Exact Time Of Death Research Articles

The Impact of Voluntary Assisted Dying on Grief and Bereavement for Family Members and Carers in the Australian State of Victoria: A Qualitative Study

Prior to its introduction in Australia, many people opposed euthanasia—or voluntary assisted dying as it is known—because of its potentially detrimental impact on grief and bereavement outcomes for family members and carers. We examine the novel experiences of grief and bereavement of VAD for family members and carers who were going through, had gone through, or were contemplating VAD, juxtaposing the international literature on grief and bereavement. As such, 42 semistructured interviews with family members and carers were undertaken in the state of Victoria, which was the first jurisdiction to legislate in favour of VAD. Interviews explored many themes around end-of-life decision-making in order to ascertain the ways in which VAD helped or hindered grief and bereavement processes. A thematic analysis of the interview data was undertaken using QSR NVivo software. Four key themes were identified: values and meaning-making, expression of a continuing bond, anticipatory grief, and the burden of care associated with supporting loved ones going through VAD. These themes were juxtaposed with the key literature on grief and bereavement to demonstrate how VAD presents novel challenges for carers. We argue that while VAD deaths share similar characteristics to other deaths; in some respects, grief and bereavement outcomes for family members and carers are unique. For family members and carers helping a loved one go through VAD, they were able to derive a sense of meaning from fulfilling their wishes and striving for them to have a “good death”; they were able to maintain a bond with them through advocacy of VAD and unique rituals; and they were able to plan and prepare effectively by knowing the exact time of death. Family members and carers also noted that VAD presents some significant challenges for grief and bereavement, especially in terms of the impact of VAD on familial relationships and burdens associated with moral predicaments. Nonetheless, VAD was generally viewed positively by family members and carers, who expressed gratitude for mitigating their loved one’s suffering.

Winter mortality of a passerine bird increases following hotter summers and during winters with higher maximum temperatures.

Climate change may influence animal population dynamics through reproduction and mortality. However, attributing changes in mortality to specific climate variables is challenging because the exact time of death is usually unknown in the wild. Here, we investigated climate effects on adult mortality in Australian superb fairy-wrens (Malurus cyaneus). Over a 27-year period, mortality outside the breeding season nearly doubled. This nonbreeding season mortality increased with lower minimum (night-time) and higher maximum (day-time) winter temperatures and with higher summer heat wave intensity. Fine-scale analysis showed that higher mortality in a given week was associated with higher maxima 2 weeks prior and lower minima in the current fortnight, indicating costs of temperature drops. Increases in summer heat waves and in winter maximum temperatures collectively explained 62.6% of the increase in mortality over the study period. Our results suggest that warming climate in both summer and winter can adversely affect survival, with potentially substantial population consequences.

Evaluation of elements in human dental tissue in terms of determination of postmortem interval: Experimental study

Despite many methods, there has not been a method yet that exactly determines PMI. This study aims to examine the relationship between the element levels in the dental tissue and the postmortem process in a corpse whose exact time of death is unknown and in the open field and to evaluate its use in determining the time of death by evaluating the increase-decrease-changes. For the study, the healthy and extracted third molars of the patients who applied to the Oral and Maxillofacial Surgery Polyclinic for the extraction of their third molars for various reasons and whose third molars were extracted by the dentists were taken. The samples were divided into 6 groups, with 10 samples in each group. The teeth were left to decay in the open air in a jaw-like plastic model. Na, Mg, P, Ca, Fe, Mn, Co, Zn, Cd, Pb, and Si elements were measured using Inductively Coupled Plasma-Mass Spectrometer analysis method. In our study, it was determined that there were statistically significant changes in the Na, Mg, Fe, Co, Pb, Si elements in the tooth structure. For the Co and Na elements, 2 regression equations were created that can be used to predict the time of death. This work showed that postmortem tooth element concentration changes can be used to predict the time of death. As a result of experiments that will cover longer periods with more elements and be carried out in different environments, a great contribution will be made to the subject of estimation of time of death which is not clear yet.

