Thesis: Cardiac Death Vs Brain Death
It can be argued that in cases of brain death, the body or organism remains alive, but the person, as distinct from the organism, has died due to irreversible unconsciousness. Some scholars argue that the terms alive and dead in this context are covertly normative, or moral terms, functioning similarly as person does in the abortion debates, and signal a moral evaluation of the permissibility of organ procurement (Flowers et al., 2000). On this view, to say that brain-dead patients are dead means that they lack moral status as members of the human community, and that removal of organs is permissible, though, again, the body remains biologically alive. This essay supports the argument that cardiac death rather than brain death should be the standard understanding to pronouncing an individual deceased and not declared dead prematurely.
Another type of view holds that whether such patients are alive or dead is in some sense a social choice, or a social construction, and that there are good social, legal and moral reasons to draw the, somewhat arbitrary, dividing line between life and death in such a way that brain dead patients are on the dead side of the line. However, each of the above views approaches the question of brain death from a largely non-biological perspective. However, the most influential views, at least in terms of law and policy, have treated death in biological terms. The President’s Council on Bioethics in 2008 reiterated this stance, “I reject the idea that death should be treated merely as a legal construct or as a matter of social agreement. Instead, I respect the biological reality of death” (Bacqué et al., 2018).
Exposition: background information and definitions
Cardiac death can be defined a condition in which the heart suddenly and unexpectedly stops beating. If this happens, blood stops flowing to the brain and other vital organs. Brain death, on the other hand, is defined as the irreversible loss of all functions of the brain, including the brainstem (Doig & Burgess, 2003). The three essential findings in brain death are coma, absence of brainstem reflexes. The established view regarding ‘brain death’ in medicine and medical ethics is that patients determined to be dead by neurological criteria are dead in terms of a biological conception of death, not a philosophical conception of personhood, a social construction or a legal fiction. Although such individuals show apparent signs of being alive, in reality they are (biologically) dead, though this reality is masked by the intervention of medical technology. In this article, we argue that an appeal to the distinction between appearance and reality fails in defending the view that the brain dead are actually dead. Specifically, this view relies on an inaccurate and overly simplistic account of the role of medical technology in the physiology of a ‘brain dead’ patient. We conclude by offering an explanation of why the conventional view on ‘brain death’, though mistaken, continues to be endorsed in light of its connection to organ transplantation and the dead donor rule.
Humanity has thoughtfully struggled with the concept and criteria for death for millennia and the line between life and death continues to be debated. The profound changes brought about by organ failure support, organ replacement technology and transplantation continue to challenge people’s notions of life and death (Flowers et al., 2000). While the discussions at this forum were about the determination of death, this focus was based on a desire to maintain a reverence for life and to further inform when life ends in view of the ongoing advances in biological insight and technology. Human death is defined based on measurable biomedical standards. Participants supported a movement away from anatomically-based terms such as brain death or cardiac death that erroneously imply the death of that organ. Emphasis was placed on the cessation of neurological or circulatory function and the predominance of brain function for determination of death.
Brain death generally is caused by blunt head trauma from accidents, falls, or crush injuries, thrombotic or hemorrhagic stroke, especially when the infarct causes brain herniation, or an anoxic injury that causes the death of brain cells that do not regenerate (Essien et al., 2017). Any injury that causes brain death injures the entire brain and its function. As with this case study, sometimes brain injury is seen in combination with cardiac arrest, which may be the underlying cause of brain death. Brain death is often confused with a coma or a persistent vegetative state, but they differ greatly. Patients in a coma or persistent vegetative state may have limited brain function, but some areas of the brain still remain intact. These patients often have intact reflexes, take spontaneous breaths, and may respond to stimuli even when higher cognitive functioning is absent. In brain death, there’s no function in the brain at all thus patients have no respiratory function, no spontaneous movements, and all reflexes are absent. Since the heart is not controlled by the brain, a patient receiving artificial ventilation may continue to have a heartbeat.
An EEG is almost always performed when there’s a suspicion of brain death. It’s used to monitor brain wave activity via electrodes on the scalp to detect electrical patterns in the brain. On the monitor screen, these patterns appear similar to chaotic ECG tracings. Brain wave patterns vary throughout the day and appear different when a person is asleep. However, in brain death, there will be no electrical activity and the wave pattern will appear flat. When an EEG is performed as a confirmation of death, the patient should be free from sedation and warmed to a normal body temperature. A negative EEG will have flat waves, showing no brain activity. When making a determination about brain death, two EEGs are conducted at least 12 hours apart. After being declared brain-dead by doctors, while a brain-dead person is not legally alive, the respiratory card, renal system gastrointestinal systems keeps on working with the help of technology (Essien et al., 2017). Without the help of technology the body dies immediately the support is withdrawn.
