Journal of Critical Care 30 (2015) 214–215
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Death: Past, present, and future
Introduction In the last three volumes of the Journal of Critical Care, we have had the opportunity to review 12 essays related to “brain death.” We have seen that despite the passage of more than 50 years, the work of untold numbers of committees and commissions, including the passage of state and federal laws, and despite near-universal acceptance, some controversy remains as to the notion of brain death and when death actually occurs. Is death when there is no longer a heartbeat, or is it when there is irreversible loss of total brain activity, regardless of the presence of a heartbeat? Is it both, or is it neither? Should the physician decide, or should the patient through an advanced directive or the patient's surrogate be allowed to make the determination? Should it be permissible to remove organs from people who have brain function but will never regain consciousness? Must all biological processes cease before a person is dead? These are all issues that need to be addressed so we can have unambiguous, rational policy. Death has been defined as an irreversible condition in which an organism is incapable of carrying on the functions of life. Bioethicists speak in terms of personhood, and to be a person means to be conscious or have the potential to regain consciousness. With this definition, anyone without “higher-brain” activity could be considered dead. There has never been a question of what death is, but in some circles, there remains ambiguity as to when it actually occurs. Instead of becoming simpler, advancements in technology have made the declaration of death more complex. Once it was shown a heartbeat could be restored and maintained by artificial ventilation, with many patients recovering to a satisfactory quality of life, the question arose, when does death actually occur? It became clear that death does not occur at the moment the heart stops beating, so the cardiorespiratory standard might as well be eliminated, but not all cultures or religions are ready to accept this. However, once a heart does stop beating, when is the point where there is no potential for the recovery of meaningful life? Irreversible loss of total brain function has become the only real standard for determining the end of life, but should it?
A perfect storm develops In the 1960s, we had the convergence of three disruptive forces that forever changed the landscape of the practice of medicine. The development of the defibrillator and ventilator showed a heart that was no longer beating did not always signal death, so the notion of death by neurologic criteria came to be. The second disruptive force was the perfection of organ transplantation. Those who previously would have died due to organ failure could be saved with a transplanted organ; however, transplant surgery was dependent on organ donation, and this usually http://dx.doi.org/10.1016/j.jcrc.2014.10.023 0883-9441/© 2014 Elsevier Inc. All rights reserved.
meant harvesting organs from those declared brain dead. The final force was the rise of the bioethics movement. It was unfortunate the concept of brain death did not occur much earlier than organ transplantation so we could have become familiar with it and accepted the fact that brain death was in fact death. However, brain death and the rise of organ transplantation occurred almost simultaneously, and many were not ready to accept or were not 100% convinced that death by neurologic criteria was really death. Many believed that physicians were hastily declaring a loved one “dead” in an attempt to “take” their organs. Convincing evidence one would never regain consciousness or recover to an interactive state often fell, and at times continues to fall on deaf ears, as family members and others often cannot accept the fact that death has occurred when the heart is still beating, regardless of whether organs will be donated. For some, religious and cultural values preclude the termination of life support measures if the heart is still beating. In addition to a new standard for death and the burgeoning field of transplant surgery, we had the rise of the bioethics movement. The field of bioethics addressed the moral failings of medical research and the paternalistic tradition in clinical medicine that had been the norm. A major focus of the bioethics movement was to advance the rights of patients, leading to a new concept of patients as actual participants in their care rather than mere objects of diagnosis and treatment. In 1979, Tom Beauchamp and James Childress published their seminal work, Principles of Bioethics, in which they identified what have come to be known as the four principles of bioethics: 1. 2. 3. 4.
