QPMPA Journal September 2011 - Qualified Private Medical ...

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views ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ death; end or beginning “The care of human life and happiness and not their destruction is the first and only legitimate object of good government.”... Thomas Jefferson “There is no quality of life when the patient is dead.”... A nurse Death is the termination of the biological functions in a living organism. The word refers both to the particular processes of life’s cessation as well as to the state of a formerly living body. Phenomena, which commonly bring about death, include predation, malnutrition, accidents resulting in terminal injury, disease and an ‘act of God’. The nature of death has been a central concern of the world’s religious traditions and philosophical enquires. A belief in some kind of afterlife or rebirth has been a central aspect of religious belief. Scientific enquiry is yet to grapple with the origin and nature of consciousness and agrees any such view about its existence or non-existence after death remains speculative as far as science is concerned. Medical science is at a loss to locate where consciousness exists; is it inside or outside the body. Neurologists think it is in brain. However, modern outlook is that if neurologists want to test ‘the higher functions’ in a living entity they must do it in ‘higher areas’ above the body; not inside it. Senescence Almost all animals fortunate enough to survive hazards of their existence eventually die from senescence. The only exception is jellyfish — Turritopsis nutricula, thought to be immortal in effect. Causes of death in humans as a result of intentional activity include suicide, homicide and war. From all causes, roughly 1,50,000 people die around the world each day. Physiological death is now seen as less an event than a process: conditions once considered indicative of death are now reversible. Where in the process, a dividing line is drawn between life and death, depends on factors beyond the presence or absence of vital signs. In general, clinical death is neither necessary nor sufficient enough for a determination of legal death. A patient with working heart and lungs and determined to be brain dead can be legally dead without clinical death occurring. Precise medical definition of death becomes more problematic as scientific knowledge and medicine advance: a strange paradox. dr. k. sasidharan Signs of death or strong indications that a person is no longer alive are: Cessation of breathing No pulse (cardiac arrest) Pallor mortis, paleness that happens in the 15–120 minutes after death. Liver 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 odour. The concept of death is a key to human understanding of the phenomenon. There are many scientific approaches to the concept. For example, brain death, as practiced in medical science, defines death as a point in time during which ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ 128 QPMPA.JMS . Vol. XXV . No. 3 . June-Sept. 2011
views ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ brain activity ceases. One of the challenges in defining death is in distinguishing it from life. As a point in time, death would seem to refer to the moment at which life ends. However, determining when death has occurred requires drawing precise conceptual boundaries between life and death. This is problematic because there is little consensus over how to define life. It is possible to define life in terms of consciousness. When consciousness ceases, a living organism can be said to have died. One of the notable flaws in this approach, however, is that there are many organisms which are alive but probably not conscious (for example? single-celled organisms). However, the greatest problem is in defining consciousness, which has many different definitions given by modern scientists, psychologists and philosophers. Vaguely problem of defining death applies to the particular challenge of defining death in the context of medicine. Other definitions for death focus on the character of cessation of something. In this context, “death” describes merely the state where something has ceased, e.g., life. Thus, the definition of “life” simultaneously defines death. Historically, attempts to define the exact moment of a human’s death have been problematic. Death was once defined as the cessation of heartbeat and breathing, but the development of CPR and prompt defibrillation has rendered that definition inadequate. Events, which were causally linked to death in the past no longer, kill in all circumstances. Without a functioning heart or lungs, life can be sustained with a combination of life support devices, organ transplants and artificial pacemakers. Today, where a definition of the moment of death is required, doctors and coroners usually turn to “brain death” or “biological death”. People are considered dead when the electrical activity in their brain ceases. It is presumed that an end of electrical activity indicates the end of consciousness. However, cessation of consciousness must be permanent and not transient as in sleep or coma where EEGs can easily tell the difference. However, the category of “brain death” is seen by some scholars as problematic. For instance, Dr. Franklin Miller notes, “By the late 1990s, the equation of brain death with human death was increasingly challenged based on evidence regarding the array of biological functions displayed by patients diagnosed with brain death who were maintained on life supporting systems for substantial periods of time. These patients could sustain circulation and respiration, control temperature, excrete wastes, heal wounds, and fight infections. The most dramatic is brain dead pregnant women gestating foetus.” Those people maintaining that only the neo-cortex is necessary for consciousness argue that electrical activity alone should be considered to define death. Eventually it is possible that the criterion for death will be the permanent and irreversible loss of cognitive functions, as evidenced by the death of the cerebral cortex. All hopes of recovering thought and personality is then gone, given the current and foreseeable medical technology. However, at present, the more conservative definition of death as irreversible cessation of electrical activity in the whole brain, not just in neo-cortex has been adopted. In 2005, the Terri Schiavo case brought the question of brain death and artificial sustenance to the front of American politics. Even by whole-brain criteria, the determination of brain death can be complicated. EEGs can detect spurious electrical impulses, while certain drugs, hypoglycaemia, hypoxia, or hypothermia can suppress or even stop brain activity on a temporary basis. Because of this, hospitals have protocols for determining brain death involving EEGs at widely separated intervals under defined conditions. Legal In the United States, a person is dead by law if a licensed medical practitioner issues a Statement of Death or Death Certificate. Various legal consequences follow death, including the removal from the person of what in legal terminology is called personhood. The possession of brain activities, or ability to resume brain activity, is a necessary condition to legal personhood in the United States. “It appears that once brain death has been determined ... no criminal or civil liability will result from disconnecting the lifesupport devices.” Misdiagnosed There are many anecdotal references to people being declared dead by doctors but then “coming back to life”, sometimes days later in their coffins, or when embalming procedures are about to begin. From the mid-18th century onwards, there was an upsurge in the public’s fear of being mistakenly buried alive and much debate about the uncertainty of the signs of death. Various suggestions were made to test for signs of life before burial, ranging from pouring vinegar and pepper into the corpse’s mouth, to applying red-hot pokers to the feet, or into the rectum. Writing in 1895, the physician J. C. Ouseley claimed that as many as 2,700 people were buried prematurely each year in England and Wales. In cases of electric shock, CPR for an hour or longer can allow stunned nerves to recover, allowing an apparently dead person to survive. People found unconscious under icy water might survive if their faces are kept continuously cold until they arrive at a hospital. This “diving response”, in which metabolic activity and oxygen requirements are minimal, is something humans share with cetaceans. ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ QPMPA.JMS . Vol. XXV . No. 3 . June-Sept. 2011 129
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