How The Definition Of Death Has Changed

How The Definition Of Death Has Changed
How The Definition Of Death Has Changed

Video: How The Definition Of Death Has Changed

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Video: How technology has changed the definition of death 2023, February
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Compared to the middle of the 20th century, all aspects of the end of our life have radically changed - from what we die, when we die, where we die and how we die. As a result of advances in medical science and medical technology, even the very definition of death is now formulated differently. In fact, death is no longer just defined as "cardiac arrest." In his debut book, Dr. Warrich talks about the modern language of death. T&P publishes an excerpt from the book, where the author explains the new understanding of death with examples from life.

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Modern Death: How Medicine Changed Leaving Life

Hyder Warrich

Alpina non-fiction publishing house, 2021

Medicine is, for the most part, recognizing patterns and signs. Radiologists look at CT scans and X-rays as if they were coffee grounds showing the future. Pathologists examine the jubilant crowds of cells through a microscope, looking for those who are too drunk or too loose among the normal ones. In medicine, the patient is a code that the doctor must unravel. We assimilate the information that we receive as a result of laboratory tests, diagnostic studies, external examination and, most importantly, conversations with the patient (doctors call this anamnesis), after which we make the most accurate, in our opinion, assumption about the diagnosis. However, a single diagnosis option is rarely a reliable starting point, since too often the doctor clings to his first guess, and subsequent data contradicting it can no longer convince him to put forward another option. But in this case, it was difficult not to jump to conclusions: from the text message that came to my pager from the emergency department, I only learned that a 32-year-old man had cardiac arrest. During those long, dark winter months, a young man could end up in hospital with cardiac arrest for only one reason.

Heroin addicts have various names for their disastrous source of inspiration: "white," "gloomy," "dark," but that morning the most appropriate name would be "dead on arrival." It's always difficult to judge a person's height when you first see them lying in a hospital bed. However, this patient was definitely very tall and very thin. Just looking at a patient is probably the most underestimated step in a physical examination. This one was lanky, but not so lanky that one could assume that he had something like Marfan's syndrome - a disease in which the aorta is so dilated that it can easily burst.

Often I begin my examination by feeling the patient's feet. This is a good opportunity to establish a relationship, as well as receive invaluable information about the state of an organ that is very far from the feet - the heart. Swollen feet are a common sign of heart failure, while cold feet can indicate that the heart is not doing a good job of pumping blood to the tissues. The young man's feet were cold, but this was more likely due to the fact that we connected him to a device that cooled his body. I did not notice any injection marks on his arms and legs, which spoke in favor of the fact that he was not a drug addict. He had a neat haircut and clean shaven, and all of his tattoos were done years ago.

His girlfriend was standing near the bed. Her blonde hair was disheveled. She looked haggard, and half of the letters were missing from the shiny lettering on her T-shirt. As soon as I looked at it, I already knew half of the story. Their relationship was not easy. After the baby was born, things got even worse. He was unemployed, and heroin addiction sucked all his vitality out of him.She kicked him out of the house, but he apparently needed such a shake-up, because he found a job and stopped using drugs. A year of abstinence allowed him to return life to normal, and the girl let him back. “No heroin for over a year. He had a good job, a stable relationship,”she told me, but her speech became more muffled and illegible.

She just had the worst morning of her life. She woke up to find her boyfriend, someone who was clearly on the right track, lying unconscious on the bathroom floor, breathless, surrounded by the characteristic trappings of a heroin injection. She called 911, which immediately dispatched an ambulance to her. All this time, she unsuccessfully gave him mouth-to-mouth breathing, as well as a completely adequate, but did not give any effect, indirect heart massage. Upon arrival, paramedics discovered ventricular fibrillation in the man; after several electric shocks, they managed to restore the normal rhythm of the heart. They put an oxygen mask on his face and rushed to the nearest hospital.

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In the emergency room, he was intubated and connected to a ventilator, and also used a special device that lowers his body temperature to values ​​much lower than normal. Studies have shown that patients who have experienced cardiac arrest are more successful in recovering brain function when their temperature is lowered to very low levels. This is done using special pillows filled with cold water that are wrapped around the chest and limbs. Instead of the normal 37 ° C, some cardiac arrest patients benefit from temperatures as low as 33 ° C. Slowing down all metabolic processes gives the body time to restore some of its vital functions. After cooling down, the patient was transferred to the intensive care unit, where we met with him.