Estimation of Time Since Death from Rigor Mortis - An Autopsy Study in Tertiary Care Hospital of Malwa Region of Punjab state of India

Background: Postmortem interval estimation is an important tool in forensic medicine. Estimating time since death is extremely important in cases where there is doubt about the period of death. After death, many changes occur in a regular sequence and can be used to arrive at an approximate time since death. When a post-mortem is conducted, doctor conducting the post-mortem examination has to give his opinion about post-mortem interval i.e. the probable time that elapsed between death and post-mortem examination even in cases of decomposed dead bodies. While giving this opinion, we always think we should have some other dependable methods to be more accurate in answering this question. Algor mortis, Rigor mortis, and Livor mortis have been the basis for ascertaining the post-mortem interval collectively. Among them, Rigor Mortis is an important indicator of post-mortem interval. Although it is a dependable tool for estimating post-mortem interval, it is influenced by many endogenous and exogenous factors like nature of death, nature of the body, temperature, humidity etc. Time of death is almost always asked by investigating authorities to connect the crime with criminals. Determining the death time has always been a topic of keen interest amongst forensic pathologists from its inception to date. Many workers in forensic medicine have tried to investigate to determine the time of death based on post mortem findings. To date, it is still an important and fascinating criterion to ascertain the time since death. With this study, we aimed to demonstrate the intricacies of Rigor Mortis with fluctuating temperature and humidity of the local region. We planned to estimate and compare the post-mortem interval based on Rigor Mortis in different body muscles. Materials and Methods: This study was conducted in the Department of Forensic Medicine and Toxicology at G.G.S. Medical College, Faridkot after taking clearance from the institutional ethics committee. Thirty medico-legal autopsy cases were included in the study where the exact time of death was known and included only hospital deaths. The relatives of the deceased were explained the purpose and nature of the study and provided with the patient information sheet and informed consent was taken. The details of the cases were noted from the hospital bed head ticket, relative interview and the police inquest papers. The exact temperature and humidity were noted at the start of autopsy using a digital hygrometer. Results: A total of 30 cases were observed out of which males outnumbered the females by approximately 3:1. Maximum cases consisted of Roadside Accidents (43.3%) followed by poisoning, assault and hanging, in that order. The average temperatures during the study months varied from a maximum of 41.3°C (June) to a minimum of 33.7°C (July). The average humidity varied from a maximum of 62.6% (July) to a minimum of 29.3% (May). The average temperatures during the study months varied from a maximum of 41.3°C (June) and a minimum of 33.7°C (July). The average humidity during the study months varied from a maximum of 62.6 % (July) and a minimum of 29.3% (May). Fully established Rigor Mortis was observed at a minimum of 10 hours and a maximum of 29 hours in May and June.

ULTRASOUND STANDARDS FOR ANTENATAL FETAL DEATH

Antenatal death is the cessation of fetal heart contractions during pregnancy for more than 22 weeks prior to the onset of labor. Objective: to evaluate the capabilities of the method of ultrasound in antenatal fetal death. Tasks of ultrasound in the presence of a dead fetus: a statement of his death; determining the position, presentation, size, estimated fetal weight and gestational age; detection of congenital malformations (CM) and possible causes of death; clarification of the statute of limitations of death. We have analyzed 126 standard ultrasound protocols of pregnant women with antenatal fetal death. Ascertaining the cessation of heart contractions and determining the location of the fetus present no difficulties for the ultrasound doctor. The assessment of the conformity of the size of the fetus to the gestational period during antenatal death is better determined by measuring the diaphysis of the long bones. Head sizes are used only when it is possible to clearly assess the typical structures of a biparietal slice. The determination of the estimated mass of the fetus is difficult due to autolytic changes and, usually, lack of water. The diagnosis of CM, first established after ascertaining antenatal fetal death, should cause the doctor to doubt that it is in front of us — a developmental defect, as a possible cause of intrauterine death or post-mortem changes that depend on previous intravital changes, cause and duration of death. The article describes the dynamics of the appearance of post-mortem changes. Conclusions: with antenatal fetal death, it is impractical to determine the expected mass of the fetus, it is preferable to estimate the period of probable cessation of development from the measurement of long tubular bones; during an ultrasound of the deceased fetus, it is often impossible to reliably determine the presence/absence of CM and the exact time of death; change in the amount of amniotic fluid is not a reliable diagnostic criterion for the duration of death.

