… Or imprisonment in our own bodies over which we have no power?
● What is death? We have to deal with it, when it seems to us that we irrevocably lose contact with the patient. But how can we verify that the contact loss is irretrievable? For this purpose many different acts used to be performed, such as hammering a pin under a nail, cutting a sole of a foot with a razor, placing a feather under the nose, letting an insect into an ear, pinching the nipples with special pliers, plugging a nose with a sharpened pencil, placing a mirror in front of a mouth, measuring heart rate, screaming and playing the trumpet straight into a patient’s ear, and a special machine for removing tongue was invented. No procedure, however, was considered to be reliable. Thus, people who could afford it, demanded in their wills to have their heads cut after their death. An example of such a lack of conviction about the obvious signs of death and an upsurge in the public’s fear of being mistakenly buried alive was manifested in Europe, from the early18th century onwards, by building the so-called „Morgues lounges”. People who were considered dead were submitted in and left there until the appearance of first signs of decay. They were monitored to see if they do not come back to life.
The boundaries of death are quite blurry. The courts decide, more frequently now, whether to, at the request of the party in charge, disconnect or not life support devices. We are not sure whether the patient is alive or not, but the courts have to make these decisions. We know, from experience, that sometimes courts’ orders are fallible.
Death was once defined as the cessation of heartbeat, inability to feel the patient’s pulse, or as the cessation of breathing. Today, it is known, that even when the heart stops, organs and tissues are, for a few hours, at least, in a state of transient death. In the U.S., cardiac arrest occurs in 250,000 people a year, but about 5% of them are restored to vitality after periods of apparent death.
A special Research Committee from Harvard University U.S.A., legally and scientifically, defined death in 1968. The criteria then established have been adopted, with slight modifications, in many countries, including Poland. These criteria are (roughly speaking): deep coma, the lack of response to external factors, the lack of pupillary light reflex, the cessation of breathing, and flat EEG record. In order to obtain certainty, these symptoms must be observed within the 24-hour interval.
In Poland, for simplicity’s sake, we do not perform an EEG record, and the interval between tests was shortened to three hours.
● The corpse with a beating heart (people formally declared brain dead). Sometimes, however, even with the death of brain, thanks to the usage of a ventilator, the heart and all other organs work properly. The patient has warm skin of healthy colour; his chest rises steadily with each breath. Such person looks like any other intensive care patient. But legally he is declared dead, a perfect organ donor. It is not clear whether the patient has any kind of awareness, though there is a tendency to assume so.
In practice, the combination of irreversible coma with apnea is synonymous with death of the patient worldwide. Medically and legally the patient is dead then. He can be transported to morgue, put into refrigeration unit cell, buried in the ground or cut for the purpose of organ transplantation. Research has indicated, however, that about one-third of transplant team members believe that donors are still alive when organs are retrieved. Similarly, one- third of anesthesiologists give donors anesthetics during such donation surgeries in the belief that they feel pain. An organ donor is legally declared dead, but according to many transplant professionals, they feel like people who are alive.
● A coma. Sometimes doctors fail to awaken the patient after the surgery, or an accident. It is said that he remains in a coma. The patient is unconscious and has his eyes closed, but some brain activity is registered. Reflex limb movements can sometimes be observed. It is advised for the medical personnel to talk to the patient and to keep him in the upbeat mood. Some patients regain consciousness and are able to accurately reproduce the content of such talks and the diagnoses made by doctors, even after a long coma. A 39-year-old Belgian, who fell into a coma following
a stroke was one of such cases. The doctors, who took care of her at that time, felt that the patient would not regain consciousness and would remain in a persistent vegetative state. She remembered all the talks at her bed, including doctors’ speculations whether or not to keep her alive. Another reported case is of Jan Grzebski, a Polish railway worker who, after an accident in 1988, went into a coma. He emerged from it in 2007, and during one of his interviews in TVN 24, he summed: „When I fell into a coma there was only tea and vinegar in the shops, meat was rationed … Now, I see people with mobile phones on the streets, and the wide variety of products in the shops that can lead to a headache „.
