Disclosures

September 23, 2013

In This Article

Clinical Death

1. Cardiopulmonary death, permanent. It would seem obvious that a person is dead when his or her heart and circulation permanently cease. Over the years, the words "irreversible" and "permanent" have come into play, because there are instances of people whose hearts have stopped for several minutes, yet they were then revived or spontaneously revived. Clinical death typically leads to brain death, but these terms are not synonymous.

Apparently, on a worldwide basis, many physicians don't wait long enough to determine that cardiac cessation is permanent. In May 2013 at the Euroanaesthesia Conference in Barcelona, Spain, physicians discussed the need for a consensus for a concrete definition of death.

Dr. Alexander Manara, Regional Clinical Lead in Organ Donation for the UK South West Region, Frenchay Hospital, Bristol, United Kingdom, proposed a universal standard of continuously observing the patient for a minimum of 5 minutes to confirm absence of the circulation before declaring death. In some places, 2 minutes is standard.[2]

However, one physician in Medscape's Ethics Survey Report 2012 said, "I have seen a patient recover after a prolonged comatose state post-cardiac resuscitation that went on for 30 minutes. His therapy was thought to be futile."

How do you know when the heart has stopped for good? How much time should elapse before you call off resuscitation efforts? In the presence of related multiple organ failure or traumatic injury, it's clear that the body has reached its end. In other situations, you may not know until you've exhausted the possibilities.

2. Cardiopulmonary death, possibly not yet permanent. That brief window between "permanent" and "not permanent" contains an enormous decision.. The percentage of patients considered dead and then revived is small, but one cannot exaggerate the enormity of the issue. For a couple of minutes, the heart has stopped but the brain has not yet failed.

In August 2013, Anthony Yahle, 37 years of age, was declared dead in an Ohio hospital after receiving CPR for 45 minutes, and then remained in cardiac arrest for several minutes. "He was truly flatlined at the end of the code. He had no electrical motion, no respiration, no heartbeat, and no blood pressure," says Jayne Testa, Director of Cardiovascular Services at Kettering Medical Center in Kettering, Ohio. About 5 minutes after being considered dead, a clinician noticed a trace of electrical activity on his heart monitor. Resuscitation efforts recommenced. Yahle recovered and went home.[3]

In a study published in The Lancet in 2012, researchers found that hospitals varied in how long they spent on cardiopulmonary resuscitation (CPR), ranging from a median of about 16 minutes to 25 minutes. Patients in hospitals with more prolonged CPR survived and went home 12% more often than those in hospitals that spent the shortest time on CPR.[4] The question of permanence raises the issue of how long hospitals should work to resuscitate patients.

One physician asked, "Does that mean you're responsible for allowing death if you don't work hard enough or long enough?"

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