“Life is pleasant. Death is peaceful. It’s the transition that’s troublesome.” – Isaac Asimov -
Meet your opponent: “Death”
In the daily race between Life and Death, the first responder is the designated competitor for Life. It’s a two horse race and there can be just one winner. The only problem is – we’re not always sure where the finish line is. Physiological death is now seen as a process, more than an event. It is a process that begins when the heart stops beating, the lungs stop working and the brain ceases functioning – a medical condition termed cardiac arrest. During a cardiac arrest, all three criteria of death are present. Conditions once considered indicative of death are now reversible. Where in the process a dividing line is drawn between life and death depends on factors beyond the presence or absence of vital signs. In general, clinical death is neither necessary nor sufficient for a determination of legal death. A patient with working heart and lungs determined to be brain dead can be pronounced legally dead without clinical death occurring. As scientific knowledge and medicine advance, a precise medical definition of death becomes more problematic.
Death is the cessation of all biological functions that sustain a living organism. Phenomena which commonly bring about death include biological aging, predation, malnutrition, disease, suicide, homicide and accidents or trauma resulting in terminal injury. Bodies of living organisms begin to decompose shortly after death.
In society, the nature of death and humanity’s awareness of its own mortality has for millennia been a concern of the world’s religious traditions and of philosophical inquiry. This includes belief in resurrection (associated with Abrahamic religions), reincarnation or rebirth (associated with Dharmic religions), or that consciousness permanently ceases to exist, known as eternal oblivion (often associated with atheism).
On the living side of death, commemoration ceremonies may include various mourning, funeral practices and ceremonies of honouring the deceased. The physical remains of a person, commonly known as a corpse or body, are usually interred whole or cremated, though among the world’s cultures there are a variety of other methods of mortuary disposal. In the English language, blessings directed towards a dead person include rest in peace, or its initialism RIP.
The most common cause of human deaths in the world is heart disease, followed by stroke and other cerebrovascular diseases, and in the third place lower respiratory infections.
Almost all animals who survive external hazards to their biological functioning eventually die from biological aging, known in life sciences as “senescence”. Unnatural causes of death include suicide and homicide. From all causes, roughly 150,000 people die around the world each day. Of these, two thirds die directly or indirectly due to senescence, but in industrialized countries—such as the United States, the United Kingdom, and Germany—the rate approaches 90%, i.e., nearly nine out of ten of all deaths are related to senescence.
Signs of death or strong indications that a warm-blooded animal is no longer alive are:
- Cessation of breathing
- Cardiac arrest (no pulse)
- Pallor mortis, paleness which happens in the 15–120 minutes after death
- Livor mortis, a settling of the blood in the lower (dependent) portion of the body
- Algor mortis, the reduction in body temperature following death. This is generally a steady decline until matching ambient temperature
- Rigor mortis, the limbs of the corpse become stiff (Latin rigor) and difficult to move or manipulate
- Decomposition, the reduction into simpler forms of matter, accompanied by a strong, unpleasant odor
The Finish Line – Problems of definition
The concept of death is a key to human understanding of the phenomenon. There are many scientific approaches to the concept. For example, brain death, as practiced in medical science, defines death as a point in time at which brain activity ceases.
One of the challenges in defining death is in distinguishing it from life. As a point in time, death would seem to refer to the moment at which life ends. However, determining when death has occurred requires drawing precise conceptual boundaries between life and death. This is problematic because there is little consensus over how to define life. This general problem applies to the particular challenge of defining death in the context of medicine.
It is possible to define life in terms of consciousness. When consciousness ceases, a living organism can be said to have died. One of the notable flaws in this approach, however, is that there are many organisms which are alive but probably not conscious (for example, single-celled organisms). Another problem is in defining consciousness, which has many different definitions given by modern scientists, psychologists and philosophers. Additionally, many religious traditions, including Abrahamic and Dharmic traditions, hold that death does not (or may not) entail the end of consciousness. In certain cultures, death is more of a process than a single event. It implies a slow shift from one spiritual state to another.
Other definitions for death focus on the character of cessation of something. In this context “death” describes merely the state where something has ceased, for example, life. Thus, the definition of “life” simultaneously defines death.
