, "Every doctor in general practice knows quite well when someone is indisputedly dead, not merely clinically dead, and until then we should adhere to the dictum that 'while there is life there is hope". Nowadays, with the recognition of deep coma following overdosage from drugs and the development of intensive care techniques, we cannot be certain. Certainly throughout history there has been much philosophical argument about the diagnosis of death, and it was generally accepted as having occurred when the vital functions of respiration and circulation had ceased. But with the technical ability to maintain these functions artificially, the dilemma of when to switch off the ventilator has become the subject of much public interest. It is not agreed that diagnosis of brain death is the more acceptable definition of death, and the statement issued by the Conference of Medical Royal Colleges in 1976 defining permanent functional death of the brain stem as death is followed in this country.

Certainly in the majority of cases, since brain death is part of, or the culmination of, failure of all vital functions, there is no necessity for a doctor specifically to identify brain death individually before concluding the patient is dead. But it is in the minority of cases in which the other organs and systems can be artificially maintained, even after brain death, that has made it important to establish a diagnostic routine which will establish with certainty the existence of brain death.

But there remain some dissident voices, mainly as to the acceptance of brain stem death as the sole identification, and in this issue we present a contribution from David Albert Jones OP summarising "Nagging doubts about brain death".

That there is a problem is evident from the procedure adopted in other countries. In America, for example, a person could be considered dead in one State and not dead in another. Clinical testing is similar in the UK and in the USA. Both practices demand that the patient be in unresponsive coma and without brain reflexes. Both demand apnoea. But in many institutions in the USA there is a demand for other 'objective' tests to establish that the brain has ceased to function. The first and most widely used is the electro-encephalogram. Angiography did not catch on, but complicated techniques using intravenous bolus injections of radioactive isotopes were explored.

It is those patients with a credible diagnosis of irremediable, structural brain disease (such as head injury or intracranial haemorrhage) who after being on ventilators for several hours are found to exhibit brain stem areflexia and persistent, properly documented apnoea. The effects of their primary condition must not have been complicated by drugs, shock, recent cardiac arrest, or grossly abnormal metabolic state.

This is the state defined by the UK code and by Christopher Pallis (1) as brain stem death and not compatible with long continued spontaneous action of the heart.

There are many other countries, mainly in Europe, which require electro-encephalograms and angiograms in addition to the clinical tests. The situation is evolving rapidly but, in Sweden and Poland, although brain death was accepted, its logical extension which Pallis described as the "beating-heart cadaver" was not. Brain death was not unequivocally equated with death. Brain death warranted removal of ventilatory support, but organs could not be removed while the heart was still beating. It is interesting to note that although our code carries considerable moral authority it has no legal or even quasi-legal status. The Department of Health assists its distribution, but parliament has not addressed the matter. The advice of the committees concerned, which included coroners and lawyers, was that legislation was not needed. The precise status of the code has never been tested in a court of law.

References

Pallis C. ABC of Brain Stem Death. BMJ vol 286, p209, 15.1.1983.