Never declare a patient dead under conditions of hypothermia

Never declare a patient dead under conditions of hypothermia

 Dr KK Aggarwal, Dr R N Tandon

A core body temperature below 95°F is hypothermia. Core temperature 90-95°F is mild hypothermia, 82 to 90°F is moderate hypothermia and core temperature below 82°F is severe hypothermia.

In conditions of severe hypothermia in children, body metabolism is suspended, which may protect against hypoxia. Patients with core body temperature 82°F have been known to survive anoxia for 12-18 minutes and up to 60 minutes or more at core body temperature 68°F. Sometimes, hypothermic patients can be successfully revived with CPR even with total resuscitation time of 9 hours. Because of dilated pupils, asystole, hypoventilation, absence of shivering, the patient appears dead. Because of failure to recognize this state, the patient may be declared dead.

Successful revival is also possible in adults because of the neuroprotective effects of hypothermia. Several hours of CPR may be required for this. Efforts to revive the patient should be continued till the core body temperature reaches 90-95°F i.e. bring the temperature from severe hypothermia to mild hypothermia or normal. If the patient still cannot be revived with CPR, then he/she can be declared dead.

The recent incident of a premature (22 weeks) newborn, who was alive, but allegedly declared dead at a private hospital in the National capital has captured headlines. The other twin was stillborn. While being taken for the funeral, the newborn was discovered to be alive and is now on life support system.

In light of this incident, IMA has issued an advisory that patients should not be declared dead under conditions of hypothermia. 

It is important to recognize hypothermia so that patient can be timely revived using all resuscitative measures, including rewarming, CPR.

Learning to be good doctors from the dead

Learning to be good doctors from the dead Dissection of the human cadaver is a fundamental part of training of doctors. All specialities of medicine require a knowledge of the human anatomy. Dissection allows a student to directly see and touch the intricate structure of the human body, the various organs, muscles, bones, etc., or its various anomalies, which no digital technology can simulate, however advanced it may be. This visual imprint on the mind perhaps stays on for life. Medicine is not all science; it is not just about being able to interpret lab reports, or read an x-ray or CT scans etc. or prescribing medicines. Doctors have been regarded as next to God since Vedic times and no other profession has been accorded the same exalted status as that of the medical doctor. This places a responsibility on the doctors to nurture the doctor-patient relationship, based on trust and mutual respect. Doctors should be compassionate, empathetic, courteous and respect the dignity of the patients, their privacy and confidentiality. These are qualities that can be inculcated in doctors, right from the first day, they enter a medical college to begin their education. When a medical student enters a dissection hall for the first time, he/she may experience a mix of different emotions... anxiety, stress or even excitement in taking that first step towards being a real doctor. It is important to cultivate in them respect for the cadaver or the dead human body. While they teach us the anatomy of the human body, they can also teach us ‘humane’ qualities, which will make a medical student, a good doctor later on. These cadavers were once living persons, just like us. Disrespecting them means disrespecting the dead person. Many cadavers would have been voluntarily donated during a person’s lifetime. This is a gesture that is truly selfless and altruistic, made for research for advancement of medicine or training of medical students, the future doctors. Or, the body may have been donated after death by the family or legal heirs to teaching institutions. It is therefore important to respect the family that has suffered an irreversible loss. Disrespecting the cadaver would mean disrespecting the family of the dead person. After they have been used, the cadavers are usually buried, without any rituals. There should be a funeral service for the used cadavers with all rituals as an act of respect. Students should take a ‘Cadaveric oath’ on their first day in the dissection hall before starting the dissection. An example of such a cadaveric oath can be as below: “I … do solemnly pledge that I will always respect the cadaver. I will always treat the cadaver with dignity. I will be compassionate towards the cadaver. I will respect the privacy and confidentiality of the cadaver. I will be grateful to the cadaver and/or their family or legal heir/s for the gift of knowledge. I will be altruistic and use my knowledge for the service of society.” The way we treat the dead body will shape our interactions with a living person. A dissection hall is a good place to learn to be caring and compassionate doctors. Dr KK Aggarwal National President IMA & HCFI

