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Waking the dead? Some things you should know about dying

Not content with saving lives, doctors are now credited with (accused of?) bringing the dead back to life. But how true are the stories we hear about people “coming back” from being dead and how does it…

Cardiopulmonary resuscitation (CPR) prevents many deaths across the world, but it doesn’t bring dead people back to life. NATO Training Mission-Afghanistan

Not content with saving lives, doctors are now credited with (accused of?) bringing the dead back to life. But how true are the stories we hear about people “coming back” from being dead and how does it work?

Here’s a definition of death that gets to the heart of why this is all very complicated:

Death: 1. The end of life. The cessation of life. (These common definitions of death ultimately depend upon the definition of life, upon which there is no consensus.)

Cardiopulmonary resuscitation (CPR), first popularised in the 1960s and widely taught to both first responders and the general public, prevents many deaths across the world.

But it doesn’t bring dead people back to life. And the distinction is an important one.

The problem can be easily stated – death is a process, but is forced to be an event. Organisms die in a piecemeal manner, with the most vulnerable bits going quickest.

Some residual function can be found up to several hours past the point where the heart has stopped beating (though, contrary to myth, the fingernails do not continue to grow).

Why “when” is important

But there are cogent medical, legal and philosophical reasons for death to be considered an event.

Medically, there has to be a moment at which attempts to prolong life should cease (organ donation being a rare but important reason). Organ donation puts great pressure on doctors to define a moment of death. This is to honour the “dead donor rule”, which states that only dead people can be donors.

Legally, time of death is important for determining who out-survived whom, and thus how the deceased person’s possessions will be distributed.

Philosophically, it appears, at least to some, that the categories “alive” and “dead” are to have no overlap. Consider this from a research paper about defining death:

If we regard death as a process, then either the process starts when the person is still living, which confuses the “process of death” with the process of dying, for we all regard someone who is dying as not yet dead, or the “process of death” starts when the person is no longer alive, which confuses death with the process of disintegration.

Hmmmm.

Now we have a problem: we need to know what death is, and we need irrefutable tests to prove it. How are we doing?

Kinds of death

Obviously, it all got much harder when laws were introduced that defined two distinct kinds of death – circulatory (traditional) death and the new kid on the block, brain death.

Brain death is the ‘irreversible cessation of all function of the person’s brain’. Its.MJ/Flickr

These laws were introduced in Australia in the early 1980s to legitimise brain death as a form of dying. This had the benefits of allowing treatment withdrawal and permitting organ donation without breaking the “dead donor rule”.

Circulatory death is the “irreversible cessation of circulation of blood in the person’s body”, while brain death is the “irreversible cessation of all function of the person’s brain”.

Many researchers are scrambling to unify these two definitions, by asserting that loss of circulation would inevitably cause irreversible cessation of all brain function.

But, given that we don’t know how long the circulation has to stop before we can be confident that all brain function has stopped in all cases, it seems we are stuck with two definitions for now.

The operative word in each definition is irreversible. The reason why CPR, however prolonged and enhanced by new technologies, does not bring people back to life is that clearly the cessation of circulation and brain function are not irreversible.

So people who are “brought back to life” were, in retrospect, not dead in the first place.

Who is responsible?

But seemingly miraculous results from CPR do pose a serious challenge: how are we then to be certain that cessation of function is irreversible?

The law is steering clear of getting involved in Australia, and the decision is delegated to doctors. This was challenged in a legal case but the law, as it stands, was confirmed.

Irreversible loss of brain function does have a set of tests that appear extremely reliable, as long as they are properly conducted. And nobody declared brain dead in Australia has ever lived to tell the tale.

Irreversible loss of circulation is more difficult to certify, and has been brought into sharp focus by the re-introduction of organ donation after circulatory death, which demands both high certainty and an exact time of death.

Organ donation after circulatory death has become widespread in Australia over the past ten years as a response to the very low numbers of donors, and now accounts for about 25% of all donors.

