We often see in movies and TV dramas that on one side of the hospital bed, the amplitude of the electrocardiogram fluctuation suddenly decreases until a straight line is drawn. The appearance of this scene in film and television dramas often means that the heart has stopped and the patient has passed away. In fact, what a responsible and experienced doctor might do at this time is to quickly observe EEG . They will use an electroencephalogram to determine whether life has truly ended.
The classic news TV series "The Newsroom" (The Newsroom) has an impressive line: "Doctors can declare her dead, but the news cannot." Yes, in the professional system of social division of labor, only doctors have the specialized knowledge to judge vital signs. In the past, in traditional societies, almost every adult could more or less determine whether a person was alive or dead based on characteristics such as stopping breathing and cooling down. Therefore, there was no knowledge threshold for this matter. However, with the development of biomedical technology, a series of important reflections on life diagnosis have arisen, because we do not know which non-life characteristics ultimately mean death. In fact, even medicine has gone through many demonstrations and failures of new technologies in the twentieth century. Human beings' standards and technologies for distinguishing life from non-life and identifying the end of life have been evolving. In a sense, this is an unfinished business. The only thing that’s certain is that people won’t make the same judgment calls they used to, at least in hospitals.
The following is excerpted from Pakistani clinician Haider Warraich's "Modern Death: How Medical Treatment Can Change the End of Life" with the permission of the publisher. The content is that he received a patient with "cardiac arrest", then started thinking about "modern death", and finally returned to the original patient. The excerpt is abridged and the title is given by the excerpter. See original book for notes.
Original author｜[Pakistan] Hyder Valachi
"Modern Death: How Medical Treatment Changes the End of Life", [Pakistan] Hyder Valachi, translated by Chen Liangyu, China Friendship Publishing Company ·Houlang, November 2022.
I received a patient who suffered a "cardiac arrest"
Contemporary medicine mostly relies on image diagnosis. Radiologists look at CT scans or X-rays like tea leaves and can predict the truth.
Pathologists stare at the microscope and can distinguish which cells are normal cells in the "cell party" and which cells are drunk and even start to act drunkenly. In the medical world, the patient is like a code book waiting for the doctor to decipher. Doctors gather information from all over the place—labs, imaging, physical exam results, and most importantly—the patient’s story (what we call the “history”), and then deduce the best diagnosis. However, it is usually not a good thing to start treatment based on only one diagnosis, because doctors often limit themselves to their own intuition, turning a blind eye to data that does not conform to their own predictions, and are unwilling to consider other possible results. But when the emergency room sends information about such a patient to my pager—a 32-year-old man in cardiac arrest—it’s hard not to make assumptions. During the long, dark winter, young men are hospitalized for cardiac arrest, often for only one reason.
Addicts would give their deadly drugs some aliases, such as "brown sugar," "hard candy," and "candy rolls," but on that morning, perhaps "Immediate Death" was the most appropriate name. It's not easy to judge a person's height if they're lying in a hospital bed, but this patient was clearly tall and thin. Appearance is perhaps the most overlooked aspect of the physical examination. He is tall, but not tall enough to suffer from Marfan syndrome. Marfan syndrome patients are often accompanied by congenital cardiovascular malformations. Progressive dilation of the aorta is common, which can easily lead to vascular rupture.
I often start by touching the patient's feet as a way to build a relationship while learning valuable information about the organ furthest away from it: the heart. Edema in the feet is a sign of heart failure , and cold feet indicate an insufficient ability of the heart to supply blood to the tissues. His feet were cold, but that had more to do with us intentionally putting him in a device that kept his body temperature lower.I didn't see any needle holes in his arms and legs, so I tentatively believed he wasn't overdosing on drugs. His hair was neatly trimmed, his beard freshly shaved, and his tattoos were from a long time ago.
Stills from " Doctor Death " (You Don't Know Jack, 2010).
Beside the hospital bed, I met the patient’s girlfriend. Her blond hair was very messy, and most of the shiny lettering on her T-shirt had been rubbed off due to her rush. When I saw her, I seemed to understand most of the story. Their relationship was unstable for a time, and it went from bad to worse after they had children. He lost his job, became addicted to drugs, and his life was in despair. She had no choice but to kick her boyfriend out of the house. But perhaps it was under this stimulation that the boyfriend started working again and stayed away from drugs. After a year of detoxification, her boyfriend's life was back on track and she accepted him again. "He hasn't relapsed in over a year. He has a good job and our relationship is stable." Her voice trailed off and was almost inaudible.