Use of Optical Coherence Tomography on detection of postmortem Ocular findings: pilot data from two cases.

PURPOSE: The aim of this study was to describe by means of a portable Optical Coherence Tomography (OCT) the postmortem ocular findings in two cases of forensic interest. CASE 1. A 41-year-old Caucasian man, dead from a gunshot in the head, was found inside his car. Time of death was precisely assessed from the testimony of eye witnesses. The body was transported at the Morgue of Medico-Legal Institute at the University of Cagliari for autopsy. OCT scans of cornea, anterior chamber and retina were performed at the 6th, 12th and 24th hour postmortem without change eyelid opening status. Corneal examination showed a progressive tendency of tissue to thickening. From a morphological point of view, we also observed a progressive formation of waves in the posterior stroma and in the endothelium [we decided to call this phenomenon, described by our group for first time, Nioi-Napoli sign (NN sign)]. An ongoing modification in reflectivity between anterior (hyperreflective) and posterior (hypo-reflective) segment of the corneal stroma was detecetd and a progressive decrease in amplitude of anterior chamber, mainly related to changes in tissue curvature. The retinal tissue showed since the first scan an increasing trend of retinal oedema togheter with a diffuse vasal depletion. It was also detachable the formation of a scleral tache noir. CASE 2. A 42-year-old woman, dead from myocardial infarction, underwent an autopsy at the Medico-Legal Institute at University of Cagliari (as suspected case of medical malpractice). Exact time of death was deduced by certificate of death drawn up by the emergency medical team. Scans of cornea, retina and anterior chamber were executed at the 24th, 36th and 48th hour postmortem. From the first scan an enhancement of corneal thickness, if compared to the physiological in vivo ranges, was detected; a change in corneal curvature was observed while no images form the retinal tissue was achieved. Late scans evidenced a progressive corneal endothelial exfoliation, and an enhancement of posterior stroma waving. CONCLUSION Portable OCT may be an useful device to observe and to record postmortem ocular changes. 1,2,3 Its use could represent an important tool to study the early and the late modification of ocular tissues, with a special interest in the forensic scenario as post mortem interval estimation (PMI estimation) and in ophthalmology (viability of cornea for transplantation purposes).

Multimorbidity patterns and 5-year overall mortality: Results from a claims data-based observational study.

Background:Multimorbidity is prevalent and related to adverse outcomes. The effect on mortality is disputed, possibly because studies show differences in the diseases which operationalize multimorbidity. The aim of this study is to analyze the effects of three multimorbidity patterns (representing subgroups of diseases) on mortality.Methods:We conducted a longitudinal observational study based on insurance claims data of ambulatory care from 2005 to 2009. Analyses are based on 46 chronic conditions with a prevalence ≥1%. We included 52,217 females and 71,007 males aged 65+ and insured by the Gmünder ErsatzKasse throughout 2004. Our outcome was 5-year overall mortality documented as exact time of death. We calculated hazard ratios by Cox regression analyses with time-dependent covariates. Three statistical models were analyzed: (a) the individual diseases, (b) the number of diseases in multimorbidity patterns, and (c) a count of all diseases, all calculated separately for genders and adjusted for age.Results:During the study period, 12,473 males (17.6%) and 7,457 females (14.3%) died. The general effect of multimorbidity on mortality was small (females: 1.02, 1.01–1.02; males: 1.04, 1.03–1.04). The number of neuropsychiatric disorders was related to higher mortality (1.33, 1.30–1.36; 1.46, 1.43–1.50). Cardiovascular and metabolic disorders had inconsistent effects (0.99, 0.97–1.01; 1.08, 1.07–1.09). Psychiatric, psychosomatic, and pain-related disorders were related to higher life expectancy (0.87, 0.86–0.89; 0.88, 0.87–0.90).Conclusions:Chronic diseases have heterogeneous effects on mortality and generalized measures of multimorbidity reflect and even out the effects of the single diseases. In multimorbidity studies, a careful selection of diseases is therefore important.