● What is the minimal brain activity? To measure it we use different instruments. The most common is the electroencephalograph (EEG). EEG detects and measures the electrical impulses in the brain. A variation of EEG is ERP (event-related potentials); in simplification „a method of evoked potentials” (evoked potentials). These are averaged EEG records, of many attempts, on the person exposed to a certain stimulus. Another method for imaging brain activity, used since the early nineties, is functional magnetic resonance imaging (Functional Magnetic Resonance Imaging, fMRI). It involves the formation of a strong magnetic field and recording a magnetic field activity perpendicular to it. On this basis, we estimate blood flow between
the dissociated parts of the brain (white matter, gray matter, cerebrospinal fluid, while abscess and tumor are observed in different colours). Positron emission tomography (positron emission tomography, PET) is another method. The patient is administered
a radioactive substance and its disintegration are examined. This method is particularly useful in determining the neoplastic state.
However, the major problem in determining brain’s activity lies in the fact, that we do not know what this activity is because we do not know the mechanisms of the brain. Until recently, it seemed to us that communication within the brain took place on the basis of the conduction of electrical impulses through the neurons thinner than a hair. Neurons are immersed in the glial mass and represent only about 16% of the brain’s volume. It is presently known, however, that communication within glial cells, that are five times more in number than neurons, occurs through chemical process. The brain is sometimes called „a chemical soup that uses more than a hundred different substances for communication between neurons.” So, the brain is much more chemical than electrical while instrumentation is based on the phenomenon of electromagnetism. The methods seem so uncertain since they do not relate to the chemical transfer.
● A persistent vegetative state („sustainable plant”). A coma frequently lasts for five weeks. The patient, usually, awakens from it within a few days. Patients die, or fall in so-called, vegetative state (permanent vegetative state, pvs – first described in 1972 by B. Jennett and F. Pluma) if that does not happen. Vegetative state may last years or even decades, and at any time, can terminate by awakening or death. This state occurs in conscious, but devoid of awareness patients. Patients normally wake up and fall asleep. When they are spoken to during their sleep they can open their eyes or blink. They can follow a moving object with their eyes or turn towards the noise. Their eyes usually wander and are not able to focus for a longer period of time on any object though. Patients breathe, digest food, served to them, by themselves. They have proper blood circulation, blood pressure, heart rate, temperature and posture, as well as defense reactions of the organism. Patients perform a variety of spontaneous movements – they grind their teeth, swallow, grab things, grunt groan, cry or smile. Occasionally they may respond to strong stimuli, which can be perceived by their relatives as forms of contact. But these are not sufficient reasons to believe that
the patients make contact or respond to commands.
It is assumed that patients in the vegetative state are unconscious and therefore it is impossible to establish contact with them. Their brain activity measured by EEG is negligible, but usually constitutes at least 5% of the healthy human’s brain activity.
According to 26- year-old Kate Bainbridge from Cambridge shire / Great Britain who stayed in persistent vegetative state for six months:
„Not being able to communicate was awful. I felt trapped inside my body. I had loads of questions like ‚Where am I?’, ‚Why am I here?’, ‚What has happened?’ But I could not ask anyone. I had to work it all out. (…) Trapped inside my body, that doesn’t react at all”
(R. Morelle, I Felt “Trapped Inside my Body, internet issue “BBC News”, 7 th September 2006, http:news.bbc.co.uk/2/hi/health/5321460.stm).
However, it has been observed, that patients’ brains can respond to external stimuli in a manner detectable by fMRI. The story of 29-year-old patient, who suffered a brain injury following a car accident in 2003, became quite famous in this context. He was in the vegetative state for five years. After this time, tests were conducted, which showed beyond any doubt that, despite the vegetative state, the patient was able to answer „yes” or „no” to the questions asked correctly. The answers were seen on
the scanner as different type of brain activity. This means that he was aware of, but unable to communicate with outer environment. The patient was able to communicate his thoughts by means of fMRI. The case was described in „New England Journal of Medicine”, one of the most prestigious medical journals published by
the Massachusetts Medical Society.
In total, 23 patients in vegetative state were monitored with fMRI during three years. Signs of consciousness were detected in four of them. fMRI verifies healthy people’s responses with one hundred percent of accuracy.
● Minimal consciousness. Research conducted in the nineties, by K. Andrews, N. Childs and JT Giacino showed that nearly 40% percent of patients were wrongly diagnosed as persistent vegetative state and that they retained a significant level of consciousness. Thus, in 2002 a new name was coined – minimal consciousness (minimally conscious state, MCS). Patients in this state can follow an object with their eyes in a discontinuous manner, respond to external stimuli, and perform purposeful movements.
