Life and death are often only separated by a line,
But this "frontline" is full of mystery...
Foreign media reported one such case in September 2019:
A pregnant woman in the Czech Republic suffered a stroke and died of brain death at 15 weeks' pregnancy.
The magic is:
After 117 days, the woman gave birth to a baby girl by caesarean section.
This is the longest recorded time of artificially maintained pregnancy among brain-dead mothers.
Source: Headlines
At this point, are pregnant women "dead"?
How to define the fragile and tough line of life and death?
What state of man is defined as "death"?
Part1
How is death determined?
Death is a natural phenomenon in the biological world, and for thousands of years, the idea of "heart death" has been deeply integrated into medicine, law, ethics and morality.
The Yellow Emperor's Inner Classic, more than 2,000 years ago, said: "The pulse is short, the breath is desperate, and death." The traditional standard of death, which defines death as the complete cessation of blood circulation, the cessation of breathing and pulse, has been widely recognized around the world for thousands of years.
Image source: Stand Cool Helo
But things have changed a lot since the mid-20th century, with people beginning to question the criteria for cardiopulmonary death and beginning to explore new definitions and criteria for death.
In recent years, due to the progress of modern medicine, the effective application of modern mechanical recovery and the need for organ transplantation, there has been a further understanding of death in medicine, law, ethics and public opinion.
The traditional concept of death is constantly being attacked, and brain death has gradually been understood and accepted by the public.
In the case mentioned at the beginning, medically speaking, when a pregnant woman dies, it is actually "brain death".
"Brain death" is an already strictly defined concept that refers to "the irreversible loss of whole brain function, including brainstem function"[1].
The brain is the "general command" of the human body to receive signals and transmit orders, and all the activities of the human body are directed by it. Within the highest organs, there are also different divisions of labour.
Basic life activities that we are not aware of ourselves, such as heartbeat, breathing, blood pressure, digestion, body temperature, etc., are responsible for the brainstem.
Activities that we can consciously control, such as eating, walking, reading, studying, and talking, are responsible for other parts of the brainstem.
The task of the brainstem is to make your body function normally and survive.
The biggest difference between deep coma, loss of brain function, brain death and what we usually call vegetative people is whether the brainstem function is intact.
· Vegetative brainstem function is present, coma is only due to severe damage to the cerebral cortex, or in a state of sudden inhibition, with spontaneous breathing, heartbeat, blood pressure and some basic reflexes, and hope of awakening [2];
· Brain death does not breathe spontaneously, will not wake up again, the brain response completely disappears, consciousness is completely lost, the body's various organs can not respond to the environment, there is no autonomous activity, is a permanent, irreversible loss of whole brain function.
Although it has been half a century since the introduction of brain death, the acceptance of brain death varies from country to country: the United States, Germany, Japan, France, Finland and other countries have used laws to determine the standard of brain death;
In the United Kingdom, Switzerland, South Korea, Austria and other countries, brain death is recognized in clinical practice, but no formal legal provisions are specified.
In most developing countries, the standard of brain death is not accepted by society, and the traditional cardiopulmonary death standard still dominates, among which the countries that recognize both heart death and brain death as the basis for death judgment include the United States, Japan, Austria, Switzerland, Finland, etc.
In China, the problem of brain death has gradually entered the public eye, but there are no formal laws and regulations on brain death [3].
In 2015, the former Brain Injury Quality Control evaluation center of the National Health and Family Planning Commission established standards and technical specifications for the determination of brain death [1]. At present, the mainland still uses heartbeat and respiratory arrest as widely used clinical markers of death.
Part2
Why can brain death give birth to children?
It has something to do with medical progress.
Brain death during pregnancy is very rare, and only 30 cases have been described in the medical literature since 1982 [4,5].
In the era of underdeveloped medical treatment, once the brainstem and whole brain function are damaged, and the irredeemable loss of function is "brain death", then the body will immediately stop functioning, and the spontaneous breathing and heartbeat will stop, that is, "heart death".
Therefore, the direct result of brain death is heart death, which is equivalent to pronouncing a person's official death.
In the case mentioned at the beginning, 4 months after the brain death of the pregnant woman, the hospital maintained the vital signs of the pregnant woman with equipment such as an in vitro ventilator, injected special nutrient solution to ensure fetal nutrition, injected hormones to maintain the stability of the mother's internal environment, gave antibiotics to control infection, simulated walking with instruments to stimulate fetal growth, etc., and carried out strict testing of the mother and fetus.
