two people walking down a tunnel.

The Definition of Death in the 21st Century: Who Decides When Life Ends

The definition of what constitutes death has become the subject of an increasingly heated debate in the United States and elsewhere around the world in recent years. In addition, an associated debate centers on who should have authority to make the final determination that a person is dead.

The Standard Definition of Death

Over the course of multiple decades, the standard definition of death has seemed quite straight forward. The long-accepted definition of death has been “the irreversible cessation of all brain functions, including in the brainstem.” This constitutes death even in a situation in which lung and heart activity can be maintained mechanically.

Accompanying this definition of death, the authority of who can declare end of life also seemed to be clearly established. Physicians were granted authority to declare a person to be brain dead, and hence legally deceased. (There are some exceptions to physicians having absolute authority to declare death. For example, in the state of California, paramedics are granted the authority by law to declare death at the scene of an accident or other type of death in certain circumstances.)

Tests to Establish Brain Death

More than a few people in the community at large imagine that the test employed by physicians to ascertain brain death are some sort of complex undertakings. In fact, the tests that have been used for a very significant period of time to establish brain death are remarkably simple. The tests for brain death involve three separate assessments. 

Assessment of Consciousness

Assessment of consciousness include a trio of tests that commonly are utilized to ascertain if a patient is conscious on any level. These are:

  • Pressure on fingernail beds
  • Pinching or rubbing above the eyes, joints of the jaw, jugular, upper arm, upper leg
  • Cotton swab designed to irritate the inside of the nose

Assessment of Brain Stem Reflexes

As mentioned previously, the definition of brain death includes lack of functioning in the brain stem. This assessment incluldes three tests designed to confirm lack of brain stem functionality:

  • Shine flashlight in the eyes, which should cause pupils to get smaller
  • Move head back and forth, which should result in the eyes looking back in the direction moved from
  • Irritate the back of the throat, which should cause cough or gag reflex

Assessment of Ability to Breathe Spontaneously

The final area of testing is to ascertain whether a person can breathe spontaneously. This is accomplished by temporarily removing a patient from a ventilator.

Standards for Establishing Brain Death

Although the tests and assessments specifically delineated here are some of the principle ones used in making a determination of brain death, in 2010 the American Academy of Neurology established the most recent comprehensive set of guidelines to aid physicians in declaring brain death. As noted, some of the principle ones have been set forth here. With that noted, the guidelines contain 25 assessments all together.

Even with these standards, standards for establishing brain death is left up to the medical community itself. What this means is that the manner in which the tests for brain death, and associate assessments, do vary from one hospital to another.

For example, differences exist between hospitals in regard to how many physicians are needed to administer the test, how long to wait between administering tests and removing life support, and even the type of physician deemed qualified to undertake the testing and make a brain death determination.

A change is being adopted fairly widely when it comes to undertaking the tests for brain death. This change is ensuring that family members are present when the tests and assessments for ascertaining brain death are made.

Erosion of the Brain Death Standard

In recent years, some physicians have recognized what they are calling an erosion of the brain death standard. In other words, some challenges are being mounted to using brain death as the absolute determination of end of life.

One of the reasons this is occurring is because family members have become more active in care-related determinations for loved ones. This includes when it comes to ascertaining whether a person truly meets the definition of death.

On a related note, there have been cases in which a patient was declared brain dead and the family intervened and refused to disconnect life support. After time passed, there is an argument being made in some of these cases that ultimately there developed evidence of brain activity.

Despite these isolated cases, brain death remains the accepted means by which end of live is ascertained. With that said, challenges to this being the standard are likely to continue in the immediate future.

Photo Courtesy of quillshadow.