What we know empirically is that a heart that has stopped will not spontaneously start again after quite a short time (so-called autoresuscitation).

So cessation of circulation is permanent, but is it irreversible? It is, but only in one context; a morally and medically defensible decision not to keep trying to reverse it.

Such decisions are commonplace in modern medical practice (the no-CPR or “Do Not Resuscitate” order), and have a history almost as long as CPR itself.

There are people who cannot be, should not be, or do not want to be resuscitated. For them, permanent loss of circulation is irreversible. For the rest – go for it!

Join the conversation

28 Comments sorted by

  1. Billy Field

    logged in via Facebook

    Fantastic PS. No wonder we all love Doctors.
    I am sorry if it a bit mad but, I wonder if we legalised suicide people might donate their organs?
    As there might be a conflict of interests with Doctors needing organs is there a problem with a persons legal Power of Attorney (or family) being required to authorise any organ donation?

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    1. Kylie Webber

      Obstetrics & Gynaecology Registrar

      In reply to Billy Field

      I don't understand why people think there is some sort of personal gain for doctors in the harvest of organs. I am not involved in organ donation or recipient medicine, but when I go to work it is not to improve my own health, and I suspect transplant surgeons are no different!

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  2. Terry J Wall
    Terry J Wall is a Friend of The Conversation.

    Still Learning at University of Life

    The article has thrown some light on this important subject. So thank you for that.
    The reason why I have not signed as a donor, is because doctors still refuse to have a non industry panel to oversee professional misconduct; so I don't trust them, except of cause with injuries.
    Doctors are basically businessmen or women needing disease to make a living. When they are paid by the hour, they will especially gain more respect.

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Terry J Wall

      What an extraordinary comment from a businessperson who sells (largely superfluous) ''supplements''!

      Mr Wall - can you tell us the actual make-up of the panels that oversee professional misconduct?

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    2. Donald Runcie

      retired

      In reply to Terry J Wall

      Terry. "Doctors are basically businessmen or women needing disease to make a living" The doctors that I came in contact with in my professional working life as a consulting anaesthetist (which ended fifteen years ago) were there to practice their profession. If some one wanted just to make money, they would certainly not choose medicine as a profession. The majority of non medical commentators have no idea of the down side of medical practice; the broken sleep, the strain on family life the endless phone calls at night- I could go on. I find your comment insulting.

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    3. Dianna Arthur

      Environmentalist

      In reply to Donald Runcie

      I second Donald's opinion. While there are always exceptions, people in the medical profession are among the hardest working (with ridiculously long hours) and deeply caring people. Unfortunately, I know this having poor health and am very sensitive to callous and unfeeling attitudes; attitudes as exemplified in Terry's comment.

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    4. Lewis Rassaby

      logged in via Facebook

      In reply to Terry J Wall

      Harsh but true. Mostly, we judge ourselves via our own professional bodies like APRAH. Is that what you mean?

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    5. Sue Ieraci

      Public hospital clinician

      In reply to Lewis Rassaby

      Lewis - your ''we judge ourselves'' comment neglects the fact that panels convened through AHPRA are not just made up of doctors.

      In NSW, misconduct inquiry panels are convened through the relevant Health Professional Council (a government body in a co-regulatory relationship with the HCCC), but are independent of that Council.

      From that organisation's website:
      ''A PSC is legally separate from and independent to the Medical Council. A PSC comprises a legal practitioner, two medical practitioners and one lay, or non-medical, member. PSCs constituted from 1 October 2008 are conducted in public unless the Committee determines otherwise. PSCs constituted before this date were required to conduct hearings in private.''

      Medical regulation isn't perfect, but it most certainly is not a closed shop.

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  3. read column

    academic

    when is dead , dead. well how about we first sort out when do we start life? it differs state to state, country to country, religion to religion. both life and death are determined not by science but by our legal system. e.g when do you first become legal? at conception, when the heart starts beating at 6 weeks, at extrusion, your first breath, your registration of birth in writing....too many variables here. can an unborn child have legal rights to sue its mother after birth because she smoked, took drugs etc which compromised the childs health? yes i think this happens in the US. So when is dead dead...just leave it up to the science for the present time and leave the jury out of it......otherwise you will have lawyers saying things like : but you only did CPR for 19 min and 59 secs , not the whole 20 mins.

