1. BY VARDAN AROR

2. Contents Defining death in the law Medical defination of death Legal defination of death Determination of death UDDA Brain Death American Academy of Neurology Guidelines for Brain Death Determination Biological death and signs of biological death Quality Care at the End of Life LIFE SUSTAINING TREATMENT Decisions regarding life-sustaining treatment Autonomy, obligation to treat, and medical futility Specific treatment guidelines ICU admission CPR 3. Defining Death in the Law. The law recognizes different forms of death, not all of them meaning the end of physical life.Natural death- It is death by action of natural causes without the aid or inducement of any intervening instrumentality.Civil Death-It is used in some states to describe the circumstance of an individual who has been convicted of a serious crime or sentenced to life imprisonment. Such an individual forfeits his or her Civil Rights, including the ability to marry, the capacity to own property, and the right to contract.Legal death- It is a presumption by law that a person has died. It arises following a prolonged absence, generally for a prescribed number of years, during which no one has seen or heard from the person and there is no known reason for the person's disappearance that would be incompatible with a finding that the individual is dead (e.g., the individual had not planned to move to another place). 4. Violent death- It is death caused or accelerated by the application of extreme or excessive force. Brain death-It is a medical term first used in the late 1960s, is the cessation of all functions of the whole brain. Wrongful deathact.It is the end of life through a willful or negligent 5. Medical definition of Death Death the cessation of life i.e. permanent cessation of all vital bodily functions. For legal and medical purposes, the following definition of death has been proposed-the irreversible cessation of all of the following: (1) total cerebral function, usually assessed by EEG as flat-line.(2) spontaneous function of the respiratory system. (3) spontaneous function of the circulatory system. Brain death- Irreversible brain damage as manifested by absolute unresponsiveness to all stimuli, absence of all spontaneous muscle activity, including respiration, shivering, etc., and an isoelectric electroencephalogram for 30 minutes, all in the absence of hypothermia or intoxication by central nervous system depressants. Called also irreversible coma and cerebral death. N.B- Electroencephalography (EEG) is the recording of electrical activity along the scalp 6. Legal Definition Of Death An individual, who has sustained irreversiblecessation of all functions of the entire brain, including the brainstem, is dead (a) In the absence of artificial means of cardiopulmonary support, death (the irreversible cessation of all brain functions) may be deter-mined by the prolonged absence of spontaneous circulatory and respiratory functions. (b) In the presence of artificial means of cardiopulmonary support, death (the irreversible cessation of all brain functions) must be deter-mined by tests of brain function. 7. Determination Of Death In an era of rapid technological change, it is not unusualfor technology to overcome medical, social and legal commonplaces. One instance of this is the legal standard for determining biological death. Advances in medical techniques and equipment have made it necessary to re-evaluate traditional legal standards for declaring a human being dead. Such standards are necessary not because of deathitself, but because of the effect in the law of the biological fact of death. Determinations of death are also important in establishing the property relationships that arise through inheritance and devise. They are important in tort law to actions in wrongful death and survivor's action. The standards for determining death are not 8. The Uniform Law Commissioners (ULC) created the Uniform BrainDeath Act in 1978 in an effort to clear up the legal ambiguity that had arisen over the question of determining death. It was plain that legal recognition only of traditional criteriawhich rely on measuring cessation of respiration and circulationwould no longer suffice. Clearly the brain, as the center of the human body, is its most important organ. Its irreversible functioning should be accepted as death. Direct detection of loss of brain function is a product of very modern technology. The Uniform Brain Death Act simply established that the "irreversible cessation of all functioning of the brain, including the brain stem" is death. It then prescribed that determination of death be made in accordance with "reasonable medical standards." The ULC assumed that the traditional criteria would stand automatically alongside the brain-death standard described in the uniform act, and so did not mention those criteria in the act itself. But this omission proved confusing for states trying to adopt comprehensive legislation on the subject. The ULC corrected the situation in 1980 by replacing the act with the Uniform Determination of Death Act (UDDA). 9. UNIFORM DETERMINATION OF DEATH ACT This Act provides comprehensive bases fordetermining death in all situations. "Uniform Determination of Death Act" developed jointly by the National Conference on Commissioners of Uniform State Law, the American Medical Association and the American Bar Association, approved October 19, 1980 and February 10, 1981. 10. DEATH AS PER UDDA An individual who has sustain -either irreversiblecessation of circulatory and respiratory- functions, or irreversible cessation of all function of the entire brain, including the brain stem, are dead. A determination of death must be made in accordance with accepted medical standards. 11. Brain Death Brain death is the irreversible end of all brainactivity (including involuntary activity necessary to sustain life) due to total necrosis of the cerebral neurons following loss of brain oxygenation. It should not be confused with a persistent vegetative state. Even after brain death, the working of the heart might continue at a slow pace, but there will be no respiratory effort. Brain death, either of the whole brain or the brain stem, is used as a legal indicator of death in many jurisdictions. 12. American Academy of Neurology Guidelines for Brain Death Determination Establish irreversible and proximate cause of coma. Achieve normal systolic blood pressure. Perform 2 neurologic examinations Absence of brainstem reflexes. Apnea Test Ancillary tests 13. Biological Death 1. The death caused by degeneration of tissuesin brain and other part is called biological death. 2. Most organs become dead after biological death. 3. These organs can not be used for organ transplantation. 14. Signs of biological death Cessation of breathing Cardiac arrest (no pulse) Pallor mortis, paleness which happens in the 15120 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. 