Death, be not loud

Perhaps you might think this is creepy, or weird; I think of it as merely liminal, an exploration of boundaries -to wit, when am I dead? I have no doubts as to its ultimate finality -there’s probably a best-before date sewn into all of our genes. But it’s more than a definitional quibble, I think. I mean it’s to everybody’s advantage that no mistakes are made -the postlude is too severe.

So, what, exactly, are we supposed to rely on? At one time it used to be lack of movement, I guess -like not opening your eyes when slapped, or failure to get up in the middle of the night to visit the fridge. On TV, the police always feel for a pulse in the neck, but it seems to me that none of these are failsafe. None of these should be the judge of whether or not to start the autopsy, or nail the coffin closed.

Fortunately, in hospitals, they are more careful; they also have more equipment at their disposal, I imagine. The things most readily available, even in remote outposts, are ECGs that monitor heart rate patterns. It’s a fairly simple principle: flat line (no heart beats) no life. But still, it begs the question: how long do you wait to see if it stays like that? Especially if there is someone in the waiting room on standby for an organ. I’m rather fond of each and every one of mine, and would not want to part with anything prematurely. No hunches or ‘I-just-got-back-from-lunch-and-there-was-a-flat-line’, eh? Some things are really important to get right.

Well, as if reading my mind, if not my ECG, an article surfaced in the Conversation that looked into the matter. It was written by Amanda van Beinum, at the time a PhD candidate in Sociology  at Carleton University, and Dr. Sonny Dhanani, from the Faculty of Medicine at the University of Ottawa (https://theconversation.com/when-is-dead-really-dead-what-happens-after-a-person-flatlines-153542); they wondered the same thing: when is death?

They -correctly, it seems to me- assume that the most common indication of death is when the heart stops beating. Under the ordinary circumstances that you and I are likely to encounter from day to day, when the heart stops pumping blood and oxygen around the body, nothing survives for long -not the brain, not the intestines, not the legs… well, you get the picture.

But the question still arises about how long you should wait before you decide you can lop out a kidney, or maybe disconnect a liver to give to somebody on the list. If you wait too long it spoils, too early and I, or whoever has the ECG strapped to his chest, spoils.

With these factors no doubt in mind, the authors and an interdisciplinary team of ‘doctors, bio-engineers and experienced clinical researchers… spent the past decade studying what happens when a person dies after their heart stops.’ And more critically, perhaps, whether the heart could restart on its own, especially without CPR (cardiopulmonary resuscitation), or medications. It’s a knife-edge walk, for sure, given that we all own hearts that have been customized by lives exposed to different conditions -different genes, different diets, different levels of health…

Their study, which was published in the prestigious New England Journal of Medicine, catalogued ‘observations of the dying process of 631 patients across Canada, the Czech Republic and the Netherlands who died in an intensive care unit.’ They even developed a computer program that was able to ‘capture and review heart rate, blood pressure, blood oxygenation level and respiratory patterns directly from bedside monitors.’

Interestingly -or scarily, some might say- they found that ‘human heart activity often stops and restarts a number of times during a normal dying process… The longest that the heart stopped before restarting on its own was four minutes and 20 seconds. The longest time that heart activity continued after restarting was 27 minutes, but most restarts lasted just one to two seconds.’ But anyway, nobody survived even if it did restart; they didn’t even regain consciousness. Phew…

Another rather thought-provoking thing was their observation that ‘it was common for the heart to continue to show electrical activity long after blood flow or pulse stopped… the heart rate (electrical stimulation leading to movement of the heart muscle) and pulse (movement of blood in the veins) only stopped together in 19 per cent of patients. In some cases, electrical activity of the heart continued for over 30 minutes without resulting in any circulation of blood.’

You almost wonder if they were too curious, eh? I mean, let the poor thing let die in peace, for goodness sakes. It’s almost like taking the door off the bathroom -some things were just not meant for public display. And sans door, perhaps undo concern might be engendered by seeing bits and pieces of activity that was never meant to appear in medical credential advertisements. So, ‘stops and restarts of heart activity and circulation are often part of the natural process of dying which we’d never suspect if an ECG wasn’t strapped on.’ And, like my nocturnal fridge visitations, neither of us are always in control.

Anyway, ‘the longest pause before heart activity restarted on its own was four minutes and 20 seconds supports the current practice of waiting five minutes after circulation stops before declaring death and proceeding to organ recovery.’

Death seems to be almost as complicated as the life which it is abandoning. This is not good news. When I shuffle off this mortal coil, I’d like to think it will be graceful, with no trips or stumbles as I leave the stage. None of us get many dress rehearsals to hone our skills, so I have to hope those who are present will realize I haven’t had much time to practice. I also hope they will have read the program notes and applaud at the right time; not too soon, you understand -that would be awkward, if not embarrassing- but only after it’s evident I’m not coming back. Wait the five minutes, eh? The rest is silence…

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