On Tue, Feb 08, 2005 at 04:29:08PM -0800, lakewood at copper.net wrote:
>
> This is an interesting case that prompts questions regarding
> EHRs surrounding death of a Patient. It also serves to
> illustrate how goverment can alter what should be a rather
> clear, concise medical event that must at some time and in some
> form be entered into the EHRs.
>
This sure is an interesting case.
Getting to list mails after 10 days of absence (out of town). A
bit late to respond, but in any case this is my reading on the
Provencio case (California).
I am not very familiar with the US laws, but there seems to be
some things amiss here. I would surely like to know the Legal/
Hospital side of the story, before anything else.
>
> comply with a variety of other policies, procedures, contracts,
> statutes and 'State Agency requirements'.
>
>From the Medical side, 'deaths' can be broadly divided into two
groups:
a) Clinically Certain death
This is the case in 99% of all deaths. Clinically, there is
no pulse, BP, respiration, corneal and light reflexes are
not elicitable. ECG would show no traces, and EEG flat.There
are no problems in certifying death in such cases.
b) Brain death
This 1% or less of all deaths is the grey area. These are in
cases of coma where cardio-respiratory support has been ini-
tiated while patient is alive. The brain may die, and there-
fore life cannot be sustained, but the support system still
maintains functions of certain organs. Exactly when to call
the person as being 'dead' (or 'brain dead') is a very very
difficult decision ... This determines the following:
- When to shut off life support systems
- When organs can be taken out for transplant (if donor)
Once the heart and lungs stop organs like 'liver' are of no
use within 15-20 mins for transplant purposes. The criteria
for such 'brain death' certification are varying at differ-
ent places/ states/ countries, but usually the following
apply:
- EEG is flat (no activity) in ALL leads
- Stoppage of cerebral circulation, demonstrated by carotid
angiography.
So obviously, a relatively advanced medical facility is a
prerequisite for declaring anybody 'brain dead' ... Other
organs may be quite functional.
> I was asked to comment on this. My response is private. For
> purposes of this list my position is that some provisions
> should be made to handle these weird cases. There is as of this
> date no solution to this case.
For purposes of the EHR, I suppose death certification based on
the following generally accepted criteria should suffice:
a) Death due to Certain Clinical death
o No pulse
o No BP
o No respiration
o No Corneal reflex
o No light reflex
o ECG - isoelectric (no pattern) (optional)
o EEG - isoelectric (all leads) (optional)
b) Death due to Brain death
o Comatose case (obligatory)
o EEG - isoelectric (obligatory)
o No Cerebral Blood flow (angiography) (subject to facility)
(doppler evidence is not sufficient)
I am not quite certain that from the medical side we should go
into things like 'legal', 'statutory', 'judicial', 'extra-
judicial' and other forms of 'death' for want of satisfactory
qualifying criteria to adopt such terminologies.
Dr USM Bish
Bangalore
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