The effect of elapsed time on cardiac troponin-T (cTnT) degradation and its dependency on the cause of death

PurposeThe aim of the present study is to evaluate the effect of elapsed time on cardiac troponin-T degradation and its dependency on the cause of death. MethodsThe cases included in this study were divided into six groups depending upon the cause of death without any prior history of disease that died in the hospital and their exact time of death was known. The analysis involves extraction of the protein, separation by denaturing gel electrophoresis and visualization by Western blot. ResultsWestern blot data shows the rate of degradation of cTnT into lower molecular weight fragments with respect to time. In cases of control group the greatest amount of protein breakdown was observed within the first 64 h while in MI cases within first 6 h, the original band of cTnT (42 kDa) decreased markedly into seven major fragments, with 25 kDa & 20 kDa fragments being the most prominent. In burn group, at 41.40 h blot shows maximum fragmentation. In electrocution group the greatest amount of protein breakdown was observed within the first 50 Hrs. Within asphyxia cases, the original band of cTnT (42 kDa) decreased markedly into many major and minor fragments which continues up to 210 Hrs while the original band of cTnT (42 kDa) in poisoning cases decreased markedly into many major & minor fragments up to 140 h but after it blot shows only intact protein of very less intensity with few minor fragments. ConclusionIt can be observed that in case of death due to MI, the intact cTnI fragmented at a much faster rate than in burn, electrocution, control, poisoning and asphyxia group. Thus, the rate of fragmentation of intact cTnT into lower molecular weight fragments depends upon the cause of death.

Estimation of postmortem interval using the data of insulin level in the cadaver׳s blood.

An assessment of levels of Insulin in cadaveric fluids, to estimate the postmortem interval (PMI) was carried out.To profile postmortem changes of Insulin, it was extracted at different intervals i.e. (0, 3, 6, 12, 24 h), from the heart of 22 human cadavers. The cases included were the subjects of accidental deaths without any prior history of disease and their exact time of death was known. Immunoanalyzer Cobas e-411 instrument was used to detect the relationship between the amount of Insulin and PMI.Level of Insulin was measured in cardiac blood. Statically, significant correlations between levels of Insulin and PMI were studied and correlation coefficients were calculated. SPSS (version 12.0) was used for statistical analysis.Insulin levels in cadaver blood are correlated significantly with PMI with a p value of <0.001. When insulin level increases by 1 unit the duration decreases by 0.93 units. The least square regression line is: [Duration(Y)=22.71−0.93 Insulin level (X)]

Estimation of Time since Death from Rigor Mortis in Central India

Rigor mortis is an important factor in determination of time since death. Appearance and disappearance of rigor mortis and other factors influencing the development of rigor mortis like age, sex, weight and temperature were studied in 121 medico legal autopsies, in which exact time of death was known. In 21–60 years age group, the mean time of appearance and full development of rigor mortis was 1.46 hrs and 8.40 hrs, respectively. There was no obvious difference between males and females as regards to commencement and full development of rigor mortis. Time required for commencement of rigor mortis prolongs, as weight increases. In a temperature range of 21°C to 25°C, mean time for appearance and full development of rigor mortis was 1.31 hrs and 8.23 hrs respectively, while time range for start of disappearance was 14 to 23 hrs.

