Concepts of Death in Medicine

Concepts of oddment in MedicineHufsa AliThe concept of expiry is oneness that has been shrouded with mystery and wonder for as long as human beings pick out lived and died. The arrangement and implications of devastation find varied greatly across eras and cultures. Historically, there has been little soundbox in the dread of the concept of the payoff of demolition, the moment at which one is dead. The Oxford English Dictionary defines end as the subvert of action the permanent tip of the live functions of a somebody or electric organism2. This definition, while precisely written, leaves considerable ambiguity nigh the diction of the definition itself. It is shy what is meant by life and bouncy functions of a person or organism. Further, one may question whether the vital functions of humans as persons differ from those of humans as organisms. Is ending a process rather than an event? If so, when does it begin and end, and when is it book to decl ar destruct ion? Is it possible that a human may experience deuce closings, death of the person and death of the organism? If so, which death is applicable to medicine? In this paper, I allow review the evolution of the definition of death in the Western world in the context of locomote medicine, and explore the implications in relation to organ donation.The philosophical examination of human death has concentrated twain underlying questions what is human death, and how brook we determine that death has occurred?3 The inaugural question addresses the concept or definition of death, while the second concerns developing the corresponding standards criteria and clinical protocol to be used to declare death. Examples of the practice to the first question include death as the functions of an organism or human death as the permanent discharge of personhood (Stanford Encyclopedia of Philosophy, 20114). Examples of answers to the second questions include the cardiopulmonary standard, the una nimous- soul standard, and the cerebral standard. It was not until the last cytosine that seeking answers to these questions became the source of a painstakingly complex on-going debate about death, personhood and medicine.Prior to the advent of the stethoscope in the 19th century, completion of breathing marked the occurrence of death (Daroff)5. Then, the loss of pulse became the characterizing event (Jennett, 2001). The ordinal Edition of Blacks Law Dictionary was published in 1951, reidentifying the occurrence of death as the cessation of life, defined by physicians as a total stoppage of heart of the circulation of the railway line67 in the United States. The definition of death (particularly the bank note between death of the body and death of the person) was not relevant because the death of the instinct and the rest of the body t protrudes occurred concurrently. Cardiopulmonary failure inevitably led to irreversible loss of all heading functions, and the irreversible l oss of all wittiness functions quickly led to cardiopulmonary arrest.The issue of distinguishing between cardiopulmonary failure and school principal function failure was not clinically relevant until the designing and widespread use of mechanical resuscitation and ventilation devices8. A halt heart could now be restarted and blood could be oxygenated without functioning intercostal and pleural muscles, after the threads of the mind-set had began ischemic necrosis1. Although they were still occurring, the functions of circulation and respiration were existence performed by mechanical respirators and defibrillators. While this did not meet the criteria for death as defined in 1951, it is all important(p) to note that such perseverings would cast off met the criteria for death as soon as the use of life-support machines was discontinued. Essentially, this meant that either death could be reversed, or that death could be delayed well beyond the failure of vital organs. This also meant that a body with irreversible loss of brainpower functions could be indefinitely kept alive. This high gayed the distinction between neurological failure, and circulatory and respiratory failure.During the 1950s, several physicians around the world began to recognize the futility of continuing interposition for patients who had lost all neurological functions. In 1954, a neurologist practicing in Massachusetts, Dr. Robert Schwab, noted this while examining a comatose brain hemorrhage patient who was on a respirator. The question was, Is this patient alive or dead? Without reflexes, without breathing and with total absence of evidence of an electroencephalogram, we considered the patient was dead in spite of the carriage of an active heart maintaining circulation. The respirator was therefore turned off and the patient pronounced dead. In 1959, cardinal French neurologists came to the same conclusion. However, they some of them preferred the term coma dpass, meaning be yond coma (Mollaret, 1959)9. This was the prognosis of certain death, they argued, that not did not meet the criteria for death itself. Schwab disagreed, stating that death of the the death of the nervous carcass would be death of