She had just experienced the most painful morning of her life. When she woke up, she found her prodigal boyfriend unconscious and not breathing in the bathroom, with tools for injecting heroin scattered around him. She called 911 and asked the hospital to send an ambulance immediately. She also gave him artificial respiration and pressed his chest hard, but it didn't work. When the emergency medical team arrived, they found that his heart was in ventricular fibrillation . It took several electric shocks to return to normal rhythm. The doctor put an oxygen mask on his face and rushed to the nearest hospital.
He was intubated in the emergency room, hooked up to a ventilator, and then put on a device that drastically lowered his body temperature. Studies have shown that cardiac arrest patients' brains recover better when their body temperature drops to extremely low levels. Emergency doctors wrapped the patient's chest and limbs in pads filled with ice water to regulate body temperature. The normal core body temperature of the human body is about 37°C, and being below 33°C may be more beneficial for some cardiac arrest patients. Reducing the metabolism required by the body can buy time for the body to restore some functions. After his body temperature dropped, he was transferred to the ICU ward, which is where I saw him.
His girlfriend asked what to do next, and I replied that I didn’t know, which was indeed the case.
The distinction between life and non-life: many attempts
Life has always been regarded as a privilege, and human beings have been considered the highest form of life.
Although we have such a close connection with life, it is still impossible to determine the criteria for distinguishing life and non-life to a certain extent. Life is so complex, and may have different meanings to biologists, theologians, astrobiologists, mathematicians, physicists, ethicists, judges, philosophers, doctors, and even everyone, so it is surprising that there is no generally accepted definition of life. But what is certain is that we are still trying to define it.
Ways to distinguish between living and non-living things were figured out long ago, before people could even understand the basic concepts of biology . Before science, our view of life was largely reflected in our children.
The youngest children believe that everything around them has life and consciousness. As they grow older, they will go through various stages of animism, a term coined by Jean Piaget, a pioneer in the study of child behavior. In the early stages of the "animism" stage, children believe that a glass jar can be alive, but that it is no longer alive when the jar is broken (or "killed," as they may view breaking as a form of destruction). After this stage, the child will associate life with dynamic movement. For example, a bicycle is alive when it is moving, but not when it is stationary. Likewise, children believe that the sun, wind, clouds, and fire are alive, capable of feeling pain, and have self-awareness. Furthermore, when children understand that animals are alive, about 1/3 of children aged 8 to 11 will think that plants are not alive, even though they know that plants can grow.This association is not limited to childhood. Emotional attachment allows us to still think of inanimate things as alive when we grow up.
The ancient building blocks of life can be seen in the curriculum now taught to fourth-grade students in the United States: Living things have the ability to grow and change, respond to their environment, require some form of energy, and can reproduce. In the TV series "Star Trek: The Next Generation," a character once explained this definition to a robot named Data, but Data countered that fire also consumes, moves, metabolizes, and even grows, so fire meets all the characteristics of life. It is not difficult to understand why fire was widely worshiped by people in ancient times.
Stills from "Star Trek: The Next Generation" (Star Trek: The Next Generation, 1987).
Reproduction is another characteristic often associated with living organisms. Nobel Prize winner German scientist Hermann Muller said at a conference in 1959: "I think the most basic characteristic that distinguishes life from non-life is the ability to reproduce itself, which can also be used to define life." However, some crystals molecules can also grow and pass on some of their characteristics, but they are not considered living organisms. Even apart from these exceptions, the recognition of reproduction as a fundamental feature of life still raises other controversies.
Assume that I am trapped on a desert island without a suitable partner and unable to pass on my genes to the next generation. Am I "inanimate"?
None of the definitions of life are satisfactory
As science continues to develop, the focus of the definition of life has shifted to metabolism. Metabolism is caused by a series of chemical reactions that occur within cells, allowing them to survive and regenerate. In the mid-20th century, scientists regarded metabolism as the most critical feature of life. John Bernal, one of the most famous and controversial scientists in Britain at the time, believed that life "is the embodiment of a self-sustaining chemical process within a certain amount." The definition of life is perhaps most important to astrobiologists as they work to explore the edges of the universe, trying to find the tiniest evidence of life.
