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Defining Death and Giving The Gift of Life

Defining Death and Giving The Gift of Life. Jacques Mistrot M.D. What Is Death?. Catholic Teaching on Death. SIN CAUSES DEATH Death is contrary to God’s original plan Death is the last enemy to be conquered CHRIST TRANSFORMS DEATH Adam’s disobedience – changes blessing to curse

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Defining Death and Giving The Gift of Life

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  1. Defining Death and Giving The Gift of Life Jacques Mistrot M.D.

  2. What Is Death?

  3. Catholic Teaching on Death • SIN CAUSES DEATH • Death is contrary to God’s original plan • Death is the last enemy to be conquered • CHRIST TRANSFORMS DEATH • Adam’s disobedience – changes blessing to curse • Christ’s obedience – transforms curse to blessing • SOUL • Separation of the soul from the body • Body is given incorruptibility when reunited to the soul at resurrection

  4. Catholic Teaching on Death • Firm grip on this Catholic understanding of death is necessary when dealing with many bioethical issues • How one views death greatly influences one’s judgments about end of life issues!

  5. Patient Concerns About Death Will I be declared dead prematurely? Time is of the essence with organ donation! Rooted in concern for self

  6. Patient Concerns About Death Buried Prematurely

  7. Patient Concerns About Death Will I be declared alive after I have physically died and be kept on life support too long? Rooted in concern for family’s misplaced hopes/medical costs

  8. When Does Death Occur?

  9. Definition of Death Philosophical and Theological Separation of the soul from the body

  10. When Does Death Occur? • Death is the instant of separation of soul and body • Science cannot see that instant! • Science must estimate that point by observing certain signs of the irreversible condition we call death

  11. When Does Death Occur? • Death has been defined as a dualistic event Cardio-respiratory death . . OR . . Brain death • However it is instead a unified concept THERE ARE NOT TWO DEATHS!!

  12. Death Definition vs. Determination

  13. When Does Death Occur? “When the spiritual principle which ensures the unity of the individual can no longer exercise its functions in and upon the organism, whose elements, left to themselves, disintegrate.” John Paul II, January 1990

  14. When Does Death Occur? Determinationof the moment of death HELPS SOLVE THE CONFLICT Duty – - to respect the life of one person - to save the life of another when an organ transplant is needed

  15. Determination of DeathBiologic The brain is the physical instrument through which the spiritual principle (soul) exerts its action the integrating material entity Therefore biologic death is brain death

  16. Historical Perspectives Pre-1950”s • Cardio-respiratory criteria defined death 1950’s • first organ transplants successfully done (1955-56) • mechanical ventilators developed allowing life support • Cardio-respiratory criteria for death had to be re-examined

  17. Historical Perspectives 1960’s • rapid development of cardiac-supportive medications • criteria sought to determine when a donor was really dead

  18. Determination of Death • Harvard Criteria 1968 • Death defined as brain death and rigid criteria described • UDDA (Uniform Determination of Death Act – 1981) • Death could be pronounced by either: 1) irreversible cessation of circulatory and respiratory function or 2) irreversible cessation of all functions of the entire brain, including the brain stem

  19. UDDA Dead Donor Rule • Death must be determined by either complete loss of cardio-pulmonary function …. or …. • Complete loss of all brain function • Cerebral • Cerebellar • Brain stem

  20. Lost circulation to the brain • 5 minutes – cortex lost (thinking, sensations, movement) • 10 minutes – brain stem lost (regulation of vital functions – BP, HR, breathing, reflexes) • > 30 minutes – autolysis (all cellular function ceases)

  21. Whole Brain Concept UDDA assessment of entire brain function both cerebral and brain stem

  22. NOT 2 DEATHS!! • Brain death is determined • Life support removed • Not 2 deaths • Mr. Sam Brown died at 6:02PM but was taken off the respirator at 8:45PM … causes confusion

  23. What is the significance of irreversible loss of brain stem function? assures that the individual breathing spontaneously is not declared dead

  24. Brain Death Criteria • No spontaneous movements • No responses to painful stimuli • Coma and cerebral unresponsiveness • Irreversible apnea • Pupils unresponsive to bright light • Brain stem reflexes are absent • **One of following must be verified: • EEG silence for 30 minutes • Cerebral circulation at a standstill • Caveats: Body temperature > 90o F; absence of certain drugs and metabolic abnormalities must be determined • Step 7a should be reconfirmed in 6 hours (adult) or 24 hours (child).

  25. Catholic Church Teaching “With regard to the parameters used today for ascertaining death—whether the ‘encephalic’ signs or the more traditional cardio-respiratory signs—the Church does not make technical decisions.” John Paul II Address to International Congress of Transplants August, 2000

  26. “Here it can be said that the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology. Therefore a health-worker professionally responsible for ascertaining death can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgment which moral teaching describes as moral certainty.“ John Paul II International Congress on Transplants August 29, 2000

  27. Catholic Church Teaching The address of John Paul II to the International Congress on Transplants on August 29, 2000, was a watershed in the clarification of the Church's teaching on the use of brain-based criteria for the determination of death … What must be emphasized … is that no Catholic physician or Catholic recipient of a donor organ should be made to feel that the Church has any ambivalence about the moral legitimacy of brain-based criteria for the determination of death when the criteria are appropriately applied in a clinical setting. Eugene Diamond, M.D. Director of Linacre Institute of the Catholic Medical Association Editor-in-Chief Linacre Quarterly

