The Line Between Life and Death

New York Times
May 10, 2005

The Line Between Life and Death

By GARY KALKUT AND NANCY NEVELOFF DUBLER

LATE last month, New York's major newspapers
reported that a 13-year-old boy had "died" after he
was taken off "life support." That assertion
reflected a fundamental misunderstanding of death as
defined by the laws of all 50 states. In fact, the
boy had died more than a week earlier - from a
severe brain infection - after transfer to the
hospital where we work. In the interim, advanced
medical technology supported his organs, not his
life.

Death shouldn't be this hard to understand, yet
it often is. According to the 1987 New York State
Public Health Regulation, death occurs when
either the heart or the brain irreversibly ceases to
function. Before medical technology provided
breathing machines, there was no meaningful
distinction between brain and cardiac death. Once the brain
stopped sending signals to the lungs to breathe -
on account of a stroke or head injury, for
example - the heart would stop within minutes. Now that
machines can deliver oxygen to the lungs,
however, the heart can continue to beat for days without
any signal from the brain.

For centuries we understood death, whatever its
cause, as the cessation of heart and lung
function. A person was dead when the pulse faded, the
heartbeat became inaudible and the chest ceased to
rise. Brain death is harder to discern. A brain
dead person whose heart and lungs are sustained by
machines looks as if he's in a coma. For a family
who has lost a loved one, often from an acute
illness or terrible accident, it is unspeakably
difficult to accept that this warm body with a
heartbeat is lifeless. And yet, to imply that a
brain-dead person is still alive only prolongs the loved
ones' anguish. Such misunderstanding gives false
hope and preys on the survivors' feelings of
guilt.

The way this subject has been addressed in recent
news stories could leave a person bewildered, but
the facts are actually straightforward. Brain
death should not be confused with a persistent
vegetative state or a coma. In brain death, the entire
brain irreversibly ceases to function. Everything
shuts down: the cerebral cortex, which controls
higher functions, as well as the brainstem, which
regulates automatic actions like heartbeat and
breathing. In a persistent vegetative state, the
cerebral cortex has been destroyed, leaving the
person incapable of thought or memory, but the
brainstem remains intact and functional. A person in a
persistent vegetative state can live for years
without a mechanical ventilator or other
technological support. That was Terry Schiavo's situation.
There was no question that she was alive. Her
heart and lungs received signals from her brainstem
- they didn't need machines to sustain their
activity.

Then there's coma, which is just a general term
for lack of responsiveness. A person can fall into
a coma for any number of reasons. The coma can be
temporary, as it is during general anesthesia, or
permanent, as sometimes happens following injury.
Only detailed neurological testing can determine
the extent of brain injury or its prognosis.

The 13-year-old boy who died this April was not
in a coma or a persistent vegetative state. He
died of a brain infection a week before he was taken
off mechanical support. The obligation of a
hospital after the death of a patient is to turn its
expertise toward supporting the family. After this
child passed away, his family's personal tragedy
was laid bare in court and in the news media, as
a result of a dispute between the family's lawyer
and our hospital over the continued use of a
respirator.

With a better understanding of death, this could
have been avoided. The dead are not kept alive on
life support, and they don't die again when
machines are stopped. We need to make this clear if we
wish to honor the dead, protect vulnerable
families and use the astonishing medical technology at
our disposal to heal those whom we can actually
help.

Gary Kalkut is vice president and medical
director of the Montefiore Medical Center. Nancy
Neveloff Dubler is director of its division of
bioethics.