In 1976, the "Viking 1" and "Viking 2" probes launched by the National Aeronautics and Space Administration (NASA) landed on Mars and collected surface soil for three experiments. These experiments reflected the metabolism center theory at the time. The first test tests whether water can be metabolized by life forms that may be hiding in the soil to form carbon dioxide . The other two experiments try to determine whether soil and water can produce a reaction similar to plant photosynthesis (converting water to release oxygen ). Surprisingly, all three tests came back positive, but further testing showed there was absolutely no evidence of organic life on Mars. I think these false positive results about metabolism reveal a fatal myth about using metabolism to define life—our understanding of metabolism is limited to what life forms on Earth exhibit. This observation puts an end to the hypothesis that carbon is at the center of organic life, and that perhaps our view of the universe is too narrow.
Stills from "Mind" (Patch Adams, 1998).
Although Charles Darwin never defined life, most scientists agree that Darwinian evolution may be its most essential characteristic. Errors, in the form of mutations, are at the heart of replication during evolution. Errors confer varying degrees of fitness on offspring—some adapt better to their environment, others not. When enough errors accumulate, they lead to a continuous evolution of life until it becomes super-Darwinian, when genetic diseases can be cured or eradicated and genetic defects that determine the health of a given organism can be overcome. According to this principle, the most accurate and comprehensive description of life we have should be a definition of life from NASA: "A self-sustaining chemical system with the capacity for Darwinian evolution.""
But even this definition has its loopholes.
Take the virus as an example. Viruses are not self-sufficient. They constantly look for hosts that can be invaded and use their own mechanisms to create more viruses. As big as a blue whale, There is no single definition that encompasses all living things, as small as viruses, so some people conclude that life exists only in people's consciousness and that there is no such thing as life. Life is just a concept used to conveniently represent the complex machines that exist in nature and are, in fact, what defines life. NASA scientist Gerald Joyce believes that life is more of a popular idea than a scientific concept, which makes it impossible to define in a scientifically rigorous way
"Doctor Death" ( You Don't Know). Jack, 2010) stills.
No definition of life is satisfactory, perhaps because our pace of understanding life has never stopped. We stopped looking at the general characteristics of living things, such as eating, breathing, moving, and excreting, and started looking at processes common to all living things. We find that the range of life is so wide, from complex multi-celled organisms such as animals and plants, to the simplest organisms, such as those between living and non-living things. Viruses. This diversity represents the journey of the evolution of life, from simple chemical reactions to independent machines that maintain their own self-sufficiency. Although various mistakes may occur, that is the premise of evolution. Defining all forms with one equation is a hobby of theoretical physicists and mathematicians, but it has never worked for biologists.
However, our definition is as limited as our specimen. Now, we still don’t really know ourselves , perhaps this means that it is possible for us to evolve and develop towards more advanced forms. It's one thing to understand how cells live or die, but it's another to fully understand life. Perhaps one day, like children, we will understand life as the inherent quality of everything around us.
Electrocardiogram, Electroencephalogram: Identifying the Progress and Limitations of Life
However, when I was working, life was much more than a simple concept. Focused on the waiting room Not even for families waiting anxiously to find out from doctors whether their loved one will survive. When the patient's girlfriend asked me if he would survive, she was definitely not asking me if his cells were still alive, or if his cells were still hydrolyzing or replicating. But her problem is anything but simple. There is no more controversial question than this: when is a person alive, and by extension, when is he or she irrevocably dead?
《House Doctor》（House M.D., 2005) Season 2 stills.
Technological advances in the 20th century, such as the application of ventilators and cardiopulmonary resuscitation, challenged the definition of death at that time. These technologies make obsolete death signals obsolete. It has been reported that some patients' electrocardiograms, which had become straight, spontaneously resumed fluctuations, albeit only briefly.
The heart was once thought to be the console of all organs, holding the power of life and death, but later, more and more scientists began to look at the organs between our ears and behind our eyes, looking for signs of life. In the 19th century, the technology of stethoscope and electrocardiogram (ECG) began to develop. As long as a few wires were placed on the surface of the body, a door to the heart could be opened. special window, but no such tools for examining the brain existed at the time. For a long time, it was believed that the brain was simply an organ used to cool the body down from the heat generated by the heart. But now, our understanding of brain function has changed dramatically.
In the first half of the 20th century, the development of electroencephalography (EEG) filled this gap. Electroencephalography can capture changes in brain electrical activity through a probe fixed on the human head, and then display it in a wave pattern. Similar to an electrocardiogram, an electroencephalogram converts the complex activity of an organ into valuable information. EEG has uncovered key mechanisms of sleep and epilepsy and, more importantly, is the first objective test that can tell whether a person's brain is dormant or dead.
