Tuesday, February 1, 2022

The last breath

Rodman A, Breu AC. The Last Breath: Historical Controversies Surrounding Determination of Cardiopulmonary Death. Chest. 2021 Aug 13:S0012-3692(21)03631-X. doi: 10.1016/j.chest.2021.08.006. Epub ahead of print. PMID: 34400157. 


Cardiopulmonary determination of death is a mainstay of the practice of internal medicine and pulmonary physicians. Despite this, there is considerable variability in death examinations. This article tracks the evolution of the tripartite death examination, initially developed in the middle of the 19th century to protect against premature burial. Although the societal context for controversies about death determination has shifted to discussions about end-of-life care in ICUs and organ transplantation, the cardiopulmonary death examination has largely remained unchanged from its original formulation. The recognition of coma dépassé and brain death has further pushed the focus of the death examination onto the neurological system. Despite advancing diagnostics and legislative attempts to standardize the definition of death, cardiopulmonary death determination largely remains an ad hoc process.

From the article:

On June 25, 1858, a prisoner named James Magee was hanged in Boston, Massachusetts. As was common in the United States in the 19th century, he was condemned not only to death, but to public dissection.2 The Harvard doctors who had come to attend his autopsy performed a death examination informed by the latest in medical science. As Magee hanged from the rotunda of the jail, his chest was auscultated with a stethoscope, with an initial heart rate of 100 beats/min; after 12 minutes it had decreased to 60, and by 14 minutes his heart had gone silent. Magee was lowered from the noose, and note was made of absent impulse of the heart and dilated pupils. The gathered doctors started their autopsy; the chest was opened, and the heart was noted to be still beating: “The right auricule was in full and regular motion, contracting and dilating with beautiful distinctness and energy.” Complete movement of the heart did not stop for 5 hours and 18 minutes after death had been declared. Had the doctors and their death examination been wrong—had they dissected a still-living man?...

At the time of Magee’s death, physicians and the lay public on both sides of the Atlantic were well primed for a scandal surrounding death determination. The New York Times declared that Magee had died “not from the hangman’s rope, but from the surgical operator.”  The Lancet decried the doctors who had “performed what would appear to be little less than a vivisection.”  The doctors of the Boston medical establishment pushed back against these accusations. The Boston Medical and Surgical Journal attributed these findings to “inherent irritability of the muscular structure of the heart,” and the Boston Evening Traveller defended the death examination itself, asserting the scientific fact that “all signs of life were absent” when he was cut down and alluded to his severed spinal cord that “no one will pretend that a man could be alive after being beheaded, unless it is supposable that Magee was St. Francis.” ...

The prize was ultimately won by Eugene Bouchut, who used the recently invented stethoscope, noting that death was always present in animal experiments if heart sounds were absent for longer than 2 minutes. By 1883, Bouchut had expanded his death examination to encapsulate what he believed were the three core organ systems—cardiovascular, pulmonary, and neurologic. For cardiac death, he recommended the absence of heart sounds with a stethoscope for 5 minutes, the Hippocratic facies (also known as the cadaveric face, the sunken eyes and temples prognostic of death), pallor of the skin, the opacification of the nailbeds, and the absence of an “inflammatory halo” when the skin was burned. Pulmonary death involved observation of lack of respiration of the nares and auscultation with a stethoscope. Death of the neurological system was determined via absence of “intellectual faculties,” release and dilation of the sphincters, and glazing of the cornea. If Bouchut’s tripartite death examination, comprising a dozen items, was unwieldy for practicing physicians, this paled in comparison to the definition of death described in the Dictionnaire Dechambre, a 100-volume encyclopedia of the medical sciences, which had 27 major signs of death, and dozens more minor signs. Although it did not make a recommendation on which signs of death were most accurate, the Dictionnaire stressed the importance of combining multiple: “The risk of error is greater when observation concentrates on only one point.” ...

One hundred fifty years have passed since Magee’s execution, and in many ways, the context surrounding the death examination is unrecognizable today. Death is now highly institutionalized, and physicians have a wide variety of diagnostic and imaging studies at their command. Uncertainty in the determination of death remains controversial, but these controversies have shifted from fears about premature burial to debates about withdrawal of cardiopulmonary support, brain death, and organ transplantation. Swaths of laws have been passed to better clarify the conditions under which practitioners can declare death. Physicians of 2021 find themselves in much the same position as the doctors gathered in a Boston prison back in 1858—using some version of Bouchut’s tripartite examination to make the ultimate determination, without formal guidelines or even a formal education, which is still largely practiced as Justice Potter Stewart defined obscenity: “I know it when I see it.” 44 Despite the context changing considerably, there remain unchanged fundamental tensions between the physiology of dying, the limits of the tools of the physician, the pragmatic needs of the legal system, and the certainty required by society.

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