Why is brain death a more scientific criterion than cardiac death? Are vegetative patients dead or alive? What's the deal with "coming back from the dead"?
A little boy died of a lung infection, treatment was ineffective, due to unpaid bills, the body was placed in the hospital morgue, two days later, the child's parents to raise the cost and ready to cremate the child's body, did not expect to pull the drawer, the child sat up and said, "It's so cold."
Confused perceptions of death occur not only among the general public, but even in the medical community. In this country, those who insist on resuscitating brain-dead people are generally publicly funded, and those who are willing to give up are self-funded.
Confused perceptions of death occur not only among the public at large, but even in the medical profession. Almost all developed countries and regions have now adopted the brain death standard, while China still uses the backward heart death standard. The reporter interviewed Prof. Chen Zhonghua, director of the Institute of Organ Transplantation at Tongji Hospital of Huazhong University of Science and Technology in Wuhan. This at the same time working at the University of Cambridge Clinical School of Surgery, "transnational" medical doctor, examined the Chinese people and even the medical profession in the concept of death and some related issues with the world **** knowledge of the differences, and seek to start from the medical profession to update the concept.
Why is there a "resurrection from the dead"
Reporter: I recently heard of a story about a boy who died of a lung infection about 10 years ago, and because he owed money for the treatment, his body was put in a hospital morgue. It was winter and the room temperature was low, and no refrigeration equipment was turned on. Two days later, the child's parents gathered the expenses, ready to cremate the child's body, did not expect a drawer pull, the child sat up and said: "so cold ah." This kind of "back from the dead" thing is really bewildering. Even three-year-old children know what death is all about, in the past, the lack of breathing, heartbeat recognized as death, in recent years, the medical profession and put forward regardless of whether the heart stops beating, whether breathing disappears, people as long as the brain death is equal to the body of the whole death of the new concept, is it possible that the doctor will get it wrong?
Chen Zhonghua: you said this matter, I am not very clear about the specific details, so I can not specifically comment, but I can certainly say that "back from the dead" is usually in the death of the diagnosis of the error. Death is indeed three-year-old children know, but you just said the words are wrong, the first sign of brain death is the complete loss of spontaneous respiration, you missed the "spontaneous" and "completely" four words, the fallacy of a thousand miles.
As a modern practicing physician in China, even if you can't properly stop pointless medical activity at this point, you don't have to know exactly when a patient has died.
Reporter: To say that a practicing physician doesn't always know exactly when a patient has died sounds like an exaggeration.
Chen Zhonghua: You should notice that I emphasize "modern practitioners" because modern society requires more precision in determining death. When I was checking on a patient who was already brain dead, I asked the doctors, "This patient is already dead, if the patient's family wants us to use a ventilator to maintain his breathing, and after a period of time, the family asks us not to maintain it any longer, and we stop the ventilator, and his breathing stops, when do you say that his death should be counted from what time? More than one doctor replied that of course it was counted from the time the ventilator was stopped. I said, "Wrong! Doesn't that make it so we called him dead? In fact, he was not breathing on his own at the time of his brain death, and we were only giving him artificial respiration to satisfy the request of his relatives to maintain him post mortem, and this kind of respiration could not bring him back to life at all. This is an error of expertise and not at all exaggerated! Of course it is not the fault of any physician; on the one hand, the old concepts have been followed for so long that the slightest inattention slips with the inertia, and on the other hand, it must be admitted that we are lagging behind in our understanding of death.
"Vegetative" is dead or alive
Reporter: I did a questionnaire survey, 70% of the people think that vegetative is brain death. I also asked a lot of doctors, but few of them said clearly the difference between the two and the relationship. The report on the awakening of the vegetative person is even more puzzling.
Chen Zhonghua: There is no "vegetable" in foreign countries, and it should be called a vegetative state, which means that a person has a life like a plant, that is, he can't move actively on purpose, so the vegetable should be put in quotation marks. There is no strict definition of "vegetative" is very easy to confuse with brain death, so should try to avoid using.