Autonomy Beneficence Nonmaleficence Justice
Although there can be no denying the importance of the four principles, there are occasions when there is conflict between a physician's duty to do what is best for the patient along with not harming the patient, and the patient's right to autonomy. Justice has remained a problem, as everyone is clearly not treated equally. With the emphasis on patient rights, some bioethicists expressed the view that it should be the patient's or the patient's surrogate's right to choose which standard of death to apply and not that of the physician. Although there was near universal acceptance of death by neurologic criteria, the bioethics movement gave support to those who were not ready to accept the concept of brain death. When it comes to end-of-life decisions, there are no issues if a patient has an advanced directive specifying the desire to not undergo futile treatment, to not have resuscitative efforts made, and to not be placed on a ventilator. There are also no issues if surrogates decide the same. However, there is likely to be conflict if a patient's surrogate
Editorial / Journal of Critical Care 30 (2015) 214–215
insists on futile treatment against the recommendation of the medical team or will not accept brain death when the patient is found to be dead by neurologic criteria. Although there have been great strides made in respect for the rights of patients, perhaps the pendulum has swung too far to this side. Patient autonomy was not meant to give a patient or surrogate the power to demand and receive treatment that is futile or to maintain patients on life support indefinitely when they are considered dead by neurologic criteria. However, many feel that they have this right. The principle of autonomy was meant to foster shared decision making, not to give complete control to patients. Unfortunately, both patients and surrogates have become emboldened by the notion of autonomy, and very often, physicians and hospital administrators are not clear where patient autonomy ends or how to interpret existing laws. As our existing health care system becomes increasingly unsustainable, we recognize the need to change the way medical care is delivered. We need to recognize we cannot afford to provide futile treatment, so resources can be put to more effective use. In many cases, this means terminating life-sustaining therapies. Unfortunately, as long as someone or some entity stands to make money based on whether life support is maintained or discontinued, there is an obvious conflict of interest, which further fuels the public's distrust of the system.
Where are we headed? It has been said that brain death and procurement of organs for transplant are not related, which they should not be, but many see them as inextricably tied together. The reasons to declare death while the heart is still beating should only be to prevent further suffering of the patient and to not waste resources when there is no possibility of recovery to an interactive state. It should not be for the purpose of procuring organs, although that is an inevitable benefit. Our society must come to terms with the fact that a beating heart does not mean life, and we have to be willing to terminate life support efforts when there is evidence that there is no chance for recovery to an interactive state.
215
Perhaps we should change the current standards for death to a single standard: death. Death should be declared when there is evidence to support death by neurologic criteria, regardless of the reason for the loss of consciousness, with or without a beating heart, and without the possibility of challenge. We would still need to resolve the obvious conflict of interest when various entities stand to profit or benefit by declaring death while the heart is still beating. Wemustinteractwiththefamiliesofpatientsascompassionatelyaspossibleandkeepinmindthetremendouspaintheyarein.Astragicasthesecasesare, withconvincingevidence,physiciansneedtoremainfirmthattheconditionis whatitis,andnotsacrificemedicalintegritytoplacateafamily.Judgesarenot physicians,yetsomefamiliesfeelthattheycanusethejudicialsystemtochange amedicaldecisiontheydisagreewith.Thisshouldnotbeallowedtooccur. Most people already accept the concept of brain death, although somewhat hesitantly in many cases. Through education and the elimination of conflicts of interest, which will probably mean changing the way our health care system is financed, we may be able to overcome the remaining resistance. The public should be educated to the fact that death will be declared and life support measures terminated, regardless of willingness to donate organs, when there is evidence of irreversible total brain failure. We are past the point wWe are past the point where patienhere patient autonomy can force physicians to provide futile treatment at a cost we can no longer afford. In addition, we must deal with the issue of those in altered states of consciousness without total brain failure. We may ultimately decide it is in their and society's best interests to forego long-term treatment when there is virtually no possibility of meaningful recovery. It is vitally important to respect a patient's wishes and to allow the patient or surrogate to actively participate in the decision-making process. We must allow for every benefit of the doubt when making decisions regarding potential recovery, but at some point, a line must be drawn. Rodney S. Barron MD, MS Beverly Hills, CA E-mail address: [email protected]
