The Tribune, Chandigarh, India

Death: a process, not an event
By Dr Vij, K

Perhaps one of the most difficult situations in medical practice is the management of the dying patient because in caring for such a patient, doctors come face to face not only with the limits of their medical capabilities and with the morality of the patient but also with their own morality.

Death has traditionally been defined as the cessation of life. Historically, law has accepted medicine's definition of death. Technological developments in the medical field have precipitated the need for a legal-re-evaluation of the medical definition, since death has both medical and legal status.

The interest of the deceased and the family, health-care-providers and society, all require a reliable process of determining when death occurs. Legal systems usually contain provisions regarding the "presumption of death" and the "presumption of survivorship" depicting the importance of these aspects.

Sections 107 and 108 of the Indian Evidence Act lay down that if it is shown that a person was a live within 30 years, and there is nothing to suggest the probability of his death, it is presumed that he is still alive unless proof is produced to show that the same person has not been heard of for seven years by those who would naturally have heard of him had he been alive.

Legal controversies may also arise over the question of which of the two persons died first in a common accident when both were found dead or where both bodies were not recovered. If the examination of the available bodies and the opinion of the experts do not provide factual support for determination, the issue may remain unresolved. However, if the two were husband and wife, or other relatives such as siblings, testamentary documents may establish a rule of inheritance or succession by providing that property will pass in a certain way in the case of simultaneous death".

When does death occur?

As a first consideration, it must be realised that there is no specific moment of death, or, putting it in another way, it may be stated that "death is the end of dying". It is a process rather than an event. During the ebbing of life there is a progression from clinical death to brain death, to biological death, to cellular death etc. Clinical death occurs when the body's vital functions — respiration and circulation — cease. When the brain is deprived of oxygen because of the cessation of circulation, brain death is inevitable because the human brain cannot survive the loss of oxygen for more than 6-10 minutes under normal conditions. If resuscitative measures are instituted at the moment of clinical death, brain death can be averted. On the other hand, brain death may follow despite re-animation efforts.

Interestingly, the brain also dies in steps because various strata of the brain behave differently in their response to oxygen deprivation. The cerebral cortex, the site of the highest centres, ceases to function first, then the cerebellum (the older part of the brain developmentally, having to do with the equilibrium) and lastly the so-called lower brain centres controlling respiration, heart rate and blood pressure die. If irreversible destruction of the highest centres of the brain occurs without damage to the vital centres as stated, there occurs permanent loss of consciousness and the victim may remain in deep coma. This may be termed as a persistent vegetative state or "the living cadaver". Ultimately, when all the components of the brain, including the vital centres, become dead, brain death gets established. The victim is dead in the somatic sense though not yet dead in the cellular sense. It is through this "physiological window" that the advances in removing the organs from the cadavers for transplantation purposes have broken through.

Medico-legal considerations of brain death:

The case State vs Shaffer, (perhaps the only case involving the question of the constitutional validity of the law of brain death), occurred during 1977 in Kansas on twin grounds — the statute allowed alternative definition of death too and that the statute did not spell out the necessary criteria or observations to be applied in declaring brain death and left it to the medical profession. (The first statutory definition of brain death was adopted by the Kansas Legislation in 1970).

Both challenges were dismissed by the Supreme Court of Kansas by laying down that the State Constitution did not require a single standard to be applied to all human deaths. On the second point, the court held that defining death should obviously be under the ambit of the medical profession as medical science formed the basis for the evaluation of the determinants of death and it was more so since medical science was subject to change and advancement. The court expressly recognised the need to keep the heart-lung equipment functioning as long as the donor was declared dead under the applicable law before any surgery was performed for the removal of organs for transplantation.

With the advent of the "Transplantation of Human Organs Act, 1994' (it was enacted in July, 1994, and the notification was issued in the Gazette of India on February 4, 1995), India has also given statutory sanction to the concept of "brain death". The aspect which deserves consideration is the criterian to be followed in switching-off the heart-lung apparatus since the maintenance of circulation and respiration by artificial means inherits some legal implications. It is obvious that artificial aids may be applied in the hope that natural circulation and respiration may get resumed after the "aids" are continued for some time. But natural functions may not get restored even after the use of artificial means for a considerable period. Therefore, where lies the point of demarcation, i.e when the artificial aids are to be stopped so that the doctor may not get involved in the charge of "culpable homicide not amounting to murder "or one of "rash and negligent act", if he has removed the "aids" indiscriminately. Ordinarily, it may be sufficient to wait for 10 to 15 minutes. If no evidence of spontaneous functioning of respiration/circulation is forthcoming, the doctor(s) may be justified in disconnecting the artificial aids because serious permanent impairment of the brain cells can occur with only four to six minutes of oxygen deprivation and the total loss of function generally supervenes when the deprivation exceeds 10 minutes.

