Correspondence
Case 32-1997: Rocky Mountain Spotted Fever
N Engl J Med 1998; 338:1318April 30, 1998
- Article
To the Editor:
We were surprised by the description of a patient's demise at the end of the presentation of Case 32-1997 (Oct. 16 issue),1 which concluded: “The patient was declared brain-dead. She died after life-support measures were terminated.”
Since the definition of brain death was established by the Ad Hoc Harvard Committee in 1968,2 the determination of death has been based on either of the following medical criteria: irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem.3
The description of events in Case 32-1997 is of more than semantic importance. It is medically and legally clear that a patient who manifests the criteria of brain death is dead. If the patient was truly declared brain-dead, then death was determined at the time of that declaration, not when life-support measures were later terminated. There should be no confusion about what is now a well-accepted and fundamental determination of death.
3 ReferencesFrancis L. Delmonico, M.D.
Richard S. Luskin
New England Organ Bank, Newton, MA 021581
Case Records of the Massachusetts General Hospital (Case 32-1997)
Full Text | Web of Science | Medline2
A definition of irreversible coma: report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death
CrossRef | Web of Science3
Guidelines for the determination of death: report of the medical consultants on the diagnosis of death to the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research
CrossRef | Web of Science
Author/Editor Response
Dr. McNeely replies:
To the Editor: My apologies to Dr. Delmonico and Mr. Luskin and others who were troubled by my conclusion of the Case Record in question.
The case was particularly tragic because it concerned a healthy woman who contracted a serious but treatable disease, and I was struck by the problems of putting the clues together. It was in this frame of mind that I put down the facts and then read the final note, which stated that brain death had been declared, that the life-support systems had been removed, and that the patient's husband was in her room listening to the faltering beeps on an electrocardiographic monitor.
That mental image took me back to too many previous experiences and the attendant emotions, and I simply wrote what I had written so many times through the years after the heartbeats ceased: the patient was pronounced dead.
William F. McNeely, M.D.
Massachusetts General Hospital, Boston, MA 02114-2696