Estimation of postmortem interval using vitreous potassium levels in cases of fatal road traffic collision

To produce a formula that can accurately predict postmortem interval (PMI) based on vitreous potassium levels using road traffic collision fatalities. Vitreous humour samples were taken from 78 individuals who had died following road traffic collisions between 2010 and 2015. Samples were obtained from both eyes and were sent for on-site analysis. Measurement of potassium was by an indirect ion-specific electrode Siemens diagnostics ADVIA 2400 chemistry system. Exact time of death was known from police reports, the time of postmortem was recorded and the postmortem interval was calculated. Linear regression was then used to analyse the relationship between the two. The impact of age was also assessed. PMI was between 6 and 162 hours. As vitreous potassium increases, the PMI also increases; exhibiting a linear relationship. This is illustrated by a regression equation of PMI = 6.42[K+] - 40.94, R = 0.67 (p < 0.001). This produced a formula closely comparable with three other studies proposed in previous literature and produces estimates that may exceed one calendar day. When both age and medical intervention are accounted for there is an insignificant improvement in prediction. Validated methods have been used to produce a formula for prediction of PMI using vitreous potassium. Although this is specific to road traffic collisions, the methods are transferable and can be seen to be comparable with other recently published methods. Nonetheless, if greater levels of accuracy are required it is suggested that biomarkers delivering a higher level of precision should still be sought.

Evaluating sources of censoring and truncation in telemetry‐based survival data

ABSTRACTBias in vital rate estimation may come from failing to meet a variety of assumptions during the stages of sampling, monitoring, and analysis, though most are not commonly addressed in published studies. Here, we pay specific attention to various forms of censoring and truncation that present challenges for telemetry‐based monitoring of survival. We use simulations to assess how uncertainty about times of death and imperfect detection probabilities affect Kaplan–Meier survival estimates. We then treat monitoring of threatened woodland caribou (Rangifer tarandus caribou) in west‐central Alberta as a case study to test for potential effects of non‐random right censoring and interval censoring on survival estimates. We report that monitoring frequency (e.g., daily vs. monthly) and associated uncertainty about the exact time of death do not inherently induce bias on Kaplan–Meier point estimates of survival nor affect estimates of variance. Removing individuals from the at‐risk pool during intervals for which they were not detected did induce a negative bias on resulting survival estimates when the probability of detection was independent of the animals' fates. We recommend using subsequent detections to impute animals' fates during missed intervals in such cases when all animals' fates are eventually known or permanently right censored and when missed detections are not related to changes in mortality risk. Although some assumptions remain difficult to test and of continued concern, we find no evidence of biases in the methodology of Alberta's woodland caribou monitoring program. Our results lend credence to recent evidence of widespread declines in woodland caribou populations across the province. © 2015 The Wildlife Society.

Anomalous equivalent potential temperature: an atmospheric feature predicting days with higher risk for fatal outcome in acute ischemic stroke-a preliminary study.

Acute stroke is a life-threatening condition. Fatal outcome is related to risk factors, some of these affected by climatic changes. Forecasting potentially harmful atmospheric processes may therefore be of practical importance in the acute care of stroke patients. We analyzed the history of all patients with acute ischemic stroke (N = 184) confirmed by neuroimaging including those who died (N = 35, 15 males) at our hospital department in the winter months of 2009. Patient data were anonymized, and the human meteorologists were only aware of patients' age, gender, and exact time of death. Of the meteorological parameters, equivalent potential temperature (EPT) has been chosen for analysis. EPT is generally used for forecasting thunderstorms, but in the case of synoptic scale airflow (10(6) m), it is suitable for characterizing the air mass inflowing from different regions. The behavior of measured EPT values was compared to the climatic (30 years) averages. We developed meteorological criteria for anomalous periods of EPT and tested if such periods are associated with higher rate of fatal outcome. The duration of anomalous and non-anomalous periods was nearly equal during the studied 3 months. Stroke onset distributed similarly between anomalous and non-anomalous days; however, of the 35 deaths, 27 occurred during anomalous periods: on average, 0.56 deaths occurred on anomalous days and 0.19 on non-anomalous days. Winter periods meeting the criteria of anomalous EPT may have a significant adverse human-meteorological impact on the outcome in acute ischemic stroke.

