When do we really die?

Dr S. Sahariah

When is a person really declared dead? Till recently it was universally accepted that a person is declared dead when he or she stops breathing and the heart stops beating. As the heart pumps blood which supplies nutrient for all the organs, lack of it leads to death of all the organs within a very short time which is irreversible. But during recent times the concept of death had to be revisited both by the medical and legal fraternity as well as the social scientist.

With the introduction of sophisticated medical devises like ventilator, heart lung machine and drugs like dopamine, dobutamine and hormones etc it has now become possible to keep a terminally sick patient including patients with severe head injury or brain stroke alive for a considerable period of time thus giving an opportunity to try all possible means to bring back life.

The introduction of organ transplantation as a life saving procedure and the acceptance of the same by the global community has made declaration or definition of death much more complicated. Theoretically when the brain, which controls all body functions, is permanently damaged the person may be declared as dead and they are labeled as Brain Dead. But life of these brain dead patients can be temporarily prolonged with artificial life support.

Way back in October, 1976 the Royal College in United Kingdom first introduced the concept of Brain Death which can be diagnosed with certainty by following the laid down criteria. However the group did not make any reference to organ transplantation nor commented whether death should be presumed to occur when brain death is diagnosed.

The subsequent report submitted by the same committee was published in the prestigious British Medical Journal in 1979. To summarize the report:

  1. Exceptionally as a result of massive trauma death occurs instantaneously. More commonly death is not an event, it is a process where various organs and systems supporting the continuation of life failing and eventually ceasing to function altogether.
  2. Cessation of respiration and cessation of heart beat are examples of organ failure occurring during the process of dying and it has for many centuries been accepted as the moment of death itself without any serious attempt being made to assess the validity of this assumption.
  3. It is now universally accepted by lay public as well the medical profession that it is not possible to equate death with cessation of the heart beat. Elective cardiac arrest in open heart surgery and spontaneous cardiac arrest followed by successful resuscitation is seen quite often in medical practice.
  4. In majority of cases in which a dying patient passes through a process leading to death, successive organ failure eventually reaches a point at which brain death occurs and this is the point of no return.
  5. In some cases brain death does not occur as a result of failure of other vital organs but as a direct result of severe damage to the brain either due to head injury or spontaneous intracranial hemorrhage. Here the order of the events is reversed. Instead of failure of such vital functions as heart beat and respiration eventually resulting in brain death, brain death results in cessation of spontaneous respiration which is normally followed immediately with cessation of the heart beat due to hypoxia. If however oxygenation is maintained by artificial ventilation the heart continues to beat for few days which is adequate to maintain function of other vital organs like liver, kidneys, lungs etc.
  6. It is the conclusion of the conference that the identification of brain death means that the patient is dead whether or not the function of some organs such as heart beat is still maintained by artificial means.

Till the time organ transplantation was accepted as a life saving procedure for patients with terminal organ failure Brain Death concept was not taken very seriously. But over the years it has been observed that in spite of organ transplantation became a reality most of the patients with terminal organ failure was facing imminent death as there was not enough human organ for transplantation. On the other hand suitable transplantable organs were either buried or burned along with the body as they could not be harvested on time due to lack of  legal support for determination of brain death. This concept of brain death as termination of human life was extensively debated and later recognized in the highest national and international bodies including World Heath Organization (WHO) thus paving the way for possibility of organ harvesting from such patients. The Indian parliament through the Human Organ Transplantation Act (1994) has legalized concept of brain death as end of life to facilitate deceased donor organ transplantation. Brain death is normally diagnosed by a group of experts not directly involved in the care of the victim by following laid down criteria as approved by the international body. Brain death is permanent and cannot be reversed. As the body organs totally gets damaged within a very short time once the heart stops beating these organs become useless for transplantation and hence the concept of brain death has become very important for a cadaver donor organ transplant programme.

About 75 percent of the organ transplanted in western countries is harvested from brain dead donors as the concept of brain death has been understood and accepted by the people and they are coming forward for organ donation. In India the concept is relatively new and people are not very much aware about brain death and organ donation. The union government through National Organ & Tissue Transplant Organization (NOTTO) and State government through State Tissue & Organ Transplantation Organization (SOTTO) has started various programme for public education so that organ donation rate can be improved from present dismal figure 0.5 PMP (per million population) which is one of the lowest in the world to a more acceptable level so that precious human lives can be saved with the help of organ transplantation.

The writer is a nephrologist and organ transplant specialist. He was honoured with the Padmashree, the fourth highest civilian award in India for his contribution towards the field of medicine. He can be contacted at sahariah@eth.net.

(This is an opinion piece and the views expressed above are the author’s own. TIME8 neither endorses nor is responsible for the same.)