EEG gives clinicians another tool that can give them an extra level of confidence when declaring death, especially in patients who are mechanically ventilated, where declaring death can be difficult because they don't experience the classic "heartbeat jerk" when they take their last breath. However, neuroscientists commented in "Journal of the American Medical Association " that the emergence of technology can only allow people to "maintain the appearance of life in the face of death." The electrocardiogram draws a straight line, indicating that the heart has stopped. This is a TV scene that often appears, but in reality, doctors have begun to observe the electroencephalogram, check whether the waveform changes from up and down fluctuations to static, and recommend using electroencephalogram to determine death.
The groundbreaking contribution of two French doctors, which connects the patterns displayed by electroencephalograms to the changes that occur in brain tissue. In 1959, Pierre Mollaret and Maurice Goulon published an article entitled "Le coma dépassé" ("Irreversible Coma"), describing the cases of 23 patients in deep coma. Their electroencephalograms showed a straight line, and the autopsy results showed that the brains had extensive necrosis. These findings form a template for modern death. But at that time, even the author who discovered "irreversible coma" could not convince himself to withdraw life-support equipment and give up treating patients who seemed to still be alive.
The use of electroencephalography to diagnose death made people excited, but this excitement was quickly extinguished. Some patients regained all brain functions after a brief quiescence in brain waves . EEGs can be interfered with by things like trauma, hypothermia, or drugs (such as barbiturates) and fail to translate into useful information. However, for patients who have been dependent on ventilators for a long time, it is still very difficult to provide prognostic information through EEG to help doctors and family members make decisions.
Screen from the documentary "Chinese Doctor" (2019).
To fill this gap, some groups have begun to set their own standards for using EEG to determine death. Neurologists at Massachusetts General Hospital put forward their criteria. In addition to EEG results, they also need complete loss of reflexes, respiratory arrest for 60 minutes, and laboratory results to rule out any reversible coma. But parts of the standard are unconvincing. If a person is alive before the test, allowing his or her breathing to stop for 60 minutes is no different than killing him outright. Therefore, Richard Schwab, who formulated this standard, gave a 24-hour continuous observation time in an interview with Time magazine in 1966. This shows that even he himself cannot come up with a definite standard for how long it takes to monitor a patient before declaring him dead. Around the same time, other tests to assess brain damage also emerged. In 1956, an experiment used X-rays to detect blood flow in the brain. One paper described the cases of six patients on ventilators who were unable to breathe on their own and did not exhibit any brain reflexes. The article appeared in an obscure Scandinavian journal and was only discovered in recent years.
Transferring the key to life from the heart and lungs to the brain
The scientific and technological progress in the first half of the 20th century has undoubtedly transferred the key to life from the heart and lungs to the brain. However, death is still defined as the moment when the heart stops. Nothing changed in this situation even after the advent of CPR, which showed that cardiac arrest was not the end, but rather something that could be intervened and reversed. Even Pierre Molare, the man who influenced the definition of death through his electroencephalographic studies, would not “regard any suggested standard as absolute.” This was despite the fact that some patients' brains were actually mush and could sometimes be seen "running out like gruel when the skull was drilled." In the 1920s, Hans Berger recorded the first human EEG. But decades have passed, and the significance of EEG to human life and death is still limited to medical journals. How to correctly use it to diagnose death has not yet been determined.
Henry Beecher, who was not a neuroscientist, defined death neurologically.
Although Beecher wrote General Principles of Human Experimentation as early as 1959, it was not until the mid-1960s that he brought the horrors of human experimentation into the spotlight of the public and medical profession. At a conference in rural Michigan, he presented 18 cases of serious ethical violations to assembled reporters. He claimed that this was common practice at top academic centers, which caused an uproar in public opinion and made him criticized by his fellow doctors. Beecher wrote a review article about these cases, which was rejected when submitted to the Journal of the American Medical Association, but was later published in the New England Journal of Medicine in 1966. "Among articles on human experiments, its influence cannot be surpassed by other articles." It elaborated on 22 cases of inappropriate treatment without the consent of the patients. These treatments were not only unbelievable, but even aggravated the condition.
