Friday, September 22, 2023

Health. Brain death, clinical death, coma, vegetative state: what are we talking about?

The Biomedicine Agency declares itself “very embarrassed” by “the falsehoods” sometimes spread in the context of dramatic news, such as the death of Sefa in a clash with the police in Élancourt and that of Socayna, killed by a lost ball in Marseille . . The public agency notes that “brain death is often described as a coma rather than a death.”

Regarding Socayna, the Agency is surprised by a widely reported statement from the Marseille prosecutor’s office, according to which “the 24-year-old girl who was suffering from brain death finally died.” For Sefa, the teenager who died shortly after a collision with a police vehicle, a report mentions the young man in a state of brain death “transferred to Turkey for treatment.” Which means that she could survive, but that is not the case: brain death is death, irreversible: “she is a deceased person. (…) his organs were kept artificially active, but his brain suffered irreparable damage, which constitutes his death,” the Agency detailed to Libération.

Brain (or encephalic) death

In cases of brain death, doctors notice a physically dead brain, with irreversible damage. In addition to a clinical examination, two flat encephalograms observed for at least 30 minutes allow this status to be established. Computed tomography angiography, with contrast material, may also be used. “We can then pronounce the state of brain death, which is superimposed on the expression “coma overcome””, Philippe Charlier, forensic doctor, explains to franceinfo.

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This state, however, can give “the illusion of life,” as forensic doctor Philippe Boxho calls it, because the heart still beats. “It is a difficult death to understand,” explains anesthesiologist Benoît Averland, deputy director of “collection and transplants” at the Biomedicine Agency: “We have a warm body, which moves” and we can “continue to fabricate the death of a dead person.” heartbeat, thanks to an artificial respirator.

But not without that: “If the brain stops working, there is no breathing and the heart stops after a few minutes,” he remembers. On the other hand, the installation of artificial ventilation can prolong for a long time – and unnecessarily – the state of “brain death”, with the brain destroyed but the heart beating.

Comme l’a rappelé mi-septembre sur is dead “.

Cardiac (or clinical) death

In short, “there are two ways to die,” remembers Benoît Averland: “Either the heart stops beating or the brain stops working.” However, a person’s death can only be noticed after his heart has stopped. Without help, a brain-dead patient’s heart quickly stops, leading to… cardiac death.

This cardiac (or clinical) death is the “real and constant” stoppage of the heartbeat. This quickly causes closure of the muscles, lungs and brain and therefore death.

There are many cases of “apparent death” (patients sometimes mistakenly present themselves as “coming back to life”) after severe hypothermia or taking beta-blockers, for example. Some were also able to be resuscitated for long minutes after cardiac arrest. But these situations, actually reversible, remain totally exceptional. It is also not uncommon for these patients to ultimately die in the following hours or days.

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Coma: generally reversible, but…

When not artificially induced to prevent suffering or accompany the end of life, coma assumes a reversible state: even unconscious for a long time, a person in a coma shows brain activity. Sometimes at least…

Coma, according to the Inserm definition, is “the most serious form of alteration of consciousness. A patient in a coma appears to be asleep, but does not respond to any stimuli, not even painful ones. This state, generally transitory, can be observed in a large number of diseases, neurological or not. »

In this state, there is no talk of death… except when it becomes irreversible. A few weeks before his death, on March 30, 2022, Yvan Colonna was presented by his lawyer Patrice Spinosi in a “post-anoxic coma”, related to a lack of oxygen in the brain. Clearly, the brain lesions were incomplete and low neurological activity persisted. But the inmate attacked in prison died in less than three weeks.

The difference is sometimes tenuous: this type of so-called “vegetative” coma was mainly embodied by Vincent Lambert, who spent more than ten years between life and death before dying in July 2019. According to Philippe Charlier, despite the brain damage severe, May breathe spontaneously or move some muscles. But without the ability to interact with the outside world, which characterizes a vegetative state, unlike the “pauci-relational” state (with a minimum level of interactions) defended by some of those close to him.

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Non-trivial consequences

As in the Vincent Lambert case, which sparked more than ten years of judicial battles, these designations are not without consequences: they allow judicial procedures to be qualified. Therefore, an investigation opened for “injuries” or “attempted homicide” can be reclassified as “homicide.”

With effects on the investigation itself, the prosecutions, but also the holding of the trial and the eventual reparations paid.

In terms of health, the Biomedicine Agency points out that only 1% of deaths, or about 5,000 a year, are due to brain death… but that they account for almost 80% of organ extractions. It is then essential to maintain cardiac activity until the transplant, to preserve the organs. A single brain-dead patient can save up to seven people. However, the Agency often faces, in addition to refusals of donations, a persistent misunderstanding of the nature of this irreversible state that is brain death.

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