Dead or alive? The doctor’s challenge

Being declared dead while still alive is, thankfully, a very rare occurrence. A recent New York Times report described an incident in an Iowa nursing home where a 66-year-old woman was declared dead by staff members and transported to a funeral home. However, when staff at the funeral home unzipped the body bag, they were taken aback when the woman’s chest moved and “she gasped for air”. The unfortunate victim, who had end-stage dementia, was then brought to hospital where she died two days later.

Back in the 18th century, uncertainty about the diagnosis of death led to some unusual practices. In 1799, George Washington allegedly made the following dying request: “Have me decently buried, but do not let my body be put into a vault in less than two days after I am dead.” A pervasive fear of being buried alive also led to the construction of “waiting mortuaries” and security coffins with alarm mechanisms and permanent air supplies.

In 1846, Dr Eugene Bouchut won the Academy of Sciences prize for “the best work on the signs of death and the means of preventing premature burials”. He advocated the use of the stethoscope, invented in 1819 by René Laennec, as a technological aid to diagnose death. Fellow contestants for the prize advanced alternate ideas for diagnosing death including the application of specially designed pincers to the nipples, and piercing the heart with a long needle with a flag at the end, which would wave if the heart were still beating.

Bouchut’s idea was the welcome beginning of scientific method in the diagnosis of death. Further technological aids have been developed since, but doctors routinely use a stethoscope to listen for some time for breath sounds and a heartbeat. In addition they use a pen light to check if the pupils are reacting to light and to confirm that they are fixed and dilated. Firm pressure above the eye looking for a reaction to a stimulus completes a routine check for signs of life.

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Unfortunately, there have been instances where death has been confirmed by this process, yet the patient has shown signs of life afterwards. Some prescribed drugs can make the task harder. While protecting the brain from oxygen starvation, sedating drugs reduce responsiveness and depress the breathing and circulation, leading to the impression of death. As the drug is cleared from the body, the person may wake up.

Immersion in cold water can also lead to the illusion of death because of its effect on slowing the heart rate. The victims must be allowed slowly warm up. Good neurological recovery has been reported after periods of cold water immersion of up to 70 minutes.

Dying is a process, and it affects different functions and cells of the body at different rates. The challenge for doctors is to decide at what moment along this process there is permanence and death can be appropriately declared. Where rigor mortis has set in (usually about three hours after death), this is a relatively easy decision. Additional criteria for diagnosing death may be used in a hospital setting, especially when the person is on a ventilator and a harvesting of organs for donation is planned.

But in general practice, previous knowledge of a person’s lifestyle may be sufficient to avoid a premature declaration of death.

A now-deceased rural GP told the story of a patient who was more than fond of a drop of poitín. Called to his house to confirm the man had passed away, he arrived to find candles lit around his body. The doctor marched over to the patient and brought his heavy doctor’s bag firmly down on the man’s chest. The patient woke up spluttering to the amazement of his surrounding family. It may have been an unusual way to provide a stimulus, but it confirmed the propensity for poitín to induce a comatose state mimicking death.

mhouston@irishtimes.com