The vegetative state is medically called "decortication syndrome". The criteria for determining a vegetative state are very specific. There are two types of vegetative state: persistent vegetative state and permanent vegetative state. Time is the criterion for judgment, but the standard is not uniform in different countries. China's 1996 Nanjing conference to determine the coma for a month can only be called a vegetative state, more than three months can be called persistent vegetative state. Vegetative state in more than a year of patients, the consciousness recovery rate is 1%; 6%, in a state of severe disability, so some people will be more than a year of patients called permanent vegetative state.
Nowadays, with the help of advanced medical equipment and technology, it is possible to maintain the breathing and heartbeat of a patient in a vegetative state for a long time, and to remove waste products from the body. But this does not mean that the patient is still alive, nor does it mean that the dead can be resurrected. Therefore, a large portion of what is commonly referred to as "vegetative patients" may have already died. The correct approach is to conduct a systematic examination of the brainstem or the central nervous system above the brainstem as soon as possible and carefully in order to determine whether brain death has occurred. If brainstem death or a permanent vegetative state caused by diffuse cortical necrosis is confirmed, all medical activities aimed at resuscitation should be stopped.
Brainstem death = brain death = death
Reporter: The threshold of death is set at the position of brain death, which is shifted forward from the position of cardiac death that is currently commonly recognized in China, on what basis?
Chen Zhonghua: In fact, the ancient beheading as capital punishment shows that human beings in practice have long recognized the head as the head of life.
The exact brain death includes three aspects:
The first is the change of the cerebral cortex. The cerebral cortex is responsible for human thinking, conscious activity and other psychological functions. Once the cerebral cortex is dead, the above functions cease to exist, which is medically called diffuse cerebral cortex death. At this point, at least a diagnosis of sociological death can be made.
The second is brainstem death. The human body has 12 pairs of cerebral nerves emanating from the brainstem, which are in charge of important physiological functions such as sensation and respiration. Modern medicine recognizes that the primary physiological feature of human life is respiration, and the central nervous system that governs respiration is located in the brainstem. Therefore, brainstem death is recommended as a criterion for reaching the threshold of death, and is also used as a criterion for determining human brain death and mortality. After brainstem death, some of the biological features, including the residual heartbeat, that can be maintained by modern medical treatment no longer indicate the continuation of life. This is the "4#0;3#0;2" law of modern medicine: brain stem death = brain death = death.
The third is whole-brain death. Diffuse cerebral cortical death + brainstem death = total brain death. Whole brain death should be declared instantly once it occurs and the individual is dead.
In fact, when diffuse brain injury occurs, cortical death generally precedes brainstem death, so it is more conservative, safe, and reliable to use brainstem death as a criterion for determining individual death. For example, in hypoxia, the tolerance time of brain cells to hypoxia is 4#0;6 minutes for cerebral cortex; 5#0;10 minutes for midbrain; 10#0;15 minutes for cerebellum; and 20#0;30 minutes for medulla oblongata/brainstem, respectively.
Who benefits from brain death
REPORTER: Much of the publicity calling for the implementation of diagnostic criteria for brain death says it is so as not to add to the suffering of patients. But when a loved one dies, many people want to keep him a little longer, waiting for the heart to stop, human nature, why not?
Chen Zhonghua: Your words are wrong again! The first thing you need to do is to get your hands dirty. There's no such thing as "staying a little longer", and you're still treating the brain-dead as if they were alive. It's a shame that such a misconception is in the propaganda, and it must be corrected once and for all. But I think you raise a question that is well worth answering: what is the point of brain death diagnosis and legislation.
People are usually able to respect people who are not incapacitated, but they are always unwittingly imposing their subjective emotions, and even the needs of their personal interests, on the dying. As society progresses, dying with dignity is valued as much as living with dignity as a personal right. Therefore, the first beneficiary of the implementation of diagnostic criteria for brain death should be the patients themselves.