Cardiac death/body death/physical death is characterized by the heart’s intrinsic electrical system that can keep the organ beating for a short time after a person becomes brain-dead, this the body is still alive hence the individual is still alive. Cardiac, or circulatory death, is what most lay people think of when they think about the definition of death (Bacqué et al., 2018). It is typically seen when the heart has stopped beating or is beating too irregularly to sustain life. The heart’s main function is to pump blood through the lungs for oxygenation and then out to the rest of the body. When the heart stops contracting, tissues are deprived of oxygen and become ischemic. Cardiac arrest causes a generalized lack of perfusion to all organs, anaerobic metabolism, and global cellular death.
Signs and symptoms of acute cardiac arrest (cardiac death) include the absence of all peripheral pulses, cyanosis, and possibly apnea. Patients who are not apneic may present with shallow, irregular, gasping breathing known as agonal respirations. The rhythms that coincide with cardiac arrest are asystole, ventricular tachycardia, and ventricular fibrillation, which may be seen on the ECG (Nowak et al., 2014). However, a patient may appear to have normal electrical activity but have no pulses. This is called pulseless electrical activity and it may look like a sinus rhythm or sinus bradycardia on the monitor, but no peripheral pulses will be present. Although cardiac arrest may be reversed with the rapid initiation of CPR and ACLS, most instances are not reversible. If a perfusable rhythm is not restored quickly, the risk of permanent damage increases. The sooner circulation is restored, the better the patient outcome. After 3 to 5 minutes, brain cells start to die and this damage is irreversible. With a ventilator, some biological processes including kidney and gastric functions, can continue for about a week but without the brain, the body does not secrete important hormones that is needed to keep the biological processes alive/going.
Studies have proved that cardiac death should be declared the ultimate death. This is due to the fact that at first, there is the brain death, then organ failure follows as brain is not supporting vital functions to continue life (Doig & Burgess, 2003). Once cardiac death/organ failure occurs, all life has ceased, thus individual should be declared deceased/dead. Death has always been a difficult topic, but technology has caused people to redefine what it really means. Although most patients experience cardiac death, brain death is an important consideration. There have been several sensational cases that have continued to blur the lines, but life legally ends when the heart stops beating or there is no brain function. Recognizing both forms of death and their signs will help a doctor educate and guide families through an already difficult time. Family and doctors can keep someone on a machine to prevent cardiac death as long as the family accepts the situation because there is no specific time line. Humane timeline outlines the major events in the development of the human.
If appropriate, it is advisable that the hospital’s pastoral care or the patient’s own religious figure is involved to help the family process the patient’s death. Everyone deals with death and dying differently. Brain death cases usually require additional compassion and support. Although it may be difficult for the family to process, the doctor should not give the impression that the patient will improve. All team members must be clear about the patient’s death so that the family can grieve properly. Family members may not understand brain death. They will have questions about why their family member’s heart is still beating and why he or she is not being fed. It is due to this that the doctor need to be prepared to answer difficult questions with both fact and compassion. Until life support is withdrawn, it is important to continue to provide support and education when appropriate. There are also religious aspects that should be put into consideration. Although transplant services have become more common, there are still some religions that don’t endorse organ donation (Hassan et al., 2011). For instance, certain Jewish denominations are less likely to donate their organs post brain death.
Medical team caring for the patient are not often directly involved in the organ donation process, but in most states are encouraged to contact the organ bank if brain death is suspected. A medical coordinator will often review the patient’s chart to see if the patient is an appropriate candidate. Age, infection, and cancer are common reasons that a patient is not a donation candidate (Iserson, 1999). Another consideration in patients with suspected brain death, especially in a younger person, is the possibility of organ donation. Although bone and corneas can be harvested after cardiac death, most major organs need to be harvested while there is still circulation. Brain death allows for this unique opportunity, but causes added stress for the family members making the decision. Due to the delicate nature and legality of organ donation, there is usually a dedicated team that approaches the family about organ donation.
Although many people feel that an individual can only be declared dead when his brain stops functioning, the medical world terms cardiac death as the legal death. A GCS score of less than 6 should trigger a call to the local organ bank (Hassan et al., 2011). This should however be preceded by authorization from the family who would ascertain that they are comfortable with the idea of having their loved ones organs donated to the bank. In addition, as has been mentioned, pastoral care should be consulted for any patient with a risk of imminent death. All members of the healthcare team need to be supportive but not provide the family with false hope of recovery. They should advised on the reasons for withdrawing a life support among other issues. It has been outlined that the subject of organ donation should be addressed with the family by the organ donation team. Further, basic nursing care and practices that include turning the patient, bathing, oral care among others, should continue until life support is withdrawn.
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