Catholic Medical Quarterly Volume 62 (1) February 2012, p42
The Diagnosis of Death;- Never say die
Margaret Sealey (Retired consultant anaesthetist)
It occurred to me recently that during our training at medical school in the 'sixties we never received formal education on the diagnosis of death. Rather, we learned the signs by which one reached the conclusion that cardiopulmonary resuscitation was indicated: loss of consciousness, failure to respond to stimuli, fixed dilated pupils and cessation of cardiopulmonary function. In short, loss of cerebral, pulmonary and cardiac function that hopefully could be reversed if treatment was instituted rapidly enough. The difficulty was knowing when to stop trying to revive the patient, since one was never quite sure what brain damage had occurred during the anoxic/hypoxic period and whether the heart with good effort might not ultimately start again and deliver an adequate output. In a way, one was not allowed to consider death as a clean cut event that one could diagnose confidently and without a lot of heart searching about the appropriateness of one's diagnosis. I imagine much the same problem remains for those called to treat cardiac arrest today.
One needs to establish in one's mind the clear (and traditional) signs of death: the triad of persistent loss of consciousness, no heart function and no breathing.
There is some unease about the diagnosis of brain stem death as a valid diagnosis of death. After all, because there is ventilatory and circulatory support, the patient seems to be a lot more alive than one who has just suffered cardiac arrest, despite the fact that cardiopulmonary function would cease without the ventilator and the signs of severe irreversible brain stem damage, (which means severe irreversible cerebral damage and permanent loss of consciousness) are well established. There is a greater and clearer case for the diagnosis of death here than for the cardiac arrest patient who is not responding to treatment.
This 'never say die' attitude on the part of medical practitioners and failure to grasp the definitive criteria of death not surprisingly has given us problems with diagnosing death.