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  4. Stephen H

    In a contemplative fashion...

    Here I was hoping for some information about the side-effects of CPR (broken ribs, damage to internal organs), and the fact that a fairly large proportion of people who are "saved" survive with brain damage and other permanent injury.

    Some of us do not want to be resuscitated because we recognise that life after resuscitation is likely to be very different to life before resuscitation. Unfortunately, even with clear "do not resuscitate" instructions you may find yourself a victim of CPR (http://www.dailymail.co.uk/health/article-2153013/Do-rescuscitate-orders-ignored-doctors-try-revive-patients-suffering-cardiac-arrest.html).

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Stephen H

      Stephen Hines - the post-resuscitation condition of a person who has had a cardiac arrest depends on many factors - particularly the type of cardiac arrest, the cause, how well they were before the episode, and how long it took for someone to start effective resuscitation.

      Certainly, if the person was very disabled prior to the cardiac arrest, they won't suddenly be a lot better if resuscitated. A person who has had no effective circulation for a prolonged time prior to resuscitation will likely…

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    2. Edwin Flynn

      I am a early retired executive at Worked in Local Government, Education and Financial Services Industries

      In reply to Stephen H

      Interesting topic. It appears to me that the majority of humanity would be grateful to anyone who is successful in their resuscitation. I often wonder what the circumstances are that would make someone consider themselves "Unfortunate, when even with clear "do not resuscitate" instructions they find themselves the "victim" of CPR. The implication being that if they find themselves the "victim of CPR", the CPR was successful and they are well or at least returned to their prior state of health…

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    3. Peter Campbell

      Scientist (researcherid B-7232-2008)

      In reply to Edwin Flynn

      Slightly glib comment: I guess if we had voluntary euthanasia doctors could resuscitate where possible and correct the situation if, on being resuscitated, the patient makes it clear they would rather not have been resuscitated.

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    4. Edwin Flynn

      I am a early retired executive at Worked in Local Government, Education and Financial Services Industries

      In reply to Peter Campbell

      So what is the point that you are making Peter?

      Let me give you a real life example of the dilemma of when is death.

      Whilst returning from Iraq via India my son, in the navy at the time, was with a group of ship mates doing the tours. One had taken or was given a substance that caused him to lose consciousness. The friends rushed the young man to a local hospital, but for reasons unknown the hospital refused to admit the seriously ill man.

      My son would not let his friend die and after…

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    5. Edward Pritchard

      general manager (retired)

      In reply to Stephen H

      You can be very lucky.
      Our family butcher was just packing our weekend meat order when without warning Terry's heart stopped and he lost consciousness. My son who was being served and who's an orthopaedic surgeon, initially thought Terry must have fainted, but when got behind the counter and pulled Terry from under his own chopping block, he realised our very long standing family butcher had lost the lot - he had no circulation whatsoever and had very little time before brain damage would be permanent!
      It took 12 minutes of CPR (my son tells me very, very hard work) before the ambulance arrived and then three bursts of high voltage electricity to spark Terry back into life.
      Terry is back at work with two pacemakers to keep him ticking over. And brain damage sustained was 'NIL' - he's a very, very lucky man!

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  5. Chris Richardson

    Doctor

    Sounds all a bit semantic and circular...you're dead only when you're irreversibly not alive. Or possible you could be dead, but only reversibly dead, or perhaps you could be come undead. Or part of the Undead.

    It reminds me of that great scene in the Princess Pride when Billy Crystal's character Miracle Max is asked to perform a miracle on the apparently dead Man In Black. He says...

    "It just so happens that your friend here is only MOSTLY dead. There's a big difference between mostly dead and all dead. Mostly dead is slightly alive. With all dead, well, there's usually only one thing you can do...go through his pockets for loose change..!"

