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Ethical Considerations in the Determination of Death

Thomas A. Nakagawa, MD, FAAP, FCCM

Determination of death has been a subject of ongoing discussion among scholars and physicians for centuries. Some have expressed belief that the difference between the living and dead was defined by heartbeat. Others believed that breathing was central to life, because without breathing, one could not exist and organs would soon die. Still others reasoned that the brain was the primary organ responsible for life and not the heart and lungs, since the brain controlled all bodily functions. Continued understanding and increasing knowledge resulted in more refined definitions describing death as a continuum of cell death ultimately leading to the disintegration of the organism when function ceased. Others viewed death as an event when loss of integrative function of the entire body and the soul—the loss of the whole being, occurred. Central to this issue is whether loss of circulation and respiration defined death or whether they are mere indicators of death.

As science and technology advanced, the ability to restore and maintain breathing and circulation complicated the determination of death. Use of mechanical ventilation allowed a machine to breathe for a patient, and resuscitation procedures including electrical shock and primitive compression techniques allowed circulation to be restored and maintained. Development of inhalational anesthetic agents allowed patients to exist in a controlled, reversible state of unconsciousness that further confused issues surrounding life and death. Some physicians and scientists believed that the only way to determine the living from the dead was to allow rigor mortis or putrefaction of the body to occur. Unfortunately, this practice was limited because exposing others to infected and decaying bodies would result in more disease and mortality. Continued confusion about when a person was truly dead led to public concerns and anxiety that live people would be buried prematurely.

The importance of precisely determining death became very apparent in 1967, when the first heart transplant occurred. This transplant was markedly different from the recovery of cadaveric kidney transplants from non-heart-beating donors that occurred in the 1950s. This transplant occurred from a heart-beating donor who had been declared brain dead. Continued advancement of modern technology with mechanical circulation techniques, such as extracorporeal membrane oxygenation (ECMO), capable of supporting circulatory and respiratory function has required the medical community to review and further understand when death occurs.

Determination of Death

Progress in modern transplant medicine has forced the medical community to critically review issues related to death and dying. Patients previously determined dead based on loss of circulation, respiration, and consciousness could now be supported using advanced technology to sustain respiration and circulation, raising an important question: When is a person dead? Although the general public tends to believe that death occurs when heartbeat ceases, evolving medical technologies and further understanding of death required those in the medical field to better define and understand issues related to death and dying.

Currently accepted guidelines for the determination of death are outlined in the Uniform Determination of Death Act (UDDA). The UDDA was the result of the President’s Commission study on brain death published in 1981.¹ The President’s Commission report followed the Harvard Ad Hoc Committee on Irreversible Coma, which defined irreversible coma as a new criterion for death.² The UDDA was designed to provide a consistent definition of death. It serves as a model for individual state laws governing the determination of death since no national law to determine death exists. This act has been revised and is accepted by most states. The UDDA states that 2 “definitions” may be used to determine death: the traditional circulatory–respiratory criteria, and brain death criteria. Specifically, the UDDA defines death as the loss of circulatory and respiratory function or loss of function of the entire brain, including the brainstem.³ However, the UDDA did not specifically define how loss of circulatory, respiratory, or neurological function should be determined, other than stating, “A determination of death must be made in accordance with accepted medical standards.” Additionally, the terms function and irreversibility were not clearly defined.

Important in the determination of death is clarifying when the event of death actually occurs. This issue is paramount to the transplantation community and is the basis for the dead-donor rule. The dead-donor rule refers to 2 widely accepted ethical principles that govern the practices of organ procurement for transplantation: (1) vital organs should be taken only from dead patients, and (2) living patients should not be killed for or by organ procurement.⁴ Given these principles, the precise moment when death occurs remains a topic of important discussion since organ recovery must not violate the dead donor rule. In situations when donation is being considered, determination of death must occur in a timely manner. Determining the precise timing of death is important because the duration of ischemia to organs prior to recovery is closely linked to the viability and quality of the transplanted organs. In addition to allowing the process of organ preservation and recovery to begin, determining death in a timely manner allows the family to begin the grieving process as they prepare for the loss of a loved one. If donation is not planned, medical therapies can be discontinued, allowing redistribution of scarce ICU resources to other critically ill and injured patients.

The lack of specific tests or standards to determine death has led to development of guidelines for the determination of death. Guidelines from national organizations are available to assist healthcare providers in determining brain death.^5-7 Circulatory determination of death has also gained much attention in past years as organizations have attempted to define when death occurs so that organ recovery can proceed. These guidelines were designed specifically to assist with determination of death for patients who do not meet brain death criteria but may be donor candidates for organ recovery based on death by circulatory criteria.^8-11 The brain death and circulatory determination of death guidelines provide minimal standards that must be accomplished to determine death when organ donation is planned. In situations where organ donation is not a consideration, death is declared when there is loss of circulatory and respiratory function. Unfortunately, no specific minimum standards have been established to assist with determination of death in this patient population. Healthcare providers rely solely on loss of heartbeat (or absent pulse) and respiration to make a determination of death in this patient population.

When Does Death Occur?

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