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TITOLO: Thresholds in the dying process

Authors (max 6, presenting author included): Carlo Alberto Defanti

The fundamental fact we face is that death today is almost never an event, but mostly a process,more or less lengthy, profoundly modified by the medical intervention. We can distinguish severalthresholds and we try to describe them in a schematical way.A first threshold is loss of consciousness: the coma state, long ago antechamber of death, now a

possible transient stage both toward death itself and awakening and life.A second threshold is the vegetative state (VS), which can be a phase precedent death in thecourse of progressive central nervous diseases, but usually is a transient condition followingcoma after an acute brain damage. VS can evolve toward awakening or minimally consciousstate, but sometimes become a stable condition: the permanent vegetative state (PVS), defined bysome cortical death.A third, most important threshold is irreversibile coma or brain death. Along with some

scholars I maintain that contrarily to the common opinion it doesnt coincide with the deathof the organism as a whole (only cardiocirculatory arrest is a good candidate for this), butcertainly is a point of no return.A fourth threshold is cardiocirculatory arrest, the old cardiac death.A possible fifth threshold is the temporal threshold of vitality of organs and tissuesafter cardiacarrest, clearly a very important point for the sake of transplantation.After this description of the stages of the dying process, we have to tackle with the moral problemraised by the treatment of the dying person during the various steps. Obviously in the coma state,when prognosis is not clear, our duty is to aggressively treat the patient in order to make it

possible for him/her to recover. Long ago this attitude was mandatory in each case, but now, atleast when strong prognostic signs announcing death or PVS are present, the correct attitude is towithdraw life- sustaining treatments.In VS patients with favorable prognostic signs the full treatment has to be given.In the case of PVS, the withdrawal of life-sustaining treatments and especially artificial nutrition

can be discussed, according to a possible advance directive executed by the patient.Brain death clearly justify withdrawal of life-sustaining treatments and harvesting organs whenthe person agreed or at least not dissented with this.In the case of sudden and unexpected cardiac arrest, a trial of resuscitation is mandatory and its

possible failure shows that the condition is irreversible and death can be declared. If cardiacarrest happens during the course of a disease with fatal prognosis, no resuscitation is mandatoryand death can be declared.Sometimes, when the dying process is due to a progressive brain disease and (cardiac) death isforeseeable, organs can be harvested a very short time after cardiac arrest, with consent of thelegal representative, according to the so-called Pittsburgh protocol.

Session: Neurology & palliative care

Chair of the session: Dott. Ignazio R. Causarano

Antea Worldwide Palliative Care ConferenceRome, 12-14 November 2008

Carlo Alberto Defanti

c.defanti t in.it

mailto:c.defanti@tin.itmailto:c.defanti@tin.it

8/14/2019 Defanti Carlo Alberto

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Neurology & palliative care