Parenthetically, it should be noted that in most cases, as "brain death" per se occurs, total cardio-vascular collapse usually ensues within three to 10 days. There have been only a few reported cases in which survival has been prolonged beyond that point in adults.

A case arose in California where the victim had been shot in the head during a robbery attempt. There was evidence of brain death by EEG, although the victim's heart and lungs continued to function on a ventilator. In that case, the victim's family agreed to have him serve as a donor for cardiac transplantation surgery at the Stanford University Hospital. The victim was pronounced dead using the criterion of "brain death" and then flown to Stanford where the heart was removed for transplantation.

The defendant's attorney objected when the charge against his client was changed from assault with intent to murder of this first degree. The defence attorney claimed that the surgeon, who removed the heart, actually "murdered" the victim by his surgical act. The court disagreed and ruled that the patient (victim) had died and was considered brain dead as a result of the criminal act itself and nothing else.

—Dr Vij, K; MD, LLB is the Professor and Head of the Department of Forensic Medicine, Government Medical College, Chandigarh.

Grafting on beating heart
By Dr Virendar Sarwal

Bypass surgery, with the help of a heart-lung machine has well established itself as a procedure which has stood by the confidence of our patient population. It has given all our patients a better quality of life and long-term survival free from the fears of sudden death and heart attacks. In India the last 16 years have seen tremendous advances in the field of cardiac surgery and now we can compare our facilities with any other facility in the western countries. Whether it comes to techniques or the results we lack nowhere.

The techniques of bypass surgery are so advanced now especially with the use of arterial grafts that we have achieved a high success rate and a high and long-term benefit ratio as compared to earlier years. In the initial years — the 1960s — when bypass surgery started and the open heart surgery was developing because of the development of the heart-lung machine by Dr J. Gibbon, the mortality rate was high and the long-term results were not good. But enthusiasm was great about this new innovation so people tried to ignore this and persisted with the technique and improvised on the various aspects. Bypass surgery in the early 60's started with vein grafts taken from the legs and in 10 years' times i.e in the early 70's, it was replaced with arterial grafts for long-term durability. Vein grafts had shown to give us patency rates of 65% at 10 years while with arterial grafts patency rates are 98% at five years and 96% at 10%.

As we are aware that bypass surgery is done with the help of the heart-lung machine which is nothing but a replacement of the heart as a pump with a roller pump and lungs for oxygenation are replaced by artificial oxygenator which are connected to the body with the help of a number of a tubings and filters. For the time the diseased vessels are to be grafted and the bypassed heart is arrested and the pumping action of the heart is taken up by the heart — lung machine pumps. Ventillation is stopped because now the blood is purified with the help of artificial oxygenators through which oxygen is mixed with the blood. To achieve all this blood from the body is drained via tubings into the oxygenator and is then pumped back.

When the blood comes in contact with the artificial surfaces of the tubings and oxygenators there is a tremendous reaction generated by the body in response which affects the organs of the body like lungs, kidneys and muscles of the heart itself. This was the reason for higher mortality and complications in the earlier years.

Slowly, with new advances, we controlled all these factors by developing better oxygenators, better pumps like centrifugal pump and drugs were invented to reduce this inflammation (swelling) in the tissues. Steroids, aspartate and glutamate were some of the newer innovations and combined with better techniques of protections for the heart muscle we have now achieved almost zero morbidity + zero mortality in worse situations. Earlier the badly damaged heart or EF below 25% was supposed to be an extra risk for this bypass surgery but now it has also fallen into a normal risk sort of situation. As this again is achieved with the help of good heart muscle protection during surgery with chemical additions and temperature control there by reducing the O2 requirement of the heart itself and then giving nutrition to heart during the arrest period. And there was special equipment developed to assist the heart if need be after or during surgery called intra aortic balloon pump.

All this has brought us to a stage where we safely can bet on bypass surgery as a successful and beneficial surgical procedure. But two issues still need to be addressed — the enormous costs involved in this procedure and a subset of patients where there was the involvement of other organs along with the heart like patients with kidney failure, or with asthmatic lungs, or with previous brain damage from strokes or very old patients.

The other group was young patients who had only one or two vessel disease and wanted to go for surgery instead of angioplasty because of better long term results. These were the patients where one would like to avoid the use of the heart-lung machine to avoid its deleterious side-effects if possible.