His girlfriend asked what his prospects were. I replied that I did not know, and that was true. The cooling procedure is designed for 48 hours: we were going to lower the body temperature for a day, and then slowly raise it. During this time, electrodes connected to his head recorded the activity of his brain. During these first two days it was extremely important that he did not feel anything, since the cold in which we immersed him would be simply unbearable. Because of this, the consciousness of such patients is usually turned off with drugs. This makes it impossible to conduct a neurological examination, which is key to assessing the likelihood of restoring the brain function, - against the background of paralytics, the real picture is simply not visible.

All this I told the patient's girlfriend and father - the only family members who came to visit him. However, I warned them against optimism: his heart did not work for God knows how long, and his brain loves oxygen very much. This will be the longest 48 hours of their life. For our part, we tried to find out what else could be the reason for the cardiac arrest. An ultrasound examination showed that his heart was surprisingly healthy, his kidneys and liver were practically unaffected, and there were no signs of infection anywhere.

The next morning, a team of neurologists joined the tour. It was more of a duet than a team - a neurologist and his student.The first, with three decades of experience, was one of the most experienced specialists in our hospital, and only his old portfolio looked like it was time for him to retire. The lanky student, on the other hand, was dressed with a needle. When their heads appeared in the doorway of the nursing room, our ICU team was discussing rounds. Few were allowed to distract us at such moments, but this neurologist was an exception. Respecting our busyness, he was laconic in his conclusion: "This man is dead."

- What do you have in mind? - His brain is dead.

Despite what the neurologist said, we were not yet ready to ascertain the brain death of our patient, but I was delegated to his bed. I went into the ward: his chest rhythmically rose under the action of the breathing apparatus, and his heart beat without interruption, giving out a clear rhythm on the heart monitor. A blush played on his cheeks. He looked the same as many other patients on a ventilator in the intensive care unit for subanesthesia - maybe even better, since he was younger and had not spent a day in the hospital before this incident. However, there was one difference: although it was difficult to tell from him, he was deader than others.

I've seen a lot of dead people. None of them looked like this man. His girlfriend anxiously asked me, "Is he dead?"

Her unprovoked question caught me off guard. In medical school and residency, we are taught to diagnose diseases, but they do not explain how to diagnose life or the lack of it. Over the past half century, the very fact of death has been disassembled and precisely defined, and then condemned and, possibly, debunked.

I was still pondering what I saw in front of me. During my residency, I have witnessed the death of countless patients. I was told that this guy was dead, but I had no tools at my disposal to confirm this fact.

His heart was beating, his pulse was felt on his wrist. I looked at the girl and said, "I don't know."

Jahi Makmat, 13, was admitted to Auckland Children's Hospital on December 9, 2013, she was an ordinary child. Classmates at the Ernestine Rims Academy of Technology and Arts called her "the quiet leader." Her favorite color was purple. While sleeping at night, she experienced apnea, which is rare in children her age, but with the spread of childhood obesity, this is becoming more common. She was hospitalized for elective surgery: her tonsils, uvula, part of the nasal concha and adenoids had to be removed from her nasopharynx to make it easier for her to breathe at night. It was by no means an easy procedure, although it has always been described in the press as "prophylactic tonsillectomy." What happened next is still not completely clear, since the girl's parents forbade the hospital management to publish the relevant information. Her mother says that after the operation, Jahi felt good and even ate ice cream. However, shortly thereafter, the girl developed bleeding in the part of the nasopharynx where the operation was performed. She was immediately transferred to the intensive care unit, where she suffered cardiac arrest.

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On December 12, three days after Jahi was admitted to the hospital, her attending physician declared brain death.Her condition met all the necessary criteria, which was also confirmed by external experts appointed by the state. Jaha's parents nevertheless refused to accept this conclusion, begging doctors to install a tube for artificial feeding and perform a tracheostomy. The hospital denied this request. Then the parents turned to reporters and flooded the air. They received funding and support from groups across America who campaigned against modern definitions of death, both legal and medical. They also petitioned the court to have their daughter examined by neonatologist Paul Berne, who opposes the concept of brain death and organ transplantation, but this was denied.