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
Death: Past, present, and future
Introduction In the last three volumes of the Journal of Critical Care, we have had the opportunity to review 12 essays related to “brain death.” We have seen that despite the passage of more than 50 years, the work of untold numbers of committees and commissions, including the passage of state and federal laws, and despite near-universal acceptance, some controversy remains as to the notion of brain death and when death actually occurs. Is death when there is no longer a heartbeat, or is it when there is irreversible loss of total brain activity, regardless of the presence of a heartbeat? Is it both, or is it neither? Should the physician decide, or should the patient through an advanced directive or the patient's surrogate be allowed to make the determination? Should it be permissible to remove organs from people who have brain function but will never regain consciousness? Must all biological processes cease before a person is dead? These are all issues that need to be addressed so we can have unambiguous, rational policy. Death has been defined as an irreversible condition in which an organism is incapable of carrying on the functions of life. Bioethicists speak in terms of personhood, and to be a person means to be conscious or have the potential to regain consciousness. With this definition, anyone without “higher-brain” activity could be considered dead. There has never been a question of what death is, but in some circles, there remains ambiguity as to when it actually occurs. Instead of becoming simpler, advancements in technology have made the declaration of death more complex. Once it was shown a heartbeat could be restored and maintained by artificial ventilation, with many patients recovering to a satisfactory quality of life, the question arose, when does death actually occur? It became clear that death does not occur at the moment the heart stops beating, so the cardiorespiratory standard might as well be eliminated, but not all cultures or religions are ready to accept this. However, once a heart does stop beating, when is the point where there is no potential for the recovery of meaningful life? Irreversible loss of total brain function has become the only real standard for determining the end of life, but should it?
A perfect storm develops In the 1960s, we had the convergence of three disruptive forces that forever changed the landscape of the practice of medicine. The development of the defibrillator and ventilator showed a heart that was no longer beating did not always signal death, so the notion of death by neurologic criteria came to be. The second disruptive force was the perfection of organ transplantation. Those who previously would have died due to organ failure could be saved with a transplanted organ; however, transplant surgery was dependent on organ donation, and this usually http://dx.doi.org/10.1016/j.jcrc.2014.10.023 0883-9441/© 2014 Elsevier Inc. All rights reserved.
meant harvesting organs from those declared brain dead. The final force was the rise of the bioethics movement. It was unfortunate the concept of brain death did not occur much earlier than organ transplantation so we could have become familiar with it and accepted the fact that brain death was in fact death. However, brain death and the rise of organ transplantation occurred almost simultaneously, and many were not ready to accept or were not 100% convinced that death by neurologic criteria was really death. Many believed that physicians were hastily declaring a loved one “dead” in an attempt to “take” their organs. Convincing evidence one would never regain consciousness or recover to an interactive state often fell, and at times continues to fall on deaf ears, as family members and others often cannot accept the fact that death has occurred when the heart is still beating, regardless of whether organs will be donated. For some, religious and cultural values preclude the termination of life support measures if the heart is still beating. In addition to a new standard for death and the burgeoning field of transplant surgery, we had the rise of the bioethics movement. The field of bioethics addressed the moral failings of medical research and the paternalistic tradition in clinical medicine that had been the norm. A major focus of the bioethics movement was to advance the rights of patients, leading to a new concept of patients as actual participants in their care rather than mere objects of diagnosis and treatment. In 1979, Tom Beauchamp and James Childress published their seminal work, Principles of Bioethics, in which they identified what have come to be known as the four principles of bioethics: 1. 2. 3. 4.