Terry Wallis of the Ozark Mountains (Arkansas, USA), who after an accident in 1984, went into a coma, which then went into a state of minimal consciousness is one of
the famous cases. He woke up from that state and conducted a conversation with
the medical staff after being in a coma for 19 years. It seemed to him that he was still in 1984. Within the course of time he also partially regained the ability to move his limbs. The case of Gary French Dockery, a policeman from Walden (Tennessee, USA), who woke up after 7.5 years of permanent vegetative state disturbed by rare eyes blinking and whining is a similar often described one by the press.
A 26-year-old Kate Bainbridge from Cambridge shire / Great Britain who was in vegetative state for six months said: “I thought I was in prison and I had forgotten how to move”.
(R. Langeth, Twilight Zone: Can Medicine Help Revive Brain-Damaged Patients Stuck in
the Netherworld between Coma and Consciousness? Internet issue “Forbes”, 4th October 2004, www.forbes.com/business/global/2004/1004/060.html).
● The locked-in syndrome (locked-in syndrome, LIS). It is the most spectacular disease entity coined by F. Plum and J. Posner in 1966. The patient is fully conscious and aware, feels and thinks just like a healthy person but is unable to communicate with the outside world, except for blinking and eyeballs movements. There are many recorded cases of people who suffered from this syndrome including Jean-Dominique Bauby, Gary Griffin, Rom Houben, Graham Miles, Gary Parkinson, and Erik Ramsey
and Julia Tavalaro.
● Death’s border. Awareness accounts barely for 1- 5% of our mental life. According to psychologists, decisions essential for our survival are made at
the subconscious / unconscious level and our consciousness only seek the reasons to support the decisions made. (1) Firstly the decision is made in the subconsciousness. (2) Secondly, our subconsciousness informs our consciousness about the decision taken. (3) At the end our consciousness looks for arguments, which militate in favor of the rationality of the decision taken by the subconscious mind. (1) What is the most important, namely the strategy, is stuck in the deepest seams of our psyche, unconsciousness. (2) The subconscious mind, which is shallower layer, performs
the tactical edge, and (3) consciousness participates only in ad hoc measures. From
the point of our mental life’s view, consciousness is of a tertiary importance, when we look at the pronouncing of death it has a prime one.
For the purpose of deciding if a person is dead or alive, a common criterion of consciousness is used. If the person is conscious then he is alive, if not he is dead. Basing on the indication of various instruments, people of medicine constantly look for arguments, for declaring a person without awareness dead, and to disconnect
the apparatus or to carve out their organs for transplant. If there is no contact with
a patient and they cannot express their thoughts, they are considered dead by
the society. Once it used to be the criterion of sleep apnoea, then the cessation of heart and now the death of the brain stem. Medical boundary of life and death continues to move, but the border of human consciousness is one that cannot be settled.
A man without awareness is dead. Very slowly we realize that sleep apnea, heart rate cessation, or brain stem death may not be synonymous with the death of our consciousness. Consciousness may exist despite the obvious signs of death. Our corpses are subjected to death accompanying farewell ceremonies (burial, cremation) despite still thinking and sentient consciousness.
Even half a century ago, people who have fallen on the above-described disease entities were most frequently considered dead. We would bury them and lit candles on their graves. Today, only in the United States there are approximately 150,000 such patients. They are somewhere on the border between what we call life, and what seems to us to be death. With the majority of them we do not have any contact. Most of them, according to our values, are not aware of their existence.
Whether a person is alive or already dead is decided on the basis of the brain’s condition. According to our current perceptions, the condition of one the body’s organ is correspondent to the condition of the entire body. Dead brain means dead body. However, we have no knowledge on how the brain operates, and what is more we do not have necessary instruments, which can clearly differentiate between life and death.
And what if we bury or cremate corpses that are conscious? Almost every day we hear about cases of „dead people” who remained aware and who returned to us from the underworld.
So keep in mind, that when we say goodbye to a corpse of the deceased and close one, at a morgue before placing in a freezer drawer, or in a crematorium before combustion in a chamber, or in a cemetery before burial in a tomb, that powerless awareness may be trapped inside. Your dead relative sees, feels and understands everything but does not have power over his own body. You will have the opportunity to check for yourself whether it is always true, at your own funeral.