The joyous/sad story of the birth of Susan Ann Catherine Torres from Susan Torres, her decease mother offers an opportunity to clarify some of the confusing terminology that surrounds the declaration of death. It was reported that her mother died after life support was withdrawn. However, in all fifty states, once a person is declared brain dead, the time of that declaration is the noted time of death. Can you die twice?

In the aftermath of the death of Terri Schiavo this year (after persistent vegetative state and withdrawal of life supporting artificial nutrition and hydration), there was continued controversy when her husbands belief that Terri had left this world in 1990 was inscribed on her tombstone.

How is the lay person supposed to sort through the semantics and get a handle on what death means? Before technology, if someone was dead, it was pretty obvious. Once artificial life support, specifically the mechanical ventilator (breathing machine) became available, the ability to continue life in the context of a persons body being unable to do so, raised many ethical questions.

In 1981 The Presidents Commission for the study of Ethical problems in Medicine and Biomedical and Behavioral Research endorsed adoption of the Harvard Medical School ad hoc groups recommendation that patients with complete and irreversible brain function be declared dead and removed from ventilators. Public policy has continued to support the concept that whole brain death equals death.

This diagnosis can only be met after the patient meets very strict neurologic criteria. There can be no uncertainty. This allows the willing patient/ family the opportunity to donate organs. In particular, heart donation can occur only when the heart has continued to be perfused, with the assistance of a ventilator. Brain death implies not only the inability of the thinking, interactive portions of the brain to function., but also the brain stem which regulates breathing.

Brain death is not the same as PVS (persistent vegetative state). With this diagnosis, patients meet criteria that predict that they will never be able to interact with their environment again (no eating, talking, walking, watching tv) but they can breathe on their own. Many of us, through advance directives and conversations with family, have spoken of our desire not to live under these circumstances, artificially sustained through medical interventions such as feeding tubes. If these supports are not administered the patient will die of dehydration or electrolyte imbalances usually within ten days. Contrary to some reports in the media, this is not regarded as painful starvation. Not eating and not drinking is a common part of the natural dying process for many totally awake patients. This is what happened to most persons before the advent of our current technologies.

Coma is another term thrown into the mix that is unrelated to PVS or brain death. It reflects unresponsive behaviors of the patient but is a state from which one can recover.
Death is a natural part of the life cycle.
The use of technology has changed the timing a bit but certainly not the outcome. Mr. Torres is probably quite pleased that his daughter benefited through that technology in spite of the demise of his wife some time ago.

– Guest Blogger Shiela Otto, Clinical Ethics Consulatation Service, Alden March Bioethics Institute