The effect of elapsed time on cardiac troponin-T (cTnT) degradation and its relation to postmortem interval in cases of electrocution

BackgroundThe estimation of postmortem interval (PMI) is of paramount importance for the police in their investigation when arriving at the scene of a questionable death. The aim of present study is to evaluate the effect of elapsed time on cardiac Troponin-T degradation and its association with PMI in cases of death due to electrocution. MethodsCardiac tissue samples were collected from medico-legal autopsies, after informed consent from the relatives. The cases included were the subjects of electrocution without any prior history of disease who died in the hospital and their exact time of death was known. The analysis involves extraction of the protein at room temperature for different time periods (∼5, 26, 50, 84, 132, 157, 180, 205 and 230 Hrs), separation by SDS-PAGE and visualization by Western blot using cTnT specific monoclonal antibodies. ResultsThe results specify a characteristic banding pattern amongst human cadavers (n = 5), a pseudo-linear relationship between percent cTnT degraded and the time since death (R2 = 0.87, p = 0.0001) was observed. The area of the bands within a lane was quantified by scanning and digitizing the image using Gel Doc (Universal Hood II). ConclusionsThe post-mortem Troponin-T fragmentation observed in this study reveals a sequential, time-dependent process with the potential for use as a predictor of PMI in cases of electrocution.

English

Death due to burn occurs frequently. This study investigated time-dependent alterations in cardiac troponin T (cTnT) associated with fatal burns. Cardiac tissue samples were collected from 10 medico-legal autopsies after informed consent from the relatives and post-mortem degradation by incubation of the cardiac tissue was studied at room temperature for different time periods. The cases included in this study were the subjects of burns without any prior history of disease who died in the hospital and their exact time of death was known. An efficient extraction protocol to analyse the banding pattern of cTnT in post-mortem tissue was developed. The data show a distinct time-dependent profile corresponding to the degradation of cTnT by proteases found in cardiac muscle. Both post-mortem interval and cardiac tissue of burned corpses had a statistically significant effect where the greatest amount of protein breakdown was observed within the first 41.20 hours, after which intact protein slowly disappears. The average molecular weight of all fragments showed intact cTnT to be rapidly degraded into smaller fragments. In cases of burns, such knowledge will assist in knowing if there were previous scars that might have mimicked a burn and also help to properly evaluate the real cause of death.

Estimating the effect of emergency care on early survival after traffic crashes

IntroductionTraffic crash mortality is higher in rural areas, but it is unclear whether this is due to greater injury severity, time delays, or Emergency Medical Services (EMS) deficiencies. MethodsData from 2002–2003 were combined from the Fatality Analysis Reporting System (FARS) and an “expanded version” of the National Automotive Sampling System (NASS) Crashworthiness Data System (CDS). Weighted Cox and Weibull models for survival time (tSURV) were estimated, with time-varying covariates (TVC) having constant effects for specified time intervals following EMS arrival time (tEMS) and hospital arrival time (tHOS). The Weibull model was repeated with tSURV interval-censored to reflect uncertainty about the exact time of death, using an imputation method to accommodate interval censoring along with TVC. ResultsFARS contained records for 92,718 persons with fatal or incapacitating injuries, and NASS/CDS contained 5517 (weighted population of 642,716) with incapacitating injuries. All models associated mortality with increasing age, male sex, belt nonuse, higher speeds, and vehicle rollover. The interval-censored model associated EMS intervention with a beneficial effect until tEMS+30min, but not thereafter; hospital intervention was associated with a strongly beneficial effect that increased with time. Rural location was associated with a higher baseline hazard; a 50% reduction in rural prehospital time would theoretically reduce 4-h mortality by about 7%. ConclusionRural/urban disparity in crash mortality is mostly independent of time delays and EMS effects. However, survival models with TVC support clinical intuition of a “golden hour” in EMS care, and the importance of timely transport to a hospital.

A Study of Correlation of Time Since Death with Vitreous Potassium and Sodium-Potassium Ratio

The interval between the death and the time of the examination of the body is known as postmortem interval. The exact time of death cannot be fixed by any method but only approximate range of time since death can be given because there are considerable biological variation in the individual cases. The present study was carried out in the Morgue and the Department of Forensic Medicine and Toxicology, of Shri V. N. Government Medical College, Yavatmal from Maharashtra. The vitreous humor was sampled from about 201 cases subjected to autopsy.

