Death is defined as the cessation of all vital functions of the body including the heartbeat, brain activity (including the brain stem), and breathing.
Description
Death comes in many forms, whether it be expected after a diagnosis of terminal illness or an unexpected accident or medical condition.
Terminal illness
When a terminal illness is diagnosed, a person, family, friends, and physicians are all able to prepare for the impending death. A terminally ill individual goes through several levels of emotional acceptance while in the process of dying. First, there is denial and isolation. This is followed by anger and resentment. Thirdly, a person tries to escape the inevitable. With the realization that death is eminent, most people suffer from depression. Lastly, the reality of death is realized and accepted.
Causes and symptoms
As of 2001, the two leading causes of death for both men and women in the United States were heart disease and cancer. Accidental death was a distant third followed by such problems as stroke, chronic lung disorders, pneumonia, suicide, cirrhosis, diabetes mellitus, and murder. The order of these causes of death varies among persons of different age, ethnicity, and gender.
Diagnosis
In an age of organ transplantation, identifying the moment of death may now involve another life. It thereby takes on supreme legal importance. It is largely due to the need for transplant organs that death has been so precisely defined.
The official signs of death include the following:
no pupil reaction to light
no response of the eyes to caloric (warm or cold) stimulation
no jaw reflex (the jaw will react like the knee if hit with a reflex hammer)
no gag reflex (touching the back of the throat induces vomiting)
no response to pain
no breathing
a body temperature above 86°F (30°C), which eliminates the possibility of resuscitation following cold-water drowning
no other cause for the above, such as a head injury
no drugs present in the body that could cause apparent death
all of the above for 12 hours
all of the above for six hours and a flat-line electroencephalogram (brain wave study)
no blood circulating to the brain, as demonstrated by angiography
Current ability to resuscitate people who have "died" has produced some remarkable stories. Drowning in cold water (under 50°F/10°C) so effectively slows metabolism that some persons have been revived after a half hour under water.
Treatment
Only recently has there been concerted public effort to address the care of the dying in an effort to improve their comfort and lessen their alienation from those still living. Hospice care represents one of the greatest advances made in this direction. There has also been a liberalization of the use of narcotics and other drugs for symptomatic relief and improvement in the quality of life for the dying.
Living will
One of the most difficult issues surrounding death in the era of technology is that there is now a choice, not of the event itself, but of its timing. When to die, and more often, when to let a loved one die, is coming within people's power to determine. This is both a blessing and a dilemma. Insofar as the decision can be made ahead of time, a living will is an attempt to address this dilemma. By outlining the conditions under which one would rather be allowed to die, a person can contribute significantly to that final decision, even if not competent to do so at the time of actual death. The problem is that there are uncertainties surrounding every severely ill person. Each instance presents a greater or lesser chance of survival. The chance is often greater than zero. The best living will follows an intimate discussion with decision makers covering the many possible scenarios surrounding the end of life. This discussion is difficult, for few people like to contemplate their own demise. However, the benefits of a living will are substantial, both to physicians and to loved ones who are faced with making final decisions. Most states have passed living will laws, honoring instructions on artificial life support that were made while a person was still mentally competent.
Euthanasia
Another issue that has received much attention is assisted suicide (euthanasia). In 1997, the State of Oregon placed the issue on the ballot, amid much consternation and dispute. Perhaps the main reason euthanasia has become front page news is because Dr. Jack Kevorkian, a pathologist from Michigan, is one of its most vocal advocates. The issue highlights the many new problems generated by increasing ability to intervene effectively in the final moments of life and unnaturally prolong the process of dying. The public appearance of euthanasia has also stimulated discussion about more compassionate care of the dying.
Prevention
Autopsy after death is a way to precisely determine a cause of death. The word autopsy is derived from Greek meaning to see with one's own eyes. A pathologist extensively examines a body and submits a detailed report to an attending physician. Although an autopsy can do nothing for an individual after death, it can benefit the family and, in some cases, medical science. Hereditary disorders and disease may be found. This knowledge could be used to prevent illness in other family members. Information culled from an autopsy can be used to further medical research. The link between smoking and lung cancer was confirmed from data gathered through autopsy. Early information about AIDS was also compiled through autopsy reports.
