Table Of ContentBRAIN DEATH
AND DISORDERS
OF CONSCIOUSNESS
ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY
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NATHAN BACK, State University of New York at Buffalo
IRUN R. COHEN, The Weizmann Institute of Science
DAVID KRITCHEVSKY, Wistar Institute
ABEL LAJTHA, N. S. Kline Institute for Psychiatric Research
RODOLFO PAOLETII, University of Milan
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BRAIN DEATH
AND DISORDERS
OF CONSCIOUSNESS
Edited by
Calixto Machado
Institute of Neurology and Neurosurgery
Havana, Cuba .
and
D. Alan Shewmon
David Geffen School of Medicine at UCLA
Los Angeles, California
~ Springer
Proceedings of the IV International Symposium on Coma and Death, held March 9-12, 2004, in Havana,
Cuba
ISSN 0065-2598
ISBN 978-1-4757-0976-6 ISBN 978-0-306-48526-8 (eBook)
DOI 10.1007/978-0-306-48526-8
© 2004 Springer Science+Business Media New York
Originally published by Springer Science+Business Media in 2004
Softcover reprint of the hardcover 1s t edition 2004
All rights reserved. This work may not be translated or copied in whole or in part without
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PREFACE
Calixto Machado and D. Alan Shewmon*
Since ancient times, Christians and Hebrews considered breath or ruach as the
hallmark of life. Greeks believed that heartbeat delimited the frontier between life and
death. Therefore, over the centuries people were deemed dead when they stopped
breathing and their hearts stopped beating. The great pandemic disasters and the need for
early burial prompted a worldwide fear of being buried alive. Winslow, in 1740,
emphasized that putrefaction was the only sure sign of death. Nevertheless, the invention
of the stethoscope in the middle of the 19th century enabled physicians to detect weak
heartbeat and restricted respirations, raising their competence. This partially alleviated
public fears of premature burial.
The remarkable technological advances of the 20th century radically changed the
course of medicine, especially intensive care. The development of effective mechanical
ventilators and cardiopulmonary resuscitation ("reanimation") compelled physicians in
the late 1950s to grapple with a condition impossible even to imagine previously: one in
which the brain is massively damaged and nonfunctional while other organs remain
functioning. Is such a patient alive or dead?
This state was documented by French neurologists and neurophysiologists at the end
of the 1950s. The end of the 1960s witnessed the next major milestone, with the Report
of the Ad Hoc Committee of the Harvard Medical School. These years marked a turning
point when brain-oriented definitions of death started to be formulated, and brain death
(BD) was gradually accepted as death of the individual.
Nonetheless, there are still worldwide controversies over the very concept of human
death and the putative neurological grounds for diagnosing it (whole brain, brain stem,
and higher brain formulations of death). There are also disagreements over the diagnostic
criteria of BD, whether clinical alone, or clinical plus ancillary tests. Moreover, a group
of scholars who were strong defenders of a brain-based standard of death are now
favoring a circulatory-respiratory view. Hence, the debates on human death are far from
concluded .
• Calixto Machado, MD, PhD, President of the National Commission for the Determination and Certification of
Death. Institute of Neurology and Neurosurgery, Havana, Cuba. Email: [email protected]. D. Alan
Shewmon, MD, Professor of Neurology and Pediatrics, David Geffen School of Medicine at UCLA, Los
Angeles, CA 90095. Email: [email protected].
v
VI C. MACHADO AND D. ALAN SHEWMON
The sunny city of Havana has become the capital for discussions on human death for
more than a decade. The First International Symposium on Brain Death was held in 1992,
and the clear consensus among delegates was that the subject of human death was far
from over. Delegates from all continents reconvened for the Second International
Symposium on Brain Death in 1996 and the Third International Symposium on Coma
and Death in 2000. These were remarkable conferences, attended by the most outstanding
personalities in the field from multiple disciplines.
At the beginning of the new millennium, Havana will once again welcome
colleagues from around the globe to hold the Fourth International Symposium on Coma
and Death (March 9-12, 2004). This book is a selection of lectures from authors who are
prominent scholars in this area. We hope it will serve as a valuable source of knowledge
for present and future generations. The motivation to ever deepen our knowledge about
human death (and life) is a matter of human dignity.
CONTENTS
PEULOSOPEUCAL, ETEUCAL, AND
LEGAL ISSUES
Brain Death: Updating a Valid Concept for 2004 .................. :. ............................. 1
Julius Korein and Calixto Machado
The Concept of Brain Death ................................................................................ 15
Jean-Michel Guent
The "Critical Organ" for the Organism as a Whole: Lessons
from the Lowly Spinal Cord ................................................................... 23
D. Alan Shewmon
"Brain Death" Is Not Death ................................................................................. 43
Paul A. Byrne and Walt F. Weaver
The Conceptual Basis for Brain Death Revisited: Loss of
Organic Integration or Loss of Consciousness? ...................................... 51
John P. Lizza
Consciousness, Mind, Brain, and Death .............................................................. 61
Josef Seifert
The Death of Death .............................................................................................. 79
James J. Hughes
vii
viii CONTENTS
The Semiotics of Death and Its Medical Implications ......................................... 89
D. Alan Shewmon and Elisabeth Seitz Shewmon
About the Continuity of Our Consciousness ...................................................... 115
Pim V ~n Lommel
Brain Death and Organ Transplantation: Concepts and Principles
in Judaism ............................................................................................. 133
Z. Harry Rappaport and Isabelle T. Rappaport
Cuba Has Passed a Law for the Determination and Certification
of Death ................................................................................................. 139
Calixto Machado and the National Commission for the
Determination and Certification of Death
DIAGNOSIS, PATHOPHYSIOLOGY AND
TREATMENT
Neuroprotection Becomes Reality: Changing Times for Cerebral
Resuscitation ......................................................................................... 143
Maxwell S. Damian
Controlled Hypertension for Refractory High Intracranial Pressure ................. 151
Philippe Hantson
On Irreversibility as a Prerequisite for Brain Death Determination ................... 161
James L. Bernat
How Should Testing for Apnea Be Performed in Diagnosing
Brain Death? ......................................................................................... 169
Christoph J. G. Lang and JosefG. Heckmann
CONTENTS IX
Evoked Potentials in the Diagnosis of Brain Death ........................................... 175
Enrico Facco and Calixto Machado
Recovery from Near Death following Cerebral Anoxia:
A Case Report Demonstrating Superiority of Median
Somatosensory Evoked Potentials over EEG in
Predicting a Favorable Outcome after Cardiopulmonary
Resuscitation ......................................................................................... 189
Ted L. Rothstein
Human Brain-Dead Donors and 31p MRS Studies on Feline
Myocardial Energy Metabolism ........................................................... 197
George J. Brandon Bravo Bruinsma and
Cees J.A. Van Echteld
Organ Donation after Fatal Poisoning: An Update with Recent
Literature Data ...................................................................................... 207
Philippe Hantson
The ABC ofPVS: Problems of Definition ........................................................ 215
D. Alan Shewrnon
Brain Function in the Vegetative State .............................................................. 229
Steven Laureys, Marie-Elisabeth Fayrnonville,
Xavier De Tiege, Philippe Peigneux, Jacques Bern~,
Gustave Moonen, Serge Goldman, and Pierre Maquet
Global Neurodynamics and Deep Brain Stimulation:
Appreciating the Perspectives of Place and Process ............................. 239
David I. Pincus
Honoring Treatment Preferences near the End of Life:
The Oregon Physician Orders for Life Sustaining
Treatment (POLST) Program ............................................................... 255
Terri A. Schmidt, Susan E. Hickman, and Susan W. Tolle
