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Declaration of Death

Artificial respiration enables the physician to discontinue respiration at any time or to continue it ad infinitum. Termination of support, however, can be regarded as unlawful killing (Gerber 1984) or euthanasia (Oehmichen 1996), an issue that was exhaustively discussed, for example, also in the controversy

Fig. 15.6a-d. Leptomeningeal reaction of the spinal cord. a Early within the SAS commonly originating from the cerebellar tonsils. leukocytic infiltration of the hemorrhagic subarachnoid space (a, c N-AS-DClAE; b, d van Gieson stain; magnification a-c X300) (SAS) and b-d late demonstration of hemorrhagic necrotic tissue

Fig. 15.6a-d. Leptomeningeal reaction of the spinal cord. a Early within the SAS commonly originating from the cerebellar tonsils. leukocytic infiltration of the hemorrhagic subarachnoid space (a, c N-AS-DClAE; b, d van Gieson stain; magnification a-c X300) (SAS) and b-d late demonstration of hemorrhagic necrotic tissue surrounding the Quinlan decision (Beresford 1977). Prolongation of artificial respiration can conflict, on the other hand, with the individual's "right to die with dignity." This in turn may be opposed by the necessity for removal of vital organs for transplantation and by the prohibitive cost of extended time on a respirator.

In cases with an unfavorable prognosis, therefore, irreversible loss of brain function is a cogent criterion on which to base declaration of death. Of fundamental importance are the clinical and technical criteria on which the diagnosis is based. In Germany, the criteria for brain death are set by the Scientific Advisory Committee of the Bundesarz-tekammer, as last issued in 1998 (Deutsches Arzteb-latt 95:B1509-B1516). Similar criteria exist in other countries (Walker 1985). These criteria resulted in a new definition of "death" that was readily accepted by physicians and judges (Grassberger 1973; Roxin 1973).

The definition of death is based on the irreversible loss of total brain functions, and - when the stipulated criteria have been met - on the termination of artificial respiration. It also enables the discontinuation of resuscitative measures if it can be assumed that brain death has already occurred. In theory then, death can be declared after circulatory arrest lasting for a period of at least 10 min; however, to allow a margin of safety, attempts at resuscitation are generally continued for 15-20 min.

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