the patient. In 1963, he proposed criteria to consider certain patients dead in spite of continuing cardiac function loss of reflexes, a flat EEG, and apnea102. Over the next pentad days, he reported having treated 90 such patients. None of them survived and autopsies showed that every one of them had pervasive tissue necrosis in their brains. His findings went on to greatly influence the legal and aesculapian redefining of death.Meanwhile, there were developing concerns about the futility of extensive, expensive medical care for patients whose deaths were imminent and inevitable. In 1957, Pope Pius XII proclaimed that physicians were not get to give extraordinary treatment in such cases11. In 1962, psychiatrist Frank Ayd published a paper in which h e contended that there was a moral obligation to withdraw care when death was inevitable. In 1965, THe American medical checkup Association held its First National Congress on medical checkup Ethics and Professionalism to detail guidelines for end-of-life-care.12As the initiation of the transition from heart to brain criteria for death, the field of organ graftingation was developing. The first successful kidney transplantation was performed between live twins in 1954 by Dr. Joseph Murray. Eight years later, Dr. Murray performed a kidney transplant from a cadaver donor. In the years following, liver, lung and heart transplants were performed, apply organs from cadavers. close to of the recipients died soon after the surgery. There was the idea that live donors would improve the chances of survival, only when physicians were weary about use vital organs from patients that were alive by cardiopulmonary criteria, even if they had lost total brain function. The ethical standa rd regarding organ retrieval is the Dead Donor Rule (DDR), which prohibits organ vital procurement from donors that have not yet been declared death. This limits possible sources of organs to cadavers that still have salvageable tissues and organs. As medical technology prevented more and more deaths through advancements in life-support technology, it also accelerated the demand for organs of dead donors, as the capacity to perform successful transplants increased. This growing concern for organ transplantation sources, match with the futility of having hopeless patients on artificial ventilation and resuscitation created a climate that facilitated the major change that occurred at the end of the 1960s.In 1968, an Ad Hoc committee was formed at Harvard University to address the ethical problems created by the hopelessly unconscious patient13. The committee developed criteria similar to the concept of coma dpass. Patients who met the criteria3 would be considered essentially dead, but not actually dead. The final report was titled A rendering of Irreversible Coma commentary of Brain Death. While this report didnt explicitly realign the definition of death to brain-based criteria, it outlined appropriate standard of care for comatose patients whose deaths were inevitable and imminent. It was never said outright, but they implied that the death of the brain is the death of the patient, and hinted that the cardiopulmonary criteria for death were ob resolete14.On the same day as the publication of the Harvard report, the 22nd World Medical Association (WMA) met and announced the Declaration of Sydney. The declaration distinguished the gradual process of the death of cells and tissues from the death of the patient. clinical interest lies not in the state of preservation of isolated cells but in the fate of a person the point of death of the different cells and organs is not so important as the induction that the process has become irreversible. While it has b een overshadowed in the United States by the Harvard report, the WMAs declaration was the first major committee distinguishment between the death of the body and the death of the person.Throughout the 1970s, widespread acceptance of the implied Harvard definition grew among the medical community. State legislatures and courts began legally recognizing some form of death based on brain-criterion, although there was little concurrence among the criteria across jurisdictions. In 1971, Mohandas and Chou (neurologist and psychiatrist, respectively) published their Minnesota Criteria, based on autopsy discoveries that identified the wipeout of the brain stem as the cause of brain death. Thus, the requirement for the EEG was eliminated4. Because both respiratory check up on and consciousness originated 15in the brain stem, the loss of brain-stem function equaled death of both persons and organisms. In the UK, the criteria for brain death was tweaked to exclude the EEG requirement, whic h meant a patient with detectable cortical activity would be dead in the UK and alive in well-nigh of the US.The Presidents Commision for the Study of Ethical Problems in Medicine and biomedical and Behavioral Research was formulated in 1979 to clarify brain death and other biomedical morality issues. The committee published a report in 1981 that provided a clearer and more practical definition of death than the previous, conceptually ambiguous ones that had