The Curious Clinicians discuss the history of death exams, scandals and ethical considerations. They explore inaccurate death diagnoses and the fear of premature burials in the 19th century. The podcast also dives into controversial methods for determining death, the role of death exams in organ transplantation, and debates about the definition of death.
The controversy surrounding the definition of irreversibility in death criteria has significant implications for organ transplantation and the success of heart donors.
The Lazarus phenomenon, where patients regain spontaneous circulation after unsuccessful CPR, challenges the certainty of death determination and raises ethical concerns about the accuracy of declaring death.
Deep dives
Controversy 1: Are patients who meet permanent criteria actually dead?
One of the controversies discussed in the podcast episode revolves around whether patients who meet permanent criteria of circulatory death are actually dead, particularly in the case of heart donors. The debate focuses on the definition of irreversibility and whether the absence of circulatory and respiratory functions, even with no chance of return after CPR, truly represents irreversible loss. This controversy becomes especially significant in the context of organ transplantation, where using the permanent criteria allows for shorter warm ischemia periods, increasing the chance of successful transplants.
Controversy 2: Can patients experience auto resuscitation?
The second controversy addressed in the podcast episode is the phenomenon of auto resuscitation, also known as the Lazarus phenomenon. Auto resuscitation occurs when patients who have experienced unsuccessful CPR suddenly regain spontaneous circulation without any medical intervention. This controversial occurrence challenges the certainty of death determination after unsuccessful resuscitation attempts. Multiple reports suggest that auto resuscitation is more common than previously believed, with patients recovering consciousness and even fully recovering from the cardiac arrest event. The implications of auto resuscitation on the accuracy of death declarations and ethical concerns surrounding it are extensively discussed.
The Need for a Revised Death Exam
Given the historical and ethical controversies surrounding death determination, the podcast episode concludes with a call for a revised 21st century death exam. Current criteria proposed by the WHO include a cardiac exam assessing the absence of pulse and heart sounds, a respiratory exam evaluating the absence of breath sounds and respiratory effort, and a neurologic exam considering coma and fixed/dilated pupils. However, it is emphasized that for patients who have undergone CPR, a longer waiting period before declaring death is recommended to account for the rare but documented cases of auto resuscitation. The importance of accurate death determination in various medical and ethical contexts is highlighted.
Impact on Clinical Practice
In terms of clinical practice, the podcast episode discusses the implications of the controversies on the death exams performed by clinicians. For patients with do not resuscitate (DNR) orders who will not receive CPR, a two-minute waiting period is generally deemed appropriate before declaring death. However, for patients who have undergone CPR, it is suggested to extend the waiting period to at least 10 minutes, or potentially even longer, before confirming death to avoid the possibility of auto resuscitation. This recommendation aims to prevent premature death declarations and the subsequent emotional impact on families and healthcare providers. Increased awareness and consideration of the complexities surrounding death determination are crucial for ethical and accurate practices.
This week, The Curious Clinicians are bringing back an episode from the archive that was originally posted in December, 2021.
Tony joined Dr. Adam Rodman as a guest on the Bedside Rounds podcast. We were thrilled to share that episode here.
How can we medically tell whether or not someone is alive or dead? The answer is more complicated than you’d think. This episode was a live podcast Adam and Tony gave at the Massachusetts Chapter of the American College of Physicians annual meeting on October 16, 2021. They track the evolution and controversies of the death exam, from a trans-Atlantic scandal surrounding a possible vivisection, a 19th century “X-prize” to determine a technology that could diagnose death, the important distinction between “permanent” and irreversible, and the mysterious Lazarus phenomenon.