Today, where a definition of the moment of death is required, doctors and coroners usually turn to “brain death” or “biological death” to define a person as being dead; people are considered dead when the electrical activity in their brain ceases. It is presumed that an end of electrical activity indicates the end of consciousness. However, suspension of consciousness must be permanent, and not transient, as occurs during certain sleep stages, and especially a coma. In the case of sleep, EEGs can easily tell the difference.
However, the category of “brain death” is seen by some scholars to be problematic. For instance, Dr. Franklin Miller, senior faculty member at the Department of Bioethics, National Institutes of Health, notes: “By the late 1990s, however, the equation of brain death with death of the human being was increasingly challenged by scholars, based on evidence regarding the array of biological functioning displayed by patients correctly diagnosed as having this condition who were maintained on mechanical ventilation for substantial periods of time. These patients maintained the ability to sustain circulation and respiration, control temperature, excrete wastes, heal wounds, fight infections and, most dramatically, to gestate fetuses (in the case of pregnant “brain-dead” women).”
Those people maintaining that only the neo-cortex of the brain is necessary for consciousness sometimes argue that only electrical activity should be considered when defining death. Eventually it is possible that the criterion for death will be the permanent and irreversible loss of cognitive function, as evidenced by the death of the cerebral cortex. All hope of recovering human thought and personality is then gone given current and foreseeable medical technology. However, at present, in most places the more conservative definition of death – irreversible cessation of electrical activity in the whole brain, as opposed to just in the neo-cortex – has been adopted
Even by whole-brain criteria, the determination of brain death can be complicated. EEGs can detect spurious electrical impulses, while certain drugs, hypoglycemia, hypoxia, or hypothermia can suppress or even stop brain activity on a temporary basis. Most commonly used method to diagnose with is with brain stem reflexes:
- Pupils fixed, dilated and unresponsive to direct light in the absence of drug effects or ocular trauma.
- Corneal reflexes absent bilaterally. The patient should not blink when the corneas are lightly brushed.
- Cough and gag reflexes absent bilaterally. The patient should not react when the pharynx is stimulated or when the endotracheal tube is suctioned.
- Doll’s eye response absent. When the head is turned from side to side, the eyes remain fixed in the orbits.
- Cold water caloric response absent bilaterally. Ice water is gently instilled into each external ear canal using a 30 ml syringe. No nystagmus (fast component towards irrigated ear) is noted. Observe each side for one minute and allow five minutes between sides.
There are many anecdotal references to people being declared dead by physicians and then “coming back to life”, sometimes days later in their own coffin, or when embalming procedures are about to begin. From the mid-18th century onwards, there was an upsurge in the public’s fear of being mistakenly buried alive, and much debate about the uncertainty of the signs of death. Various suggestions were made to test for signs of life before burial, ranging from pouring vinegar and pepper into the corpse’s mouth to applying red hot pokers to the feet or into the rectum. Writing in 1895, the physician J.C. Ouseley claimed that as many as 2,700 people were buried prematurely each year in England and Wales, although others estimated the figure to be closer to 800.
In cases of electric shock, cardiopulmonary resuscitation (CPR) for an hour or longer can allow stunned nerves to recover, allowing an apparently dead person to survive. People found unconscious under icy water may survive if their faces are kept continuously cold until they arrive at an emergency room. This “diving response”, in which metabolic activity and oxygen requirements are minimal, is something humans share with cetaceans called the mammalian diving reflex.
As medical technologies advance, ideas about when death occurs may have to be re-evaluated in light of the ability to restore a person to vitality after longer periods of apparent death (as happened when CPR and defibrillation showed that cessation of heartbeat is inadequate as a decisive indicator of death). The lack of electrical brain activity may not be enough to consider someone scientifically dead.
Near the finish line – Near death Experiences (NDE)
During a cardiac arrest, all three criteria of death are present. There then follows a period of time, which may last from a few seconds to an hour or more, in which emergency medical efforts may succeed in restarting the heart and reversing the dying process. What people experience during this period of cardiac arrest provides a unique window of understanding into what we are all likely to experience during the dying process?