Irreversible coma patients are also a topic of concern to Beecher. In an article discussing the ethical issues surrounding the "hopeless coma patient," he wrote that in a world where the heart and lungs have been replaced by the brain, it is necessary to define life, as well as determine what constitutes death and when death is considered to have occurred. Beecher defined human life as “the ability to communicate with others,” but emphasized human independence from coercion by “organ predators.” He suggested that if the impasse over the definition of death is to be resolved, doctors, lawyers, theologians and philosophers must come together. In 1968, not long after this article was published, Henry Beecher realized this wish. Not only that, Beecher and his team also compiled a modern definition of death, which is still used today.
Stills from the first season of "Grey's Anatomy" (Grey's Anatomy, 2005).
In 1967, after receiving a letter from Beecher, the dean of Harvard Medical School announced the establishment of a committee to solve a problem about death: when does a person actually die even though he still has a heartbeat or can still breathe with the help of a ventilator? Beecher was appointed chairman of the committee and convened a veritable "Ocean's Eleven", including three neurologists, a neurosurgeon, a transplant surgeon, a law professor, a medical historian, and others. Perhaps the committee understood that their findings would impact not just medicine but how ordinary people view death.
On August 5, 1968, the "Journal of the American Medical Association" published the committee's report. Even the authors themselves did not expect that this report would have an unprecedented impact on the social, legal, medical, and even philosophical aspects of death. The important thing is that, for better or worse, it made " brain dead " an everyday expression. However, before understanding brain death, it is important to understand how the brain itself works and how it contributes to our construction of life and consciousness. The brain and spinal cord together constitute the central nervous system , and the brain is mainly divided into , the brainstem, and the "advanced brain". The "advanced brain" is composed of two familiar intertwined cerebral hemispheres, occupying our cranial cavity. The brainstem is a series of structures that connect the brain to the spinal cord, extending from the cerebral hemispheres. It has some very important functions - it collects all the nerve tracts that connect the brain to the spinal cord. These nerve bundles are responsible for regulating movement and sensation of all structures below the face, such as the limbs and respiratory muscles. The brain stem also contains cranial nerves, which are connected to the brain and are responsible for regulating taste, smell, vision, facial muscle movement and sensation. The brainstem is also involved in formulating what we usually think of as the most distinctive quality of life—consciousness.
There is another way to die: the heart stops beating
We speak all kinds of medical jargon and professional terms every day, but no one behind the scenes is sure what is happening and how to process these background data. This unknown also troubles family members. The relatives on the hospital bed seemed alive, but there was no familiar trait in them.Every time families talk to us, they expect some affirmative answer. We fully understand that they need some clear information rather than vague assessments.
The unknown result is undoubtedly another blow to the family. At this point, we gathered the team together, as well as the organ bank nurse, who was the most experienced with interviews. “Follow the rules,” she insists, cueing me not to blurt out whatever comes to mind. As a medical team, we met with the family again and told them that the final outcome was uncertain and that the patient was at the critical point of brain death and could not recover neurological function. Even so, he is not brain dead yet...
Stills from "The Good Doctor" (The Good Doctor, 2011).
The father, who is also the patient's medical attorney, did not hesitate for long. These days, he has been waiting for a definite answer to his condition, and seems to have figured out what kind of decision his child would make for him if he could speak. "He didn't want to live like this," my father told us. The patient's girlfriend hugged him and buried her head in his clothes. The young man who brought them together would soon die.
What I saw on the patient’s father’s face was not pain, but comfort. Finally, his children were free from torture. While he doesn't know exactly what will happen, he knows exactly what won't: ventilators and pagers, EEG probes, and all sorts of tests. In every sense of the word, things were simpler, and this was what he considered death. We turned and left the room, leaving them some space, and began to think about the time for “end-of-life extubation,” the final step in taking a patient off a ventilator. Just as I was taking off my white coat and gloves, the patient's girlfriend suddenly asked me a question, a question we had planned to ask last: "He is always willing to help others, can he donate his organs?"
I was completely unprepared to answer this question. Since he was not yet brain dead, I thought discussing organ transplantation at this point would be a waste of time. Without being able to declare brain death, how can we fulfill the patient’s last wish? The attending doctor's words dispelled my worries: "Yes, there is a way."
Stills from "The Lost Weekend" (1945).
Indeed, there is a way. Lest we forget, there is another way to die: the heart stops beating. Stopping the heart is the surest form of death, even a child can tell with a finger on their wrist. But I still try to be cautious. The biggest revelation that those historical controversies have given us is that even the death of cardiac arrest cannot escape the increasingly stringent end-of-life examinations.
original author/[Pakistan] Haider Valachi
excerpt/Luo Dong
introduction part proofread/Liu Baoqing