As the battle continued in the court, Jahi's body began to decay. Her intestines were falling apart: her only stool in weeks were actually fragments of intestinal mucosa. Her skin cracked and her blood pressure and body temperature fluctuated dramatically without any brain control. The court finally delivered its judgment, agreeing that Jahi was indeed dead. The hospital now had the right to hand her body over to a forensic medical expert. After that, Jahi was transferred to a clinic in New Jersey - this is the only state where the continued care of patients who have been diagnosed with brain death is allowed. Her bodies continue to "support life" there to this day.

As death turned from an indisputable binary fact into a controversial amorphous concept, life became more complex and difficult to fix. Doctors deal with life and death all the time, but they rarely cross the chasm that separates the simple and the concrete from the complex and abstract. We have enough difficulties with how to distinguish a sick person from a healthy one.

Life has always been seen as a privilege, and people were considered the crown of life. Despite our close acquaintance with life, we have certain difficulties in order to establish exactly what makes things alive or inanimate. The versatility of life allows this term to mean completely different things for a biologist, theologian, astrobiologist, mathematician, physicist, ethicist, lawyer, philosopher, doctor and ordinary person. That is why, in a striking way, we do not have a single definition of life that everyone would agree with. However, the reason for this is certainly not that no one tried to formulate it.

Long before we even had the most basic ideas about biology, people came up with a scheme to distinguish living things from non-living things. We can see a rough picture of the pre-scientific perception of life in children. Kids ascribe life and consciousness to all the objects around them. As they get older, they go through several stages of “animism,” a term coined by the pioneer of the science of child behavior, Jean Piaget. At the first stage of animism, the child sees life and consciousness in a whole glass jug, but not when it is broken (or killed, as children often characterize its destruction). As he develops, the child begins to associate life with movement. The bike is alive when it rides and dead when it is still. Likewise, children see the sun, wind, clouds and fire as living, pain-sensing, and conscious. In addition, although all children know that animals are alive, about a third of them between the ages of 8 and 11 do not consider plants to be living creatures, although they understand that plants grow. Such associations are not only the prerogative of childhood.

Emotional attachment can lead to the fact that even at an older age, we see life in inanimate objects.

The modern school curriculum for the fourth grade reflects the ancient ideas of what life is: living things grow and change, respond to changes in the environment, need energy and can reproduce. In Star Trek: The Next Generation, a similar definition of life was proposed to an android character named Data, who objected that fire also consumes, produces waste, moves, metabolizes and grows, and therefore meets all of the above signs of life.It probably shouldn't be surprising that fire worship was so common in ancient times.

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Another property that is often associated with living organisms is the ability to reproduce. Nobel laureate Hermann Möller in his 1959 report stated the following: "I believe the most fundamental feature that distinguishes a living being is its ability to create new organisms in its own image and likeness, and therefore it can be used as the basis for the definition of life." However, crystals also grow and can transfer their characteristics to others, however they are not considered living organisms. Even without taking into account such exceptions, using reproduction as a fundamental criterion for life comes with other difficulties: if I am stuck on a desert island without a suitable partner, and therefore unable to produce offspring, can I be considered inanimate?

As science developed, the focus in defining life shifted to metabolism. Metabolism is carried out through a number of chemical reactions occurring in the cell, which allows it to maintain its state and self-replicate. For scientists of the mid-20th century, metabolism was a key feature of life, which prompted John Bernal, one of the most famous and controversial British scientists of his time, to state the following:

Life is "the bodily form of imprisoned in a certain volume of self-sustaining chemical reactions"

Perhaps this definition of life is of the greatest importance for astrobiologists, since in search of the smallest evidence of the existence of life, they rush to distant corners of space. The key role of metabolism was reflected in three experiments carried out on the surface of Mars by the lander launched in 1976 as part of the NAS Viking program. The purpose of the first experiment was to test whether living organisms that live in Martian soil break down water with the release of oxygen. Two other experiments dealt with reactions with the release and absorption of carbon dioxide. Surprisingly, all three tests were positive, but deeper follow-up analysis showed no signs of living organisms. In my opinion, these false positive results demonstrate a significant disadvantage of using metabolism to define life: our understanding of what metabolism is, is limited by our acquaintance with terrestrial organisms. As a result, carbon has been ascribed to a central role in any organic life, although in reality it may be little more than an artifact of our own limited experience.

In the Open Reading section, we publish excerpts from books as provided by publishers. Minor abbreviations are indicated by ellipsis in square brackets. The opinion of the author may not coincide with the opinion of the editorial board.

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