Defining Death and Giving The Gift of Life

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Defining Death and Giving The Gift of Life
Jacques Mistrot M.D.
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What Is Death?
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Catholic Teaching on Death

• SIN CAUSES DEATH
• Death is contrary to Gods original plan
• Death is the last enemy to be conquered
• CHRIST TRANSFORMS DEATH
• Adams disobedience changes blessing to curse
• Christs obedience transforms curse to blessing
• SOUL
• Separation of the soul from the body
• Body is given incorruptibility when reunited to
  the
• soul at resurrection

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Catholic Teaching on Death

• Firm grip on this Catholic understanding of death
  is necessary when dealing with many bioethical
  issues
• How one views death greatly influences ones
  judgments about end of life issues!

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Patient Concerns About Death

• Will I be declared dead prematurely?
• Time is of the essence with organ donation!
• Rooted in concern for self

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Patient Concerns About Death
Buried Prematurely
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Patient Concerns About Death

• Will I be declared alive after I have physically
  died and be kept on life support too long?
• Rooted in concern for familys misplaced
  hopes/medical costs

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When Does Death Occur?
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Definition of Death

• Philosophical and Theological
• Separation of the soul from the body

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When Does Death Occur?

• Death is the instant of separation of soul and
  body
• Science cannot see that instant!
• Science must estimate that point by observing
  certain signs of the irreversible condition we
  call death

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When Does Death Occur?

• Death has been defined as a dualistic event
• Cardio-respiratory death . . OR . .
• Brain death
• However it is instead a unified concept
• THERE ARE NOT TWO DEATHS!!

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Death

• Definition vs. Determination

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When Does Death Occur?

• When the spiritual principle which ensures the
  unity of the individual can no longer exercise
  its functions in and upon the organism, whose
  elements, left to themselves, disintegrate.
• John Paul II, January 1990

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When Does Death Occur?

• Determination of the moment of death
• HELPS SOLVE THE CONFLICT
• Duty
• - to respect the life of one person
• - to save the life of another when an organ
  transplant is needed

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Determination of DeathBiologic

• The brain is the physical instrument through
  which the spiritual principle (soul) exerts its
  action
• the integrating material entity
• Therefore biologic death is brain death

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Historical Perspectives

• Pre-1950s
• Cardio-respiratory criteria defined death
• 1950s
• first organ transplants successfully done
  (1955-56)
• mechanical ventilators developed allowing life
  support
• Cardio-respiratory criteria for death had to be
  re-examined

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Historical Perspectives

• 1960s
• rapid development of cardiac-supportive
  medications
• criteria sought to determine when a donor was
  really dead

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Determination of Death

• Harvard Criteria 1968
• Death defined as brain death and rigid criteria
  described
• UDDA (Uniform Determination of Death Act 1981)
• Death could be pronounced by either
• 1) irreversible cessation of circulatory and
  respiratory function or
• 2) irreversible cessation of all functions of
  the entire brain, including the brain stem

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UDDA

• Dead Donor Rule
• Death must be determined by either complete loss
  of cardio-pulmonary function . or .
• Complete loss of all brain function
• Cerebral
• Cerebellar
• Brain stem

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Lost circulation to the brain

• 5 minutes cortex lost (thinking, sensations,
  movement)
• 10 minutes brain stem lost (regulation of vital
  functions BP, HR, breathing, reflexes)
• gt 30 minutes autolysis (all cellular function
  ceases)

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Whole Brain Concept

• UDDA assessment of entire brain function
• both cerebral and brain stem

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NOT 2 DEATHS!!

• Brain death is determined
• Life support removed
• Not 2 deaths
• Mr. Sam Brown died at 602PM but was taken off
  the respirator at 845PM causes confusion

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• What is the significance of
• irreversible loss of brain stem function?
• assures that the individual breathing
  spontaneously is not declared dead

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Brain Death Criteria

• No spontaneous movements
• No responses to painful stimuli
• Coma and cerebral unresponsiveness
• Irreversible apnea
• Pupils unresponsive to bright light
• Brain stem reflexes are absent
• One of following must be verified
• EEG silence for 30 minutes
• Cerebral circulation at a standstill
• Caveats Body temperature gt 90o F absence of
  certain drugs and metabolic abnormalities must be
  determined
• Step 7a should be reconfirmed in 6 hours (adult)
  or 24 hours (child).

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Catholic Church Teaching

• With regard to the parameters used today for
  ascertaining deathwhether the encephalic signs
  or the more traditional cardio-respiratory
  signsthe Church does not make technical
  decisions.
• John Paul II
• Address to International Congress of Transplants
• August, 2000

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• Here it can be said that the criterion adopted
  in more recent times for ascertaining the fact of
  death, namely the complete and irreversible
  cessation of all brain activity, if rigorously
  applied, does not seem to conflict with the
  essential elements of a sound anthropology.
  Therefore a health-worker professionally
  responsible for ascertaining death can use these
  criteria in each individual case as the basis for
  arriving at that degree of assurance in ethical
  judgment which moral teaching describes as moral
  certainty.
• John Paul II
• International Congress on Transplants
• August 29, 2000

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Catholic Church Teaching

• The address of John Paul II to the
  International Congress on Transplants on August
  29, 2000, was a watershed in the clarification of
  the Church's teaching on the use of brain-based
  criteria for the determination of death What
  must be emphasized is that no Catholic
  physician or Catholic recipient of a donor organ
  should be made to feel that the Church has any
  ambivalence about the moral legitimacy of
  brain-based criteria for the determination of
  death when the criteria are appropriately applied
  in a clinical setting.
• Eugene Diamond, M.D.
• Director of Linacre Institute of the Catholic
  Medical Association
• Editor-in-Chief Linacre Quarterly

