Hi Dr USM Bish, 50 state plus the federal government plus US controlled areas adds up to considerable variance is the government's approach to death and life-support. It is a general rulle that an individual should, in advance, declare their wishes regarding life support. This, however, is not necessarily a certainty and is likely to depend more on who assumes or is assigned control over decisions (personal experience here).
The obligation placed on Healthcare Practitioners and Facilities is serious since this may result in subsequent legal action during which the Practitioners and Facilities can be involved. The need to performed detailed recording is an unknown as is the need to accumulate and 'bundle' all available Healthcare-related data, making it available to requestors. This 'wrapup' phase can be difficult and can benefit from the introduction and maintenance of EHRs. Unfortunately this is not a clean, precise topic. As an example, a recent case in the state of Florida involved a wife who was 'brain-dead' and whose husband wanted to remove life support. Her parents decided this was inappropriate and took action. A special bill was passed in the state legislature and signed by the governor requiring that life support continue. This was appealed to the highest court the members of which narrowly agreed that this was 'extra-ordinary'. The entire process, I believe, took well over one year before life-support was removed. During that time the Facility along with the Practitioners were handling the situation very carefully. This may seem like an extreme case. It has occurred in other jurisdictions. At least in the US the need to continue recording may not stop when the practitioner decides that 'death' has occurred or that 'legal death' has occurred. There may be others who disagreed. My personal belief is that 'death' is final when the body is in its final resting place and there are no outstanding court orders to the contrary. The 'end' for EHRs has to be the final resting place. But I will add a caveat, i.e., there might be some person or entity interested in digging them up and having a look. Regards! -Thomas Clark USM Bish wrote: >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 > > >- >If you have any questions about using this list, >please send a message to d.lloyd at openehr.org > > > - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