15. Quality care at the end of life is what we wish for A guiding philosophy of medicine is that the health and well being of the individual patient is of paramount consideration. There is a long-standing tradition in medicine that physicians must do everything medically possible to keep a patient alive. It is important that physicians understand and personally acknowledge that death is an acceptable outcome of care in certain circumstances, and that in many situations treatment cannot prevent death. Physicians should aim to provide their patients with care that fulfills the goals identified above, is compassionate and respectful, and allows patients to experience as dignified a death as possible. Dying patients may have last wishes relating to many issues other than treatment. Physicians should endeavour to honour the last wishes of patients wherever it is possible to do so, as respect for the autonomy of the patient must continue, to the extent clinically, physically, and legally possible, to the end of life. 16. Quality Care at the End of Life Research and experience show that patient goals forquality end-of-life care generally include the following:Medical care: Management of pain and other distressing symptoms; 2. Avoidance of unnecessary prolongation of dying; 3. Facilitation of clear decision-making and communication. 1. 17. Personal issues: 1. Treatment with respect and compassion; 2. Preservation of dignity; 3. Affirmation of the whole person; 4. Opportunity to address personal concerns; 5. Achievement of a sense of preparedness, control and meaning; 6. Preparation for death; 7. Achievement of closure. Relationships: 1. Strengthening of relationships with loved ones; 2. Relief of unnecessary burdens on others; 3. Contribution to others and continued participation and active involvement in social interactions, to the 18. LIFE -SUSTAINING TREATMENT Life-sustaining treatment is any medical intervention,technology, procedure, or medication that forestalls the moment of death, whether or not the treatment affects the underlying life-threatening diseases or biological processes. Examples include mechanical ventilation, dialysis, cardiopulmonary resuscitation (CPR), antibiotics, transfusions, nutrition, and hydration. Discussions about forgoing life-sustaining treatment will often be raised when death is the predictable or unavoidable outcome of the patient's underlying medical condition. However, a patient need not be terminally ill or imminently dying for these discussions to be held. 19. Decisions Regarding LifeSustaining Treatment Resuscitation Decisions. Judgments of Futility. Advance Directives.instructional directives. 2. proxy directives. Surrogate Decision makers. Living Wills. 1. 20. Autonomy, Obligation to Treat, and Medical Futility Patients have a right to control what happens to their bodies, so thedecision about whether to forgo life-sustaining treatment should, in the final analysis, is theirs. The physician has no obligation to render futile care and thereby violate reasonable medical standards. Rather, physicians should decide the extent of care in accordance with what they perceive is medically appropriate for that patient and inform the patient about their decisions. In all circumstances continuity of the patient's care should be assured. If the physician decides to forgo a non-beneficial treatment, the patient should be informed. Although patients do not have a right to insist on futile treatment, circumstances can arise in which providing life-sustaining futile treatment for a limited time is justifiable to achieve identified objectives. 21. Specific Treatment Termination Guidelines Intensive Care Unit Admission The following types of patients are candidates foradmission to intensive care units when it is consistent with their treatment preference and goals: critically ill patients who require life support for organ system failure that may be reversible; patients with irreversible organ system failure who cannot be treated appropriately in another setting; patients at risk of life-threatening complications who require monitoring or treatment; and patients who are receiving a trial period of monitoring or treatment when the prognosis or the effectiveness of therapy is in doubt. A decision to forgo some forms of life-sustaining treatment such as cardiopulmonary resuscitation should not automatically preclude other forms of treatment and 22. Patients who generally should not be admitted to the intensive care unit include Patients with documented irreversible cessation of allfunctions of the entire brain. Patients who have been diagnosed as irreversibly unconscious. Patients with irreversible illness who are near death Patients who, while capable of making decisions, have requested that they not receive intensive care or its equivalent. 23. Patients are entitled to refuse admission to an ICU, even when doing so puts them at risk of death. Patients should not, however, be able to demand admission to an ICU. A request by a patient or a surrogate for admission to an ICU may be denied if admission would be medically inappropriate for the patient, detrimental to patients already in the unit, or contrary to the admission criteria. These patients should be transferred from the ICU to another setting within the hospital or to another institution when intensive care will no longer benefit them, either because they have improved to a point where intensive care is no longer necessary, or because they have deteriorated to a point where it no longer offers reasonable promise of benefit. 24. Cardiopulmonary Resuscitation Cardiopulmonary resuscitation (CPR) refers to thosemeasures used to restore ventilation and circulation in patients in whom these functions have been interrupted. Resuscitation techniques have no value in the management of irreversible or terminal disease states. They are intended to revive otherwise healthy individuals who experience some reversible catastrophe that interrupts breathing and circulation. Because of the emergency character of CPR, a patient orsurrogate should ideally be consulted in advance about whether to begin resuscitation in the event of cardiac or respiratory arrest. Any patient who is at increased risk for cardiopulmonary arrest should be given the opportunity to 25. In the absence of a Do Not Resuscitate (DNR) order,resuscitation should be attempted, and if any doubt exists as to whether a decision to forgo treatment has been properly made, treatment to preserve life should be given. Deceptive resuscitation efforts, known as "slow codes" and "walk, don't run" codes are not acceptable. Any code should be a full code unless a partial code or limited resuscitation effort has been consented to by an informed patient or surrogate. At the time of cardiac or respiratory arrest, if the physician summoned to direct resuscitation realizes that CPR cannot restore cardiac and respiratory function, the physician may call off the effort. If CPR is clearly futile (i.e., does not achieve its physiological objectives, offers no benefit to the patient, and violates reasonable medical standards), there is no obligation to offer or 26. RESOURCES Guidelines for physician from AMA. Guidelines by american academy of neurology for brain death Wikipedia Cleveland clinic of medicine and research article. Yales university report. Life sustaining treatment and tough decisions article by James Bernard. GUIDELINES FOR TERMINATING LIFE SUSTAINING TREATMENT BY MICHIGAN HEALTH SYSTEM. UNIFORM LAW COMISSION PROTOCOLS.