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Why the Concept of Brain Death is Valid as a
Definition of Death  Statement by Neurologists
and Others and Response to Objections VATICAN
CITY 2008
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WHY THE CONCEPT OF BRAIN DEATH IS VALID AS A
DEFINITION OF DEATH Statement by Neurologists
and Others A. BATTRO, J.L. BERNAT, M.-G.
BOUSSER, N. CABIBBO, CARD. G. COTTIER, R.B.
DAROFF, S. DAVIS, L. DEECKE, C.J. ESTOL, W.
HACKE, M.G. HENNERICI, J.C. HUBER, CARD. A. LÓPEZ
TRUJILLO, CARD. C.M. MARTINI, J. MASDEU, H.
MATTLE, J.B. POSNER, L. PUYBASSET, M. RAICHLE,
A.H. ROPPER, P.M. ROSSINI, M. SÁNCHEZ SORONDO, H.
SCHAMBECK, E. SGRECCIA, P.N. TANDON, R. VICUÑA,
E. WIJDICKS, A. ZICHICHI
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WHY THE CONCEPT OF BRAIN DEATHIS VALID AS A
DEFINITION OF DEATH

• Brain Death is Death
• Not synonym does not imply not equal to death
• Coma, the Persistent Vegetative State, and
  the Minimally Conscious State are not Brain
  Death
• Brain Death is the Death of the Individual
• Loss of brain function other organs kept alive
  by artificial means
• Death is the End of a Process
• Injury swelling increased pressure stops
  blood flow
• Consensus on Brain Death
• Academies of Neurology USA, France, Germany,
  Italy, UK, Spain, Belgium, Switzerland, Austria,
  India, Japan, et al.
• Statistics on Brain Death
• Mayo Clinic 385 cases (1987-1996)
• Flowers Patel (Southern Medical Journal) 71
  cases 100 accuracy.

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The Gift of SelfOrgan Donationfor
Transplantation
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Catholic Church Supports Transplantation

• Living Donors
• Serious need
• Functional integrity
• Proportionate benefit
• Informed consent
• Cadaver Donors
• Noble and meritorious act a great act of
  charity
• Informed consent
• Proper determination of death
• Dead Donor Rule

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Medical Ethics in Transplantation

• Patient considerations
• Expectations
• Costs
• Efficacy

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Patient Considerations

• Age
• Status (wage earner, family)
• Culpability
• Acuteness of need
• Random selection
• Immunologic match
• Moral theologians state that since the
  transcendental nature of man must be primary
  social status and other considerations should be
  secondary and selection should be need-based

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Expectations

• What risks to donors are acceptable?
• Degree of pain and emotional trauma with multiple
  transplants (children)
• How much can be expected of relatives -
  especially siblings - as potential donors?
• Efficiency of organ use i.e. should 3 organs be
  used for 3 patients or for less?

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Costs

• Selection based on ability to pay?
• Only corneal and kidney transplants covered by
  most insurance
• Some experimental transplants are covered by
  research grants
• Children likely to need multiple serial
  transplants
• Only a dream for uninsured patients
• Is a transplant within the sphere of medical care
  that all have a right to?

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Efficacy

• Many more organs needed than available
• This disparity grows larger each year
• Waiting list deaths increase yearly (6000 in
  2008)
• There is a push to make more organs available!
• Society must be vigilant in not allowing a change
  in the criteria for defining death!!

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U.S. Waiting List2008
26,823 Single organ transplants (2007)
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Types of Donors

• Cadaver
• solitary organs - heart, liver, pancreas
• paired organs - lungs, kidneys
• Living
• paired organs/part of solitary organ
• Related
• Non-related (more common better
  immunosuppression)

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Cadaver Transplants(most common)

• Brain death criteria
• Severe brain injury (youth)
• Prolonged anoxia
• Extensive hemorrhage
• Donor after cardiac death
• ? Morality
• Subject to much abuse

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Church TeachingCadaver Transplants

• Must reflect the Culture of Life
• never reducing the dignity of the human person
• Reject euthanasia
• Respect the long-standing right to reject
  extraordinary or excessively burdensome care
• Afford an opportunity for the donation of
  unpaired organs to assist in the preservation of
  the life of another suffering from a
  life-threatening disease

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Cadaver TransplantsMedical Ethics

• No intervention allowed with the intention of
  shortening the donors life
• Care of the living patient must never be
  compromised in favor of a potential organ
  recipient
• No member of transplant team is allowed to play
  any part in the care of the dying patient

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Church Teaching Living Donors

• Serious need on part of recipient that cannot be
  fulfilled in any other way
• Functional integrity of donor as a human person
  will not be impaired, even though anatomic
  integrity will suffer
• Risk taken by donor as act of charity is
  proportionate to the good resulting for the
  recipient
• Donors consent is free and informed

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• "Transplants are a great step forward in
  science's service of man, and not a few people
  today owe their lives to an organ transplant.
  Increasingly, the technique of transplants has
  proven to be a valid means of attaining the
  primary goal of all medicinethe service of human
  life. There is a need to instill in people's
  hearts, especially in the hearts of the young, a
  genuine and deep appreciation of the need for
  brotherly love, a love that can find expression
  in the decision to become an organ donor."
• John Paul II
• August 2000
• International Congress on Transplants

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