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    1. Patrick Stokes

      Lecturer in Philosophy at Deakin University

      In reply to Chris Richardson

      'Sounds all a bit semantic and circular" - oh you would not believe how messy this stuff gets once you get it out of the clinical context and into a nice warm philosophy seminar room. Try this on on for size:

      Two identical twins, Bill and Bob, suffer physiologically identical heart attacks at the same moment. But Bill is already in a hospital when it happens and resuscitation efforts begin immediately; let's stipulate that he has a 5% chance of his heart being restarted within the first five minutes…

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  6. Patrick Stokes

    Lecturer in Philosophy at Deakin University

    Thanks for an excellent article Peter; I'll be pointing my first-year philosophy of death students towards this next semester.

    One of the questions we raise with them is whether 'alive' and 'dead' might no longer be conceptually fine-grained enough to be useful. We tend to assume that an organism is either alive or dead with no in-between ('half-dead' is usually understood to be just a metaphorical way of saying 'alive but in pretty bad shape'), but that absolute distinction may not "carve nature at the joints"; we just assume it does because for most of human history all the things that characterize biological death tended to happen all at once. So the 'dead donor' rule may be working with concepts that are just too blunt to map onto the circumstances.

    As someone who works on the philosophy of death it's great to see public discussion of these important and fascinating issues, so thanks again.

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Patrick Stokes

      Interesting comments, Patrick. Many concepts about life have changed irrevocably with the type of technology that allows us to understand the anatomy, physiology and pathology of human biological life.

      IN ancient times, before technology, the philosophers were the scientists, because scientific theorising could only be tested by the human senses. A model only had to be cognitively plausible and not in conflict with what could be seen with the human eye.

      Now we have the very different concepts of ''nearly dead'' and ''not irrevocably dead'' - where come organ systems are still functioning, or where intervention can potentially reverse the process.

      These should make your Philosophy of Death classes much more interesting!

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    2. Patrick Stokes

      Lecturer in Philosophy at Deakin University

      In reply to Sue Ieraci

      Thanks Sue. One thing I was surprised about was how widely - and how vehemently - students' responses varied when confronted with the question of whether PVS patients are alive or dead. Again the problem suggests that 'alive/dead' just doesn't cut it anymore; we might say that a PVS patient is a living human being but that the person has died, or we might say that death just isn't the (morally) decisive concept here. A whole bunch of questions about personal identity, biology and responsibility intersect here.

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    3. read column

      academic

      In reply to Patrick Stokes

      i would love to be in your class next semester. may i suggest to have your students and everyone else for that matter to simply look up the definition of death then the definition of life.....then explore both.

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    4. Patrick Stokes

      Lecturer in Philosophy at Deakin University

      In reply to read column

      There's legal definitions of death around, but if you want a more substantive philosophical definition of either death or life there's not one universally accepted definition, though there's some decent stabs that have been made at it. The intro to Chris Belshaw's book 'Annihilation: The Sense and Significance of Death' is a good place to start if you wanted to follow this up.

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    5. Peter Campbell

      Scientist (researcherid B-7232-2008)

      In reply to Patrick Stokes

      Like Schrodinger's cat, perhaps none of your examples were conclusively dead or alive until the observation was made.

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  7. Sue Ieraci

    Public hospital clinician

    Oh - and a throwaway line:

    In France, Intensive Care medicine is known as "Reanimation". Fits well with the ''waking the dead'' concept.

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  8. Whyn Carnie

    Retired Engineer

    I was around when a heroic army seargeant allowed himself to be curarisized and kept alive (barely) using the then accepted manual resuscitation techniques. All carried out ar Royal melbourne Hospital and filmed on 8mm celluloid. He also allowed a second series of trials using "mouth-to-mouth" that were compared to mechanical ventillation methods. This represented a huge leap forward in first aid for the apparently drowned and other respiratory failure victims. The sequel to theses trials was CPR…

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