I have decided to make this news report headline the focus of this post because of its importance to individuals and to our communities especially with regards to hospital practice vis-a-vis management of the dead. The details of the story are in The Times of India.
Certifying death may appear to be a routine task involving some quick procedures and paperwork, but it is as important as any other clinical work undertaken by a medical doctor. This is why in most countries, only a medical doctor, for good reasons, can certify that someone has indeed died. The mere appearance of lifelessness is not akin to death and that is why it takes the knowledge and skill of a physician to make that final call. Unfortunately, this all-important duty may be carried out rather in haste because of the general attitude of "finality" and low priority accorded to the apparently dead. Now you can imagine the risks individuals and the community at large may face in situations where the dead are "confirmed" dead at home, usually by non-doctors and the following action will be burial or embalmment in some mortuary depending on funeral practices.
Imagine the following:
1. The possibility that more people pronounced dead outside of the hospital may not actually be dead in the first place.
2. Some patients pronounced dead in the hospital and quickly (in minutes or a few hours) released to relations (who may already have a ready coffin to carry the body) for immediate burial, may not be dead after all and may have been buried in error! Immediate burial is common in some contexts in the developing world due to peculiar factors including culture and religion.
3. That the practice of immediate body preservation especially formalin embalmment, most of which in some countries are conducted outside of hospital facilities, could pose a potential risk of inadvertent termination of life of a patient in a possible state of "suspended animation". One may argue it is a remote possibility, but the loss of any life is 100% loss to the affected family.
The take-home is not that a state of "suspended animation" is such a common occurrence or that doctors often make mistakes in certifying death. The importance of this news report is the need to adhere strictly to protocol at all times, especially in dealing with the human body including after-life care. Often post-mortem care is neglected in many hospitals. The practice of calling the attention of the doctor to a "dead" patient often by other healthcare workers assisting and working closely with doctors, should be discouraged. Such labelling could be a potential block in the mind and attitude of the doctor in applying due clinical care, like resuscitation and diligent check for vital signs and reflexes before coming to a conclusion of "dead".
I'll recommend that a doctor's attention be brought to a patient with a simple and clear indication that the patient is no longer breathing or that the pulse is not felt etc. It therefore puts the doctor in the right frame of mind to trigger necessary steps including resuscitation measures, where applicable, before certifying death, especially in busy areas of clinical care like the Emergency Room. "Doctor this patient is dead" or "...has expired" should not be allowed. Certifying death should only be objective and meticulous and bodies should be deposited in a hospital mortuary preferably in a chiller for at least 24 hours before release to family. Similarly, when an autopsy is indicated, the body of the dead should not be taken straight to the autopsy table immediately after death certification at the ER or hospital ward. There are a lot of safeguards in bodies staying in a functional mortuary for at least 24 hours before further actions are taken except in exceptional circumstances. I must also state that in some circumstances, death is very obvious and does not require any further validation e.g., decapitation. However, the mere presence of certain features, usually associated with postmortem changes in the body of the dead, e.g., maggots, is not proof that this particular person is dead because the larvae can feed on any necrotic or dead tissues even in the living! This situation also applied to the index case, the "dead" man who woke up.
Whatever the situation, there must be dignified management of the dead in all cases, and no occasion should arise where "dead" bodies will wake up just before postmortem as reported in the Indian news report. It calls for due diligence in pronouncing someone dead and has medicolegal entailment.
