To most people, the term 'death' has an indisputable sense of finality to it. In the most basic, biological sense, death is simply the cessation of life. In reality, however, death is a much more complex issue. There are laws regarding death and unspoken rules among medical professionals about how to handle the death of a patient. Advancements in medical technology also play a role in the definition of death. Additionally, there are different classifications of death including cardiac death, respiratory death, and brain death.
Until the invention of the ventilator in the 1950s, the medical definition of death was rarely disputed. Death was defined as a failure in the cardiopulmonary system and the neurological system. Thus, cardiac death was more or less linked directly to neurological death. The ventilator forced healthcare professionals to redefine death in its traditional sense because neurological death was no longer a consequence of cardiopulmonary death; one could have completely normal brain function while requiring a ventilator to ensure the cardiopulmonary system did not shut down. Because of this, many important distinctions had to be made concerning differing terms in relation to the neurological state one was in.
Popular terms relating to neurological issues include coma, vegetative state, and brain death. While some might use these terms interchangeably, Dr. Joseph Vukov stressed the importance of understanding the differences between them. Coma is a state of being neither aroused nor aware. In other words, a person in a coma is not awake, and they are not conscious of their surroundings. A vegetative state, on the other hand, occurs when a person has the capability of arousal, but they are not aware. Thus, these patients are capable of growth and development, but they are devoid of sensation and thought. Additionally, people in a vegetative state do not require the use of a ventilator. As one might imagine, brain death is ultimately the most serious condition of the three. Following the invention of the ventilator, Harvard Medical School declared that brain death requires a person to be in an irreversible coma, and they must have a complete absence of brainstem function. Because of the lack of brainstem function, these patients must be on a ventilator in order to survive.
Dr. Vukov argued that the most basic step in navigating the debates surrounding brain death is to simply understand the terminology discussed above. He identified many questions and issues that come up when doctors are trying to establish brain death. Surprisingly, the tests for brain death are incredibly accurate, and Dr. Vukov cited a study in which not a single case of brain death was misdiagnosed across different hospitals for an extended period of time. If the diagnosis of brain death does not seem to be an issue, then why is there so much debate surrounding it? Much of it comes from sociologic factors that surround death as well as ethical implications. Specifically, Dr. Vukov identified one major concern that seems to arise in conversations concerning brain death: organ transplant.
An article published by Dr. Robert D. Truog et al. in the "Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death" explores the questions that remain regarding brain death and the progress that has been made since the Harvard definition of brain death was published in the 1960's. Like Dr. Vukov explained, Dr. Truog also stressed the importance and the confusion regarding brain death in relation to organ transplants. He cites that the bodies of brain dead patients do not disintegrate; they are still capable of growth and development. The question then becomes: when is it permissible to use the organs of a brain dead patient for organ transplants?
Both Dr. Truog and Dr. Vukov mention what is known as the "dead donor rule" which is an unspoken rule in the medical community that organ donors must be dead before their organs can be harvested. Since the bodies of brain dead people are capable of growth and development, are they really dead? There are many difference stances held on this issue, but they all relate back to the legal definition of death: irreversible cessation of all functions of the entire brain, including the brain stem. Thus, brain dead patients are legally and clinically dead, fulfilling the requirements of the dead donor rule and giving doctors the "all clear" for organ harvest. However, organs that are to be used for transplant must be harvested quickly after death in order to preserve their integrity. Brain dead patients do not look dead; upon touch, they are still warm, and they never lose color. This makes it even harder for families of brain dead patients to let go of their loved ones, and it takes more time, dampening the integrity of the organs that could be used for transplants.
Despite the fact that brain dead patients may appear to look alive, Dr. Truog clarifies that those cases in which a patient was pronounced 'brain dead' and then miraculously regained consciousness or functionality have been proven to be false; these patients were not brain dead, but rather had other conditions that allowed for reversibility of the condition. A brain dead patient making a full recovery would go against the very definition of brain death, and this is why not a single case of brain death has been misdiagnosed. Unfortunately, media reports of these types of cases has misinformed the public, leading to a spiral in which the three terms - coma, vegetative state, and brain death - have become almost interchangeable. In order to relieve the confusion and the spread of misinformation regarding brain death, both Dr. Truog and Dr. Vukov would stress understanding the fundamental differences in these terms.
Eventually, death is final, no matter how much medical intervention occurs. Using coma, vegetative state, and brain death in the correct situation is vital for helping both medical professionals and families of loved ones with these conditions make informed, timely decisions on how to proceed with the patient as well as the possibility of organ transplant to help others that are in need.
Powell, Tia. "Brain Death: What Health Professionals Should Know." American Journal of Critical Care, vol. 23, no. 3, May 2014. American Journal of Critical Care, www.dropbox.com/sh/yrruoccwcc8fc6i/AADV3iapxtsrrO019ar7ZD3oa/(04.02.19)%20-%20Joe%20Vukov?dl=0&preview=Powell_Brain_Death.pdf&subfolder_nav_tracking=1. Accessed 19 Apr. 2019.
Truog, Robert D., et al. "Brain Death at Fifty: Exploring Consensus, Controversy, and Contexts." The Hastings Center Report, 25 Dec. 2018. Wiley Online Library, doi:org/10.1002/hast.942. Accessed 19 Apr. 2019.
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