Research started in this direction and efforts were made to do the same grafting on the beating heart itself without the use of the heart-lung machine — thus doing a procedure on an organ which is working but still getting repaired. Initially it came through small incisions like the incision on one side of the chest called midcab instead of a big central incision. But exposure to that incision was not good and the quality of grafting was also snot adequate so surgeons have now given it up. This was then replaced with the grafting on beating heart through the standard central incision and it has brought good results. In this technique called opcab we use a stabiliser to reduce the movements of the localised area of the heart where grafting has to be done. In the last five years this technique has been developed and tried and last two years have seen a revolutionary change. The two main advantages of this technique are cutting the costs of the procedure along with avoiding the side-effects of the heart-lung machine. The early results available with this technique are encouraging though not matched to the conventional bypass surgery. But still a patient in whom the risk of conventional surgery is too high to be operated upon it is worthwhile giving him relief for his cardiac symptoms by this procedure and at the same time not damaging his other organs like kidneys and lungs further. Added to it is the lower death rates in high-risk patients. Thus this technique is proving a boon for subsets of very high risk heart patients and now we can offer them a big relief. Also it has been able to cut down the cost of surgery also as disposable costs which are used in conventional cabg are cut.

There are limitations of this technique in the form of the quality of anastomosis as it is not as good as achieved on a still heart ("If you write on a moving train your handwriting is not as good as when you are writing, sitting on a table or chair"). The short-term graft patency rates are of the order of 86%-90% in the early studies available so far but it can be attributed to learning the curve also. The other limitation is where the vessels to be bypassed are either badly diseased or are deep into the muscle. The next group of limitations is emergency surgeries or bypass surgery associated with valve replacement.

The other major limitation is the grafting of back-surface arteries of the heart where there is a lot of compromise on blood pressure when the heart, while beating, is tilted to one side to achieve a good exposure. Various methods are being developed to overcome such a position of the patient, the infusing of a lot fluids and recently special cannulaes and pumps are being devised to maintain good pressure while the heart is tilted away. This again will help but add to the cost.

Thus a very-high-risk-group patient with multi-organ involvement need not worry about increased mortality as this procedure offers them a safe relief and also in those patients where finances are an issue again this procedure comes to their rescue. But Dr Denten A Cooley is right. "We should tailor our procedure towards our patients and not tailor made our patients to the procedures". We have used this procedure very judiciously in high-risk group and have found good results. May be, a new ray of "hope for the earlier stated high-risk group of patients".

—Dr Sarwal is a senior consultant at Malhotra Heart Institute and Medical Research Centre, Lajpat Nagar, New Delhi.

Wonders of lemon
By Monica Seth

Lemon can be considered as one of the best health promoting highly liked and versatile fruit. It belongs to the family of citrus/juicy fruits. So, it has been also named as citrus lemon.

Lemon is very commonly used in many Indian homes because of its refreshing fragrance and appealing taste. Lemon and honey in water are a very popular drink, which is enjoyed by a wide majority of people. Researchers reveal that if this fresh lime drink could replace all other soft and hard drinks, almost half of the health problems of this globe would disappear.

Lemon juice is packed with certain germ-killing and disinfecting chemicals that helps in killing the toxic elements and disease-causing organisms in the body. The juice also stimulates the flow of saliva and digestive juice thus making the enzymes available for easy digestion and assimilation of food.

When lemon juice, is used in hot drinks or on hot foods, the benefit ratio increases. This unique combination has been proved to relieve gastric tensions. No wonder, hot lemon tea without milk is a part of many people's daily diet.

Not only the juice but also the rind/peel has got beneficial oils and when it is consumed with boiled water, it cures urinary disorders.

A recent study done at the University of Western Ontario in Canada suggest that every glass of citrus juice we drink strikes a blow against breast cancer.

Lemon is the nature's best cleanser and can be helpful in treating the typical teenage problem of acne or pimples. A mixture of juice of one lemon with one spoon of glycerine in water can be used as a beauty lotion before going to bed.

Lemon juice can also substitute for salt to a large extent and thus satisfy the high blood pressure patients also. Warm lemon water has always been a part of the successful weight reduction regimes as it ensures a halt in the increasing the fat factory around the abdomen. This food medicine, if consumed regularly, will prolong life.

So there are now good reasons to say no to all other drinks when you go out next for some lunch or dinner and enjoy the cool and refreshing lime drinks.

People who are having some inflammatory digestive tract conditions need to restrict the use of lemon as it may aggravate the problem.

—Ms Monica Seth is a food and nutrition expert based in Panchkula.