been used before. The commission reasoned that death occurred when the bodys physiological system ceases to require an integrated whole16. Because the brain functions as the great integrator and regulator, the death of the organism occurs when the total brain functions are lost, and the organism disintegrates to a collection of its parts. As a result, the Uniform Determination of Death Act (UDDA) gave both brain-based and circulatory-respiratory-based criteria a separate but equal status in the eyes of integrity and clinica l care. In the United States, death could now be determined by the irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain. While the UDDA recognized the whole brain standard as a means to determine death, it did not specify the neurological footrace criteria to be used. It also did not specify the amount of elapsed time required before stopped circulation can be considered irreversible. Different hospitals, providers, and associations used varying sets of tests to determine death.In 1995, the American Academy of clinical neurology (AAN) attempted to standardize the clinical protocol used to determine death using brain criteria. Tests to be performed were similar to the Harvard report criteria, without the EEG requirement and the 24-hour repeat was left unaddressed. While the UDDA and AANs guidelines have brought consistency to the clinical process of determine death, there has been widespread disagreement about the criteria of death itself.The traditional criteria for determining death, the cessation of heartbeat and breathing, have been updated by the UDDA. The circulatory-respiratory standard holds death as the irreversible cessation of circulatory-respiratory function. expiration aside the implications of word irreversible, this definition may still not be entirely accurate nor practical. earlier than changing the reality of the nature of death, life-support devices and other technologies of modern medicine have shined a light on an aspect of the process of death that was not visible before. Before the possibility of mechanically and unnaturally continuing respiration and circulation, the failure of these processes were associated with the occurrence of death. However, after such death could be reversed and institutionalise off indefinitely, it became apparent that the onset of cardiopulmonary failure was not the moment of death, but simply apocalyptic of death. As Bernat, Culver a nd Gert argue, heartbeat and regular breathing usually indicate life, but they do not constitute life (Bernat, Culver, and Gert 1981)17. Life involves the integrated functioning of the whole organism. Brain-based criteria better suited this understanding of life because the brain is responsible for much regulation of the entire organism. Thus, including brain-based criteria to declare death is seen as an update to the previous understanding of death, not a complete overhaul of it.The transition to brain-based criteria is nowhere near free of criticism. For some, one of the virtually obvious flaws in the logic behind the brain-based criteria for death was its basis on the idea that the brain is the sole organ responsible for integration of the organism as a whole. If death is defined as the irreversible loss of functioning of the organism as a whole, thusly only after the complete cessation of all whole-body integrating functions may a patient be considered dead. While the brain pl ays the biggest role in integrating interdependent functions of the body, somatic integration is a holistic phenomenon that involves organs and tissue systems throughout the body. resistant responses, regulation of blood glucose levels, and hematopoiesis are regulatory functions that can continue to occur without the entire brain (Shewomn, 2001)18. Therefore, if the definition of death is understood to be the end of the existence of the organism as an integrative whole, then the death of the whole brain does not necessarily mean the biological organism has died.Brain-based criteria may have been a step in the right direction, but perhaps for the wrong reasons. The significance and necessity of the brain may lie in another aspect of its function one that cannot be attributed to some(prenominal) other part of the body personhood. The brain is the origin of human thought, reasoning, consciousness, emotion, and self-awareness. If the entire brain is dead, than the human person is dead, even if the human organism continues to live.Another problem with the development of brain-based criteria is again unrelated to the concept itself, but how it came about as standard of care. The ethically dangerous notion that the climate of evolving medical innovation, particularly organ transplantation, had influenced and driven the acceptance of whole-brain death is a very concerning one. When the Harvard committee met to discuss brain death in 1968, they seemed to be concerned about two things the futility of spending resources on patients with no chance of recovery, and the idea of squander the organs of these patients bodies. Their main focus of concern seemed to not be the well-being of the patients at hand, but protecting the