Who should make the call that a patient is dead, and when?

When should doctors and nurses and EMTs stop trying to save or artificially preserve a patient's life? And just who gets to make the call that someone's dead?Several recent studies illustrate today's complex terrain of terminating care and declaring death in different settings.First, there's death outside the hospital, specifically death from sudden cardiac arrest, something that kills more than 160,000 Americans a year.Tens of thousands of these victims are rushed to hospitals around the country from wherever they fell, in speeding ambulances with lights flashing, staffed by paramedics who know there's only a 5 percent, maybe 10 percent, chance the patient will even be revived at the hospital, and worse odds that they'll ever go home.Researchers at the University of Michigan and Emory University recently published a study that found medics could use a simple checklist to determine when they should cease efforts to resuscitate cardiac arrest patients who are not responding to treatment at the scene and when they should continue their efforts while transporting to the nearest ER.The study examined the cases of 5,500 cardiac arrest patients treated in eight metropolitan areas around the U.S. Of those patients, emergency crews pronounced 947 dead at the scene, and transported the rest to one of 111 hospitals. But only 7.1 percent of them survived to be discharged from those hospitals alive.But if medics could use some simple standards, like whether a defibrillator was used and if a patient's blood circulation was restored or not, the researchers found that fewer than half the patients would have been rushed to an ER.Dr. Comilla Sasson, an ER doctor and researcher at the University of Michigan who was lead author of the study in The Journal of the American Medical Association, said using such a standard would reduce risks to emergency medical workers and the public from futile high speed ambulance runs, while reducing pressure on overcrowded ERs that otherwise have to re-evaluate and treat patients whose hearts had stopped long before they arrived.Other researchers have found that if standards for cardiac arrest care are vague, the protocols hospitals use to determine brain deaths are even trickier.A survey published earlier this year in the journal Neurology found that even in some of the nation's top neurology and neurosurgery centers, docs don't follow standards set by the American Academy of Neurology more than a decade ago for establishing the irreversible loss of function in the entire brain.After reviewing the 38 written guidelines for brain death determination that were available from 41 responding hospitals, "we were surprised to find such significant differences among these hospitals in terms of their guidelines,'' said Dr. David Greer, a neurologist at Massachusetts General Hospital.Among the inconsistencies: different standards for the level of training and expertise required for doctors to be authorized to determine brain death, inconsistency in conditions that need to be met to establish that the patient's condition is irreversible and differences in the type and timing of exams used to determine brain death.Still another study, published in the American Journal of Respiratory and Critical Care Medicine, found that intensive care unit doctors have a surprising tendency to gradually withdraw life support systems from patients with no chance of survival.After looking at records of 500 patients who died in the ICU or within a day of discharge at 15 Seattle area hospitals, Dr. J. Randall Curtis and colleagues found that during their final days, the patients were on an average of four life-support systems, from mechanical ventilation to tube feeding."We found that sequential withdrawal of life support is not as rare a phenomenon as previously believed,'' said Curtis, chief critical care medicine at Harborview Medical Center and the University of Washington in Seattle. "It occurred in nearly half the patients we studied."The researchers had expected that such drawn-out processes would be more stressful and upsetting to survivors (as well as patients), but found instead that most family members were more satisfied with the care than families of patients in which all therapies were stopped the same day.The bottom line, Curtis says, is that ICU doctors often aren't doing a good job communicating with families to help them prepare for the best death possible of a loved one, As a result, they often embark on a halting withdrawal of life support in order to have more time to prepare the family.On the Net: http://www.jama.comAan.orgAjrccm.atsjournals.org(E-mail Scripps Howard News Service health and science reporter Lee Bowman at bowmanl(at)shns.com.)(Distributed by Scripps Howard News Service, http://www.scrippsnews.com)