Relying on these measures, the fetus can live and grow healthily in the womb and come into the world after a cesarean section nearly four months later [6].
Part3
How does human death happen step by step?
For the vast majority of people, death does not happen suddenly, but has a gradual process. The experience of death occurs, develops, and ends.
Death begins in the near-death phase and goes through the clinical death phase to biological death. There is no clear boundary between the three phases.
Near-death
It is also called the state of dying. The main features are loss of central nervous system function or deep inhibition above the brainstem, manifested by slow response, confusion or disappearance, sluggish or weakened reflexes of various kinds, weakened heartbeat, decreased blood pressure, and weak breathing.
The duration of the near-death period varies and can range from a few seconds to a few hours depending on the health of the body and the cause of death.
The young and strong have a long period of death, and the old and infirm have a short period of death.
In general, those who die of chronic diseases have a long period of near-death, while those who die of rapid death, severe head injury, cardiac stabbing and cyanide poisoning are short or completely absent from the near-death period and directly enter the clinical death period.
Clinical death phase
When breathing and heartbeat stop, it enters the clinical death period, also known as physical death or individual death.
In this period, the inhibition process of the central nervous system is further aggravated, the deep coma, the autonomic activity completely disappears, the pupil dilates, various reflexes disappear, and the human body is unable to respond to any stimulus from the outside world.
During clinical death, the brain tolerates hypoxia for 4-6 minutes after the cessation of blood circulation, which is the duration of the general clinical death period.
Patients in the clinical death phase, if active first aid measures are taken under certain conditions to restore the patient's breathing and heartbeat, it is possible to resuscitate the body. Therefore, the rescue work must be a race against the clock.
Biological mortality period
The last period of brain death is the biological death phase, also known as total death, cell death or molecular death, which is the final stage of the death process.
In this phase, irreversible changes occur in the central nervous system, and the function is permanently stopped. Since then, the metabolism of various organ systems in the human body has stopped one after another, and irreversible changes have occurred, and the entire body function has been impossible to reverse [7].
Life and death, as the ultimate mode of existence of life, have been the proposition of medicine and philosophy since ancient times.
Life is fragile by the presence of death, but it is also resilient by the presence of death.
It is often said that tomorrow and accidents do not know which one comes first. We should cherish life, take every dawn as the beginning of life, take every dusk as the summary of life, and let the flower of life bloom to the fullest!
bibliography:
[1] Su Yingying,Zhang Yan,Ye Hong,Gao Daiqi,Chen Weibi. Criteria and Technical Specifications for Determining Brain Death (Adult Quality Control Edition)[J].Chinese Journal of Modern Neurological Diseases,2015,15(12):935-939.
[2] Proceedings of the Expert Symposium on formulating diagnostic criteria for persistent plant states in mainland China[J].Emergency Medicine, 1996(02):95.
Liu Mingyu,Sui Suli. Discussion on ethical and legal issues of brain death standards[J].Chinese Hospital,2016,20(02):62-64.
[4] Boran F, Yazar FM, Bakacak M: Assessment of somatic support process for pregnant brain death patients occurring in a transition country between Asia and Europe from medical, ethical, legal and religious aspects: J Relig Health, 2020; 59(6); 2935-50
[5] Pikto-Pietkiewicz I, Okniński A, Wójtowicz R: The management of a thirteen weeks pregnant woman rendered brain-dead following a ruptured aneurysm: J Crit Care Med (Targu Mures), 2019; 5(3); 111-14
[6] Gal R, Zimova I, Antoni H, Minarcikova P, Ventruba P, Hruban L, Hrdy O. Delivery of a Healthy Baby from a Brain-Dead Woman After 117 Days of Somatic Support: A Case Report. Am J Case Rep. 2021 May 18;22:e930926. doi: 10.12659/AJCR.930926. PMID: 34001845; PMCID: PMC8141338
Wang Baojie. Forensic Science (Fourth Edition)[M].Beijing:People's Medical Publishing House,2004,15-16.]
Review expert: Wang Chunxue| Chief Physician, Professor, Doctoral Supervisor, Department of Neurology, Beijing Tiantan Hospital
Editors: Wei Luo, Zhang Jie, Wang Yan
Proofreader: Wu Yihe
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