The dead too deserve to be treated with respect and dignity

The dead too deserve to be treated with respect and dignity Dr KK Aggarwal National President IMA “Be respectful” This is what we have been taught since childhood… our traditions and culture also teach us to always be respectful towards every living being, and not just towards another human being. The Right to Life is recognized in Article 3 of the 1948 Universal Declaration of Human Rights and Article 6 of the 1966 International Covenant on Civil and Political Rights. The ‘Right to life’ is enshrined in our constitution in Article 21, which says “No person shall be deprived of his life or personal liberty except according to procedure established by law.” The scope of Article 21 has been expanded over the years in various judgements of the Supreme Court by adding the dimensions of right to health and medical care among other things that are essential to life such as adequate nutrition, education, etc. The Right to life also means the ‘Right to live with human dignity’. In its judgement in Francis Coralie Mullin vs The Administrator, Union Territory of Delhi & Ors dated 13th January, 1981, the Apex Court held: “The right to life includes the right to live with human dignity and all that goes along with it, namely, the bare necessaries of life such as adequate nutrition, clothing and shelter and facilities for reading, writing and expressing oneself in diverse forms, freely moving about and mixing and commingling with fellow human beings… Every act which offends against or impairs human dignity would constitute deprivation pro tanto of this right to live and it would have to be in accordance with reasonable, fair and just procedure established by law which stands the test of other fundamental rights…” It’s not just the living, who deserve our respect … the dead too deserve dignity just as the living do. A dead person has the right to be treated with dignity as exemplified by the right to a decent burial or cremation. A dead person has the right to remain undisturbed and unharmed. Section 297 of the Indian Penal Code ‘Trespassing on burial places, etc.’ has recognized it as a punishable offence and says, “Whoever, with the inten¬tion of wounding the feelings of any person, or of insulting the religion of any person, or with the knowledge that the feelings of any person are likely to be wounded, or that the religion of any person is likely to be insulted thereby, commits any trespass in any place of worship or on any place of sepulchre, or any place set apart from the performance of funeral rites or as a depository for the remains of the dead, or offers any indignity to any human corpse, or causes disturbance to any persons assembled for the performance of funeral ceremonies, shall be punished with imprisonment of either description for a term which may extend to one year, or with fine, or with both.” Also, organs or tissues of a dead person can be harvested as defined under the Transplantation of Human Organs and Tissues Rules, 2014. For most organs and tissues, the time between death and donation is 12 to 36 hours. The approximate maximum time span between recovering organs/tissues and transplantation for the following organs/tissues is: Lung (4-6 hours); Heart (4-6 hours); Liver (24 hours); Pancreas (24 hours); Kidney (72 hours); Corneas (14 days); Bone (5 years); Skin (5 years); Heart valves (10 years). A dead body is living as long as organs can be harvested and the dead body deserve to be treated with respect and dignity… Vedic texts describe five different movement forces in the body: apana vayu expulses urine, stool, baby and menses; samana vayu controls the intestinal movements; vyana vayu controls the circulatory system; udana vayu controls the neurological impulses and the connection between soul and spirit and prana vayu controls the brain stem reflexes. The Soul or consciousness is linked to udana vayu and prana vayu. According to the Chandokya Upanishad, at the time of death, the Prana Vayu (life force and respiration) merges with Udana Vayu (brain stem reflexes) and leaves the body. But this does not happen immediately after clinical death, which is defined as stoppage of heart and respiration. Except for cornea many organs can be harvested for donation after a person has been declared as brain dead. The vital organs of the body such as the heart, lungs, liver, intestine, kidneys can be kept viable for some time, if a brain-dead person is kept on a ventilator to maintain oxygenation of organs, so that organs remain viable till they are harvested. This is because the body has normal Prana Vavy, Samana Vayu and Apana vavy. The patient will maintain blood pressure, GI functions, urinary functions and reproductive functions. The life force resides in each one of us… This vital force is the soul, Atman or consciousness. To summarise, a living person has a right to live with dignity so does a dead body with retrievable organs and tissues (as it is considered still a living body) and finally the fully dead body, including the mummified body or the cadaver, also needs to be treated with dignity