physicians who would withdraw care from patients that would previously have been considered alive. Without the redefinition of death, doctors would have been morally responsible for the death of such patients.Officially, the reason the Harvard committ ee cited for their efforts was to free up resources spent in vain on untreatable patients. Murray, who was on the committee specified that the primary concern was the dying patient, and that organ transplantation was distinct and unrelated, ()19 However, many have been skeptical of this separation, arguing that the motive for changing the definition of death had everything to do with organ transplantation. Neurosurgeon Richard Nilges, calls fear to the fact that respiratory and other life-support technologies had been in use for nearly two decades before the precipitate formulation of the Harvard committee, and no one had so loudly expressed the urge to end such care. Instead, he points out, that the Harvard committee met less than a year after the first successful heart transplant surgery.5 establish on the heart-lung criteria of death at the time, the act of removing the heart from a live patient on life support would have been the cause of death of that patient. Nilges suggests that a second, underlying reason for changing the criterion of death was the underlying motivation behind the Harvard report providing organs for transplantation. This situation was an ideal one for organ transplant advocates, because it was an opportunity to tailor the definition of death to fit the moral acceptability of transplanting living hearts. winning a beating heart from a body is not equivalent to taking innocent human life if brain dead individuals are defined as already dead. Interestingly, Nilges is not against the idea of using brain-based criteria for death in organ donors. Rather, he disagrees with the way this criteria is practiced. His experience working with such patients and organ transplant teams has left him with disdain towards the practice of organ transplantation. In his paper titled Organ Transplantation, Brain Death, and the slipper Slope A Neurosurgeons Perspective, Nigles proposes a causal relationship between the changes in the understanding and pract ice of death declaration to the desires of the insatiable transplant advocates. He recalls trying protect his dying patients from transplant teams, who he compares to hungry vultures eyeing a small, dying animal. He criticizes the unofficial leeway allowed when diagnosing whole brain death, pointing out that over 20% of patients declared dead on brain-based criteria actually had brain activity detectable by an EEG.Save for the finale HANS JONAS uncertainty about border b/w life, death201 Necrosis, death of tissue, can be caused by ischemia, insufficient blood supply to those tissues. Brain tissue is among the bodys most sensitive to ischemic hypoxia, and is the earliest to die. It is possible for the rest of the body to regain function after a period of time without oxygen, but the brain to have lost it permanently.2 Schwabs criteria were loss of reflexes (dilated and fixed pupils, no elicitable reflexes, and no independent movements), a flat EEG (electroencephalogram detecting no e lectrical activity in the brain), and apnea (inability to spontaneously breath).3 Harvard report criteria included the following (1) deep coma, no withdrawal from painful stimuli, (2) cranial and spinal anesthesia arreflexia, (3) apnea, persistent after disconnected from ventilator for 3 minutes, (4) flat EEG, no detectable electrical brain activity, (5) exclusion of hypothermia or drugs, which may sometimes cause false-negatives in the above tests, and (6) evaluation repeated twice, 24-hours apart.4 The brainstem is the pathway through which the brain (cerebrum and cerebellum) sends and receives signals to and from the rest of the body. If the brain stem is dead and all brainstem functions are lost, then the communication between the brain and spinal cord is severed. A body of a patient with a dead brain stem is functionally equivalent to that of a patient with whole brain death. Thus, any electrical activity in the cerebrum is not going to affect the outcome of tests of the rest of Harvard criteria.5 The first successful heart transplantation was performed in December of 1967. The committee developed their criteria in August of 1968, a mere eight months after the heart transplant.1Write later2Cite oxford english dictionary3either cite Stanford Encyclopedia of Philosophy. Definition of Death4Written 2007, revised 2011. Review?5Fix citation6Cite this7Black Laws Dictionary, 1951. 4e8cite source either de goergia, stanford, or daroff98, De Geogia10cite swchab, from de georgia, pg 67411Citation needed12another someone negotiation about this conference, but says something more relevant.13cite beecher. (From De Georgia, 674. bottom left.14cite this15use a different word. Plagiarism16cite this de georgia, 48, 49. pg 67617cite. (stanford encyclopedia, 1. mainstream view)18http//www.ncbi.nlm.nih.gov/pubmed/1158865519Murray, letter to Beecher, calling for committee formulation/meeting. De Georgia 26, pg 6752040 De goergia, pg 676