BOOKS
Finkbeiner, J. Autopsy: A Manual & Atlas. Philadelphia: Saunders, 2001.
Iserson, Kenneth B. Death to Dust: What Happens to Dead Bodies? Tucson: Galen Press Ltd, 2001.
Kubler-Ross, Elisabeth. Death Is of Vital Importance. Tarrytown, NY: Station Hill Press, 1995.
Kubler-Ross, Elisabeth. On Death and Dying. New York: Collier Books, 1993.
Lo, Bernard. "Ethical Issues in Clinical Medicine." Harrison's Principles of Internal Medicine. 14th ed. Ed. Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.
Mount, Balfour M. "Care of Dying Patients and Their Families." In Cecil Textbook of Medicine. 21st ed. Ed. Lee Goldman, et al. Philadelphia: W. B. Saunders, 2000.
Sheaff, Michael T., and Deborah J. Hopster. Post Mortem Technique Handbook. New York: Springer Verlag, 2001.
PERIODICALS
Barone, F. C., et al. "Brain Cooling During Transient Focal Ischemia Provides Complete Neuroprotection." Neuro-science and Biobehavioral Reviews 21 (1997): 31-44.
Dobell, A. R., and J. S. Bailey. "Charles Drew and the Origins of Deep Hypothermic Circulatory Arrest." Annals of Thoracic Surgery 63 (1997): 1193-1199.
Roger, V. L., et al. "Time Trends in the Prevalence of Athero-sclerosis: A Population-based Autopsy Study." American Journal of Medicine 110, no. 4 (2001): 267-273.
Targonski, P., et al. "Referral to Autopsy: Effect of Atemortem Cardiovascular Disease. A Population-based Study in Olmsted County, Minnesota." Annals of Epidemiology 11, no. 4 (2001): 264-270.
ORGANIZATIONS
American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (913) 906-6000. <http://www.aafp.org>.
American Medical Association. 515 N. State Street, Chicago, IL 60610. (312) 464-5000. <http://www.ama-assn.org>.
American Society of Clinical Pathologists. 2100 West Harrison Street, Chicago, IL 60612. (312) 738-1336. <http://www.ascp.org/index.asp>.
College of American Pathologists. 325 Waukegan Road, North-field, IL 60093. (800) 323-4040. <http://www.cap.org>.
Hospice Foundation of America. 2001 S St. NW Suite 300, Washington, DC 20009. (800) 854-3402. <http://www.hospicefoundation.org>.
Contemporary physician who has become a world authority on the subject of death and after-death states. Born in Switzerland on July 8, 1926, she worked as a country doctor before moving to the United States. During World War II she spent weekends at the Kantonspital (Cantonai Hospital) in Zürich, where she volunteered to assist escaped refugees. After the war she visited Majdanek concentration camp, where the horrors of the death chambers stimulated in her a desire to help people facing death and to understand the human impulses of love and destruction. She extended her medical background by becoming a practicing psychiatrist. Her formal work with dying patients began in 1965 when she was a faculty member at the University of Chicago. She also conducted research on basic questions concerning life after death at the Manhattan State Hospital, New York. Her studies of death and dying have involved accounts by patients who reported out-of-the-body travel. Her research tends to show that while dying can be painful, death itself is a peaceful condition. Her 1969 text, On Death and Dying, was hailed by her colleagues and also became a popular best-seller.
In 1978 Kübler-Ross helped to found Shanti Nilaya (Final Home of Peace), a healing and growth center in Escondido, California. This was an extension of her well-known "Life-Death and Transition" workshops conducted in various parts of the United States and Canada, involving physicians, nurses, social workers, laypeople, and terminally ill patients. Much of Kübler-Ross's later research was directed toward proving the existence of life after death. Her publication To Live Until We Say Good-bye (1979) was both praised as a "celebration of life" and criticized as "prettifying" the real situation. She has also dealt with issues such as AIDS and "near death" experiences. In the mid-1980s Shanti Nilaya moved from San Diego County, California, to Head Waters, Virginia, where it continues to offer courses and short- and long-term therapeutic sessions.
KEY TERMS
Angiography—X rays of blood vessels filled with a contrast agent.
Caloric testing—Flushing warm and cold water into the ear stimulates the labyrinth and causes vertigo and nystagmus if all the nerve pathways are intact.