Autonomy Beneficence Nonmaleficence Justice
Although there can be no denying the importance of the four principles, there are occasions when there is conflict between a physician's duty to do what is best for the patient along with not harming the patient, and the patient's right to autonomy. Justice has remained a problem, as everyone is clearly not treated equally. With the emphasis on patient rights, some bioethicists expressed the view that it should be the patient's or the patient's surrogate's right to choose which standard of death to apply and not that of the physician. Although there was near universal acceptance of death by neurologic criteria, the bioethics movement gave support to those who were not ready to accept the concept of brain death. When it comes to end-of-life decisions, there are no issues if a patient has an advanced directive specifying the desire to not undergo futile treatment, to not have resuscitative efforts made, and to not be placed on a ventilator. There are also no issues if surrogates decide the same. However, there is likely to be conflict if a patient's surrogate
Editorial / Journal of Critical Care 30 (2015) 214–215
insists on futile treatment against the recommendation of the medical team or will not accept brain death when the patient is found to be dead by neurologic criteria. Although there have been great strides made in respect for the rights of patients, perhaps the pendulum has swung too far to this side. Patient autonomy was not meant to give a patient or surrogate the power to demand and receive treatment that is futile or to maintain patients on life support indefinitely when they are considered dead by neurologic criteria. However, many feel that they have this right. The principle of autonomy was meant to foster shared decision making, not to give complete control to patients. Unfortunately, both patients and surrogates have become emboldened by the notion of autonomy, and very often, physicians and hospital administrators are not clear where patient autonomy ends or how to interpret existing laws. As our existing health care system becomes increasingly unsustainable, we recognize the need to change the way medical care is delivered. We need to recognize we cannot afford to provide futile treatment, so resources can be put to more effective use. In many cases, this means terminating life-sustaining therapies. Unfortunately, as long as someone or some entity stands to make money based on whether life support is maintained or discontinued, there is an obvious conflict of interest, which further fuels the public's distrust of the system.
Where are we headed? It has been said that brain death and procurement of organs for transplant are not related, which they should not be, but many see them as inextricably tied together. The reasons to declare death while the heart is still beating should only be to prevent further suffering of the patient and to not waste resources when there is no possibility of recovery to an interactive state. It should not be for the purpose of procuring organs, although that is an inevitable benefit. Our society must come to terms with the fact that a beating heart does not mean life, and we have to be willing to terminate life support efforts when there is evidence that there is no chance for recovery to an interactive state.
215
Perhaps we should change the current standards for death to a single standard: death. Death should be declared when there is evidence to support death by neurologic criteria, regardless of the reason for the loss of consciousness, with or without a beating heart, and without the possibility of challenge. We would still need to resolve the obvious conflict of interest when various entities stand to profit or benefit by declaring death while the heart is still beating. Wemustinteractwiththefamiliesofpatientsascompassionatelyaspossibleandkeepinmindthetremendouspaintheyarein.Astragicasthesecasesare, withconvincingevidence,physiciansneedtoremainfirmthattheconditionis whatitis,andnotsacrificemedicalintegritytoplacateafamily.Judgesarenot physicians,yetsomefamiliesfeelthattheycanusethejudicialsystemtochange amedicaldecisiontheydisagreewith.Thisshouldnotbeallowedtooccur. Most people already accept the concept of brain death, although somewhat hesitantly in many cases. Through education and the elimination of conflicts of interest, which will probably mean changing the way our health care system is financed, we may be able to overcome the remaining resistance. The public should be educated to the fact that death will be declared and life support measures terminated, regardless of willingness to donate organs, when there is evidence of irreversible total brain failure. We are past the point wWe are past the point where patienhere patient autonomy can force physicians to provide futile treatment at a cost we can no longer afford. In addition, we must deal with the issue of those in altered states of consciousness without total brain failure. We may ultimately decide it is in their and society's best interests to forego long-term treatment when there is virtually no possibility of meaningful recovery. It is vitally important to respect a patient's wishes and to allow the patient or surrogate to actively participate in the decision-making process. We must allow for every benefit of the doubt when making decisions regarding potential recovery, but at some point, a line must be drawn. Rodney S. Barron MD, MS Beverly Hills, CA E-mail address: [email protected]
