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Death and dying

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Death or mortality is the end of the life of a biological organism. Death may refer to the end of life as either an event or condition.[1] Many factors can cause or contribute to an organism's death, including predation, disease, senescence, malnutrition and accidents. The principal causes of human death in developed countries are diseases related to aging.[1] Traditions and beliefs related to death are an important part of human culture, and central to many religions. In medicine, biological details and definitions of death have become increasingly complicated as technology advances.


Historically, attempts to define the exact moment of death have been problematic. Death was once defined as the cessation of heartbeat (cardiac arrest) and of breathing, but the development of CPR and prompt defibrillation have rendered the previous definition inadequate because breathing and heartbeat can sometimes be restarted. This is now called "clinical death". Events which were causally linked to death in the past no longer kill in all circumstances; without a functioning heart or lungs, life can sometimes be sustained with a combination of life support devices, organ transplants and artificial pacemakers.

Today, where a definition of the moment of death is required, doctors and coroners usually turn to "brain death" or "biological death": People are considered dead when the electrical activity in their brain ceases (cf. persistent vegetative state). It is presumed that a stoppage of electrical activity indicates the end of consciousness. However, suspension of consciousness must be permanent, and not transient, as occurs during sleep, and especially a coma. In the case of sleep, EEGs can easily tell the difference. Identifying the moment of death is important in cases of transplantation, as organs for transplant must be harvested as quickly as possible after the death of the body.

The possession of brain activity, or ability to resume brain activity, is a necessary condition to legal personhood in the United States. "It appears that once brain death has been determined … no criminal or civil liability will result from disconnecting the life-support devices." (Dority v. Superior Court of San Bernardino County, 193 Cal.Rptr. 288, 291 (1983))

Those maintaining that only the neo-cortex of the brain is necessary for consciousness sometimes argue that only electrical activity there should be considered when defining death. Eventually it is possible that the criterion for death will be the permanent and irreversible loss of cognitive function, as evidenced by the death of the cerebral cortex. All hope of recovering human thought and personality is then gone. However, at present, in most places the more conservative definition of death — irreversible cessation of electrical activity in the whole brain, as opposed to just in the neo-cortex — has been adopted (for example the Uniform Determination Of Death Act in the United States). In 2005, the case of Terri Schiavo brought the question of brain death and artificial sustenance to the front of American politics.


Evolution of aging

Main article: Evolution of aging

Enquiry into the evolution of aging aims to explain why almost all living things weaken and die with age (N.B. hydra and the possibility of biological immortality). There is not yet agreement in the scientific community on a single answer. The evolutionary origin of senescence remains one of the fundamental puzzles of biology.

In medicine

Causes of human death

Death can be caused by disease, accident, homicide, or suicide.[2] The leading cause of death in developing countries is infectious disease. The leading causes of death in developed countries are atherosclerosis (heart disease and stroke), cancer, and other diseases related to obesity and aging. These conditions cause loss of homeostasis, leading to cardiac arrest, causing loss of oxygen and nutrient supply, causing irreversible deterioration of the brain and other tissues. With improved medical capability, dying has become a condition to be managed. Home deaths, once the norm, are now rare in the first world.

In developing nations, inferior sanitary conditions and lack of access to medical technology makes death from infectious diseases more common than in developed countries. One such disease is tuberculosis, a bacterial disease which killed 1.7 million people in 2004.[3]


The physician's perspective

A qualitative survey of internal medicine doctors in the United States found three sources of satisfaction from medical practice:

  1. realizing a fundamental change in perspective via an experience with a patient
  2. making a difference in someone's life
  3. connecting with patients

The authors of the survey noted how often the meaningful events, such as connecting with patients, occurred at events, such as death, that normally suggest a failure of medical care.[5] The following research suggests factors associated with a meaningful death.

A qualitative study using focus groups that consisted of "physicians, nurses, social workers, chaplains, hospice volunteers, patients, and recently bereaved family members". The groups identified the following themes associated with a 'good death'.[6] The article is freely available and provides much more detail.

  1. Pain and Symptom Management. Patients want reassurance that symptoms, such as pain or shortness of breath that may occur at death, will be well treated.
  2. Clear Decision Making. According to the study, 'participants stated that fear of pain and inadequate symptom management could be reduced through communication and clear decision making with physicians. Patients felt empowered by participating in treatment decisions'.
  3. Preparation for Death. Patients wanted to know what to expect near death and to be able to plan for the events that would follow death.
  4. Completion. 'Completion includes not only faith issues but also life review, resolving conflicts, spending time with family and friends, and saying good-bye.'
  5. Contributing to Others. A family member noted, "I guess it was really poignant for me when a nurse or new resident came into his room, and the first thing he'd say would be, ‘Take care of your wife’ or ‘Take care of your husband. Spend time with your children.’ He wanted to make sure he imparted that there's a purpose for life."
  6. Affirmation of the Whole Person. 'They didn't come in and say, "I'm Doctor so and so." There wasn't any kind of separation or aloofness. They would sit right on his bed, hold his hand, talk about their families, his family, golf, and sports.'
  7. Distinctions in Perspectives of a Good Death

A separate study suggests that the patients' preferences will not be stable as death approaches and so the physician should consider re-evaluating these issues.[7]

In an essay, 'On Saying Goodbye: Acknowledging the End of the Patient–Physician Relationship with Patients Who Are Near Death' suggestions are made to health care providers for saying good-bye to patients near death.[8] The quotes below are from the article. The article is freely available and provides much more detail.

