When is dead…. really dead?

He’d last been seen 6 hours ago. After saying he was going to head back to bed for a sleep in, it wasn’t until mid afternoon that anybody checked up on him. We arrived to find a man in his 80’s lying in his bed.  He wasn’t breathing, and he had no pulse. My partner looked at me and giving me the nod said “it’s your call.” For the first time, it was up to me to decide whether or not we try to save someone’s life.

Thankfully, it was an easy one. The patient had post-mortem lividity,  a temp of 33 degrees even though he covered in blankets, an unknown down time (but almost definitely greater than 20 minutes) and of course, no signs of life (GCS 3, no pulse/ heart sounds, pupils fixed, asystole on the monitor, etc.). With existing terminal cancer and an immense cardiac history even if we did get this patient back, he wouldn’t be leaving hospital alive. Despite this, it still haunted me a little as we set about undertaking the necessary procedures for a deceased patient.

What if I’d got it wrong?

Other calls weren’t so easy. Still an unknown down time (potential greater than 60 minutes), and still pulseless with lividity…. but the patient was found in the shower…. so he was still warm….. and the ECG showed him throwing off the odd ventricular contraction with a rate of around 4 a minute. Dude was in his 90’s and had massive cardiac scars on his chest. Again, unlikely we’d get him back. But he wasn’t completely dead.

Or was he?

See when is dead…… actually dead?

Is it when the heart finally stops….. not just beating…. but also finishes firing electrical signals? (The heart can be firing off electrical signals for a long time after the owner is brain dead and pulseless).

Is it when the brain stops receiving perfusion…. so irreversible damage occurs and eventually ceases to function entirely? Just 10 minutes without oxygen and that brain is essentially cooked.

Is it when that person no longer has a life worth living, where they’re so debilitated and medicated that they’re just a shell? (Hell, what does living mean?).

This is without even beginning to look at souls, terminal illnesses, or assisted suicide.

See this is the debate that is being thrown around now: as people live longer (and not necessarily with a good quality of life) should we keep resuscitating everyone? A lot of them don’t want to be revived. A bunch that do will only die in hospital within a few hours/days/weeks anyway, and for the few who do come out of hospital, well a huge percentage of them will have such severe deficits physically or neurologically they and their families may well wish that you had have let them die where they lay thank you very much.

Furthermore, when things are even just a little fuzzy, the default position (at least by protocol) is to commence a fully involved resuscitation. Regardless of if it’s a patient with late stage dementia and terminal cancer who just spent their 96th birthday alone in the nursing home where no one visits them.

Because unless the local hospitals and GPs are on their game…. this is exactly what happens.

And it’s traumatising for everyone.

For the patients who aren’t allowed to slip away quietly into death. For the family members who must watch and be unsure of if they should have or shouldn’t have and then perhaps even feel guilty about the outcome. For the healthcare workers who don’t want to disobey protocol but only last week had that patient verbally request to be allowed to die.

The list goes on, and this is before we even consider how many resources we utilise keeping dying patients who want to be dead, alive.

My point here is that dealing with death can be easy, hard, complicated, simple, whatever. But what matters most is that you as a healthcare worker can know in your own heart what being dead really is. That you can stand by that when you have to make decisions and that you have people to lean on and into when those decisions chase you later on. That you have no guilt for allowing someone to die when they need to, or not allowing them to die when the circumstance went beyond your control.

Because this job can suck sometimes.

And the last person you need to make enemies with is yourself.

Death has been occurring infallibly since the dawn of existence. Cheating it for a few short minutes, weeks, months, years….. well that only makes as much difference as what the patient is going to use it for.

And that is out of your hands.

 

 

 

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