The meaningless "resuscitation" and all other comforting and ceremonial medical activities after brain death have brought a huge burden to the patient's family, as well as a huge waste of national economy and medical resources. According to a rough estimate, China's annual medical expenses for this can reach hundreds of millions of dollars. A survey shows that the cost of ICU (intensive care unit) patients is four times that of patients in ordinary wards, and the cost of patients who die in ICU after failing to be resuscitated is two times that of patients who are resuscitated to life. And there is literature showing that in our country, those who insist on resuscitating brain-dead people are publicly funded, and those who are willing to give up are self-funded.
For organ transplant needs?
Reporter: I notice that as an organ transplant expert, you left out one of these implications you mentioned above: that the diagnosis of brain death has and has had positive implications for organ transplantation. Many of the calls for brain death legislation that I have heard and seen have been made by experts in the organ transplant community and are urgent, but I think they sound reasonable but not very comfortable, as if brain death legislation means that I have to admit that I'm dead sooner and then let me donate my organs. Some people around me feel the same way.
Chen Zhonghua: I do intentionally want to discuss the brain death issue separately from organ transplantation. In our country, brain death legislation was proposed by the organ transplantation community for a specific historical background and objective reasons, but in fact, in terms of the social significance of brain death legislation and the implementation of diagnostic criteria for brain death, organ transplantation should come last. Without the need for organ transplantation, the progressive nature of implementing diagnostic criteria for brain death remains, and conversely, people who receive diagnostic criteria for brain death do not necessarily have to donate their organs.
The fact that you and those around you feel "uncomfortable" confirms the criticism made by Mr. Qiu Renzong, one of China's leading ethicists: "It is unethical to link the discussion of the definition of 'brain death' to the question of the benefits of organ supply. It is unethical to link it with the issue of the benefits of supplying organs." It is true that the legislation on brain death should not be too close to organ transplantation. I suggest that the legislation on brain death should not be carried out at the same time as the legislation on organ donation and organ transplantation. Brain death legislation should come first.
A dual-track system should be adopted at this stage
Reporter: It is said that the "Brain Death Criteria and Implementation Measures (Draft)" has been handed over to the Ministry of Health, but the public survey I recently conducted shows that 67% of the people believe that the judgment of death is only related to the heartbeat and respiration, although 33% of the people realize that the judgment of death is related to the permanent loss of brain function, but it is not. permanent loss of function, yet 70% confuse brain death with vegetative state. On the basis of such public awareness, what would happen if brain-death laws were suddenly introduced?
Chen Zhonghua: The question has a point. Brain death law belongs to the law of high science and technology, human rights and ethical issues mixed, legislation must have a solid medical foundation, social foundation and legal environment, otherwise even if there is a law, it will cause confusion in law enforcement. Therefore, I advocate that the process of promoting brain death legislation should be bottom-up and then top-down, with the former including medical education, clinical practice, and scientific publicity, and the latter referring to the recognition, support, and participation of the management of state institutions, both of which are indispensable.
Based on our national conditions, a dual-track system of heart death and brain death should at least be proposed at this stage. Both programs are freely chosen by the patient. But there are two points must be initiated at the same time, one is the patient's relatives representatives or lawyers to establish a letter of "informed consent", and the second is the medical and health care management level must be clearly stipulated that: "the diagnosis of brain death is established after the cessation or withdrawal of all therapeutic measures does not violate the modern medical routine "to avoid medical disputes.
Oxygen deprivation condition human death order
Individual life death is a process, in this process there is a point, to this point, life as a complete system began to disintegrate, can never be restored to an organic whole, which is the critical point of death. If the end of life is artificially moved before the tipping point of death, it means that death is diagnostically incorrect. But no forward or backward movement in any position after the tipping point of death can change the nature of the overall life that has died.
After death, a variety of isolated organs can be safely preserved for a period of time with the help of organ preservation fluids: two hours for the small intestine, six hours for the heart, 24 hours for the liver, and 48 hours for the kidneys. This is "life" in death, but this "life" can no longer indicate the continued existence of the living individual.