  1. Choose an Appropriate Time and Place
  2. Acknowledge the End of Your Routine Contact and the Uncertainty about Future Contact The doctor could say, "You know, I'm not sure if we will see each other again in person, so while we are with each other now I want to say something about our relationship."
  3. Invite the Patient To Respond, and Use That Response as a Piece of Data about the Patient's State of Mind The authors suggest saying "Would that be okay?" or "how would you feel about that?"
  4. Frame the Goodbye as an Appreciation The authors suggest examples such as "I just wanted to say how much I've enjoyed you and how much I've appreciated your flexibility [or cooperation, good spirits, courage, honesty, directness, collaboration] and your good humor [or your insights, thoughtfulness, love for your family]."
  5. Give Space for the Patient to Reciprocate, and Respond Empathically to the Patient's Emotion If the patients becomes tearful, the doctor can provide silence to allow the patient to respond, or the doctor may ask about what the patient is feeling.
  6. Articulate an Ongoing Commitment to the Patient's Care Do not make the patient feel abandoned, "Of course you know I remain available to you and that you can still call me".
  7. Later, Reflect on Your Work with This Patient

A randomized controlled trial of communication between health care providers and family members at the time of death reported that the intervention decreased the burden of bereavement.[9] The intervention consisted of a brochure and family conference that focused on the following items that are remembered with the mnemonic value:

  • to Value and appreciate what the family members said
  • to Acknowledge the family members' emotions
  • to Listen
  • to ask questions that would allow the caregiver to Understand who the patient was as a person
  • to Elicit questions from the family members. Each investigator received a detailed description of the conference procedure

Other difficult issues for physicians include providing sedation for a patient at death and discontinuing life support. The following case reports detail these experiences from the physician's perspective.[10][11]

Death in culture

Main article: Death in culture

See also


  1. 1.0 1.1 Kastenbaum, Robert (2006). "Definitions of Death". Encyclopedia of Death and Dying. Retrieved on 2007-03-31. 

  2. WHO: 1.6 million die in violence annually
  4. SJ Olshanksy et al (2006). Longevity dividend: What should we be doing to prepare for the unprecedented aging of humanity?. The Scientist 20: 28-36.
  5. Horowitz C, Suchman A, Branch W, Frankel R (2003). What do doctors find meaningful about their work?. Ann Intern Med 138 (9): 772-5.
  6. Steinhauser K, Clipp E, McNeilly M, Christakis N, McIntyre L, Tulsky J (2000). In search of a good death: observations of patients, families, and providers. Ann Intern Med 132 (10): 825-32.
  8. Back A, Arnold R, Tulsky J, Baile W, Fryer-Edwards K (2005). On saying goodbye: acknowledging the end of the patient-physician relationship with patients who are near death. Ann Intern Med 142 (8): 682-5.
  9. Lautrette A, Darmon M, Megarbane B, Joly LM, Chevret S, Adrie C et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007 February 1;356(5):469-78. PMID 17267907
  10. Edwards M, Tolle S (1992). Disconnecting a ventilator at the request of a patient who knows he will then die: the doctor's anguish. Ann Intern Med 117 (3): 254-6.
  11. Petty T (2000). Technology transfer and continuity of care by a "consultant". Ann Intern Med 132 (7): 587-8.

Additional references

  • Pounder, Derrick J. POSTMORTEM CHANGES AND TIME OF DEATH. University of Dundee. URL accessed on 2006-12-13.
  • Vass AA (2001) Microbiology Today 28: 190-192 at: [1]
  • Piepenbrink H (1985) J Archaeolog Sci 13: 417-430
  • Piepenbrink H (1989) Applied Geochem 4: 273-280
  • Child AM (1995) J Archaeolog Sci 22: 165-174
  • Hedges REM & Millard AR (1995) J Archaeolog Sci 22: 155-164
  • Cook, C (2006). Death in Ancient China: The Tale of One Man's Journey, Brill Publishers.
  • Maloney, George, A., S.J. (1980) The Everlasting Now: Meditations on the mysteries of life and death as they touch us in our daily lives. ISBN 0877932018

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