  28. Why the Concept of Brain Death is Valid as a Definition of Death • Statement by Neurologists and Others and Response to Objections • VATICAN CITY • 2008

  29. WHY THE CONCEPT OF BRAIN DEATH IS VALID AS A DEFINITION OF DEATH Statement by Neurologists and Others A. BATTRO, J.L. BERNAT, M.-G. BOUSSER, N. CABIBBO, CARD. G. COTTIER, R.B. DAROFF, S. DAVIS, L. DEECKE, C.J. ESTOL, W. HACKE, M.G. HENNERICI, J.C. HUBER, CARD. A. LÓPEZ TRUJILLO, CARD. C.M. MARTINI, J. MASDEU, H. MATTLE, J.B. POSNER, L. PUYBASSET, M. RAICHLE, A.H. ROPPER, P.M. ROSSINI, M. SÁNCHEZ SORONDO, H. SCHAMBECK, E. SGRECCIA, P.N. TANDON, R. VICUÑA, E. WIJDICKS, A. ZICHICHI

  30. WHY THE CONCEPT OF BRAIN DEATHIS VALID AS A DEFINITION OF DEATH • Brain Death “is” Death • Not synonym – does not imply – not equal to death • ‘Coma’, the ‘Persistent Vegetative State’, and the ‘Minimally Conscious State’ are not Brain Death • Brain Death is the Death of the Individual • Loss of brain function – other organs kept alive by artificial means • Death is the End of a Process • Injury –swelling – increased pressure – stops blood flow • Consensus on Brain Death • Academies of Neurology USA, France, Germany, Italy, UK, Spain, Belgium, Switzerland, Austria, India, Japan, et al. • Statistics on Brain Death • Mayo Clinic 385 cases (1987-1996) • Flowers & Patel (Southern Medical Journal) 71 cases – 100% accuracy.

  31. The Gift of SelfOrgan Donationfor Transplantation

  32. Catholic Church Supports Transplantation • Living Donors – • Serious need • Functional integrity • Proportionate benefit • Informed consent • Cadaver Donors – • Noble and meritorious act – a great act of charity • Informed consent • Proper determination of death • Dead Donor Rule

  33. Medical Ethics in Transplantation Patient considerations Expectations Costs Efficacy

  34. Patient Considerations • Age • Status (wage earner, family) • Culpability • Acuteness of need • Random selection • Immunologic match Moral theologians state that since the transcendental nature of man must be primary – social status and other considerations should be secondary and selection should be need-based

  35. Expectations • What risks to donors are acceptable? • Degree of pain and emotional trauma with multiple transplants (children) • How much can be expected of relatives - especially siblings - as potential donors? • Efficiency of organ use – i.e. should 3 organs be used for 3 patients or for less?

  36. Costs • Selection based on ability to pay? • Only corneal and kidney transplants covered by most insurance • Some experimental transplants are covered by research grants • Children likely to need multiple serial transplants • Only a dream for uninsured patients • Is a transplant within the sphere of medical care that all have a right to?

  37. Efficacy • Many more organs needed than available • This disparity grows larger each year • Waiting list deaths increase yearly (6000 in 2008) • There is a push to make more organs available! Society must be vigilant in not allowing a change in the criteria for defining death!!

  38. U.S. Waiting List2008 26,823 Single organ transplants (2007)

  39. Types of Donors • Cadaver • solitary organs - heart, liver, pancreas • paired organs - lungs, kidneys • Living • paired organs/part of solitary organ Related Non-related (more common – better immunosuppression)

  40. Cadaver Transplants(most common) Brain death criteria Severe brain injury (youth) Prolonged anoxia Extensive hemorrhage Donor after cardiac death ? Morality Subject to much abuse

  41. Church TeachingCadaver Transplants Must reflect the Culture of Life never reducing the dignity of the human person • Reject euthanasia • Respect the long-standing right to reject extraordinary or excessively burdensome care • Afford an opportunity for the donation of unpaired organs to assist in the preservation of the life of another suffering from a life-threatening disease

  42. Cadaver TransplantsMedical Ethics • No intervention allowed with the intention of shortening the donor’s life • Care of the living patient must never be compromised in favor of a potential organ recipient • No member of transplant team is allowed to play any part in the care of the dying patient

  43. Church TeachingLiving Donors • Serious need on part of recipient that cannot be fulfilled in any other way • Functional integrity of donor as a human person will not be impaired, even though anatomic integrity will suffer • Risk taken by donor as act of charity is proportionate to the good resulting for the recipient • Donor’s consent is free and informed

  44. "Transplants are a great step forward in science's service of man, and not a few people today owe their lives to an organ transplant. Increasingly, the technique of transplants has proven to be a valid means of attaining the primary goal of all medicine—the service of human life. … There is a need to instill in people's hearts, especially in the hearts of the young, a genuine and deep appreciation of the need for brotherly love, a love that can find expression in the decision to become an organ donor." John Paul II August 2000 International Congress on Transplants

  45. Thank Youwww.catholic-bioethics-nc.org

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