What can we learn from near death experiences? A near-death experience (NDE) refers to personal experiences associated with impending death, encompassing multiple possible sensations including detachment from the body, feelings of levitation, total serenity, security, warmth, the experience of absolute dissolution, and the presence of a light. These phenomena are usually reported after an individual has been pronounced clinically dead or has been very close to death. With recent developments in cardiac resuscitation techniques, the number of reported NDEs has increased. Brain death is one of the deciding factors when pronouncing a trauma patient as dead. Determining function and presence of necrosis after trauma to the whole brain or brain-stem may be used to determine brain death, and is used in many states in the US.
In 2008, academic neurosurgeon Eben Alexander had an NDE while attached to an electroencephalogram which demonstrated a total lack of neural activity. After resuscitation, he found he was able to identify the face of a deceased biological sister whom he had previously not known existed (he had been raised in an adoptive family). Prior to his NDE, Alexander had been non-religious. Afterwards, he gained a definite belief in the existence of an afterlife, and went on to write a book about his life-altering experience. Alexander states that the elaborate, highly detailed, and even prescient experiences he had while his brain activity was clinically non-existent provide definitive proof that consciousness can exist without the need for a functional brain. So the plot thickens.
Researchers have identified the common elements that define near-death experiences. Bruce Greyson argues that the general features of the experience include impressions of being outside one’s physical body, visions of deceased relatives and religious figures, and transcendence of egotic and spatiotemporal boundaries. Many different elements have been reported, though the exact elements tend to correspond with the cultural, philosophical, or religious beliefs of the person experiencing it, but taken together, the scientific experience suggests that all aspects of near-death experience have a neuro-physiological or psychological basis.
Studying the area close to the finish line.
I am sure many of you will remember the movie “Flatliners” – a 1990 American sci-fi thriller film directed by Joel Schumacher, starring Kiefer Sutherland, Julia Roberts, Kevin Bacon, William Baldwin and Oliver Platt. Five medical students use physical science in an attempt to find out what lies beyond death. They conduct clandestine experiments that produce near-death experiences. So these ideas are not new. More and more people wants to know what they can expect after death before they die. Is it possible to create NDE artificially? Without going to the extent the Medical students did in the movie.
Dimethyltryptamine (DMT) is a naturally occurring psychedelic compound of the tryptamine family. DMT is present everywhere in Plants and in Mammals. In humans it is secreted by the Pineal gland. Rick Strassman advanced the hypothesis that a massive release of the psychedelic dimethyltryptamine (DMT) from the pineal gland prior to death or near-death was the cause of the near-death experience phenomenon. This in order to explain NDE on a biological basis. So can we create a NDE by administering exogenous DMT?
The Hallucination produced by exogenous intake of DMT are Reported by many people. “Recreational NDE experiences” is currently one of South America’s most lucrative tourism activities through Ayahuasca retreats. The ingestion of Ayahuasca, which is a psychedelic brew made from the bark of Banisteriopsis caapi vine alone or in combination with various plants, contains a high concentration of DMT. The ingestion is often referred to as a “little death”. People to this in order to experience a “spiritual awakening” and many reports that Life hasn’t been the same ever since their experience.
Real death (RD) vs. Near Death Experience (NDE) vs. Artificial Near Death Experience (ANDE)
So with all these similarities it is very likely that a type of Near Death Experience can be simulated by an exogenous intake of hallucinogenic substances for example DMT.
So why is this important to the first responder? This is our race. This is why we get up in the morning – to compete. We are the ones who tries to win the race and make it “not today”. Sometimes we succeed and sometimes we don’t. Do we “lose” if we don’t succeed? It is important to know and understand who and what we are up against. Sometimes we don’t know that we may have already crossed the finish line. When we win, we brisk the patient off to the hospital with wailing sirens. What does Death do when he wins? Understanding the finishing line will help us understand our opponent, the race and the prize. The exact definition of death, as with life, has been delusive through the ages. Religions where the only ones who attempted to define what happens during this inevitable ending to all life. Now, as we start to understand the process on a biological basis, there is an overlap of medicine and human spirituality. What we know now will probably not be true in 5 – 10 years. So while we huddle in the trenches on the blurry front line of life – the most important thing is to race well.
“The boundaries which divide Life from Death are at best shadowy and vague. Who shall say where the one ends, and where the other begins?” - Edgar Allan Poe -
By Dr. Adriaan van der Wart
Iridia Medical Physician, Mobile Medical Unit