Postmortem vitreous chemistry – An evaluation of sodium, potassium and chloride levels in estimation of time since death (during the first 36 h after death)

Estimation of time since death is a paramount medico-legal issue in any postmortem examination. The present study is intended to study the correlation between postmortem interval and vitreous humor chemistry for sodium, potassium, and chlorides. The study is aimed to find male–female differences and differences between right and left eyes in vitreous chemistry. The vitreous humor samples were collected in 114 autopsies conducted in the study center and analyzed biochemically. All the cases where exact time of death was known and where the time since death ranged between 0 and 36 h were included in the study. Data obtained was analyzed statistically using spss version 11.0. The present research did not find a significant correlation between vitreous chemistry and postmortem interval. The differences in vitreous sodium, potassium, chloride levels and the sodium potassium ratio among males and females and between right and left eyes were not found to be statistically significant.

Donation After Cardiac Death: Perceptions Versus Reality

The paper by Rady et al 1 criticizes donation after cardiac death (DCD) on 3 levels: (1) it defies the spirit if not the letter of the dead donor rule; (2) asserts some manipulations of the DCD patient may inappropriately hasten death in patients technically still alive by brain death criteria, and (3) claims DCD is a threat to public trust in the organ donation system. These criticisms should stimulate further debate on these issues. The authors suggest that DCD evolved to access more viable organs from the potential pool. However, some have stated the primary reason was a utilitarian argument to allow families of severely brain injured (but not technically brain dead) patients to circumvent the dead donor rule to donate. If the dead donor rule interfered with the altruistic desire to donate organs from a patient who would die anyway, the dead donor rule was perceived as impedimentia. So there was incentive to circumvent it by creative interpretation. This is a shaky argument. It does not matter if there is an intent to resuscitate or not. Neither the patient nor his or her family can consent to any procedure that will result in death, nor can the family consent to the patient’s being dead in a predetermined number of hours or minutes. Consenting to either of these options is tantamount to consenting to euthanasia. The most fundamental criticism of DCD involves ambiguity in the rules created to determine whether a potential donor’s organs are alive enough to donate but the whole patient is dead enough to avoid vivisection. What ethicists call “irreversible cessation of the integrated functioning of the organism as a whole” (not the whole organism). The rules seem clear. In 1968, the Harvard Criteria objectified the progression of disease, thereby making it possible for clinicians to predict inevitable death, but the Uniform Determination of Death Act (UDDA) of 1980 made brain death an objective criterion for death. The UDDA specifically required that death be irreversible. This act states that an individual who has sustained either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem, is dead and that a death certificate may then be filled out. However, the UDDA does not elucidate how these 2 differing standards reflect the same phenomenon, opening the interpretation that there are actually 2 kinds of death: brain and cardiac. This ambiguity made the issue of determining death amenable to a creative interpretation. Pronouncement of death could make brain function irrelevant if the heart stops. A problem with this interpretation is the inability to establish precisely when death transitions from a reversible process to an irreversible event. Brain death is an actual diagnosis of death and is clearly defined in terms of irreversibility. Cardiac standstill is a prognosis of death. When the heart stops, the brain will die in time, but its progress is unknown and unmeasured. Because the point of irreversibility is not known at the time death is declared, the exact time of death cannot be determined. Technically, the From the Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Mechanisms for programmed cell death in the nervous system of a moth.

In the moth Manduca sexta 50% of the abdominal motor neurons and interneurons die during the first days after the adult emerges. Although the dying motor neurons innervate larval muscles that also die at this time, the death of the neurons has been shown to be a direct response to an endocrine signal, the decline in ecdysteroids that occurs at the end of metamorphosis. The response to the withdrawal of the hormone apparently requires new synthesis of RNA and protein, as actinomycin-D and cycloheximide can prevent neuronal death. This selective neuronal death probably results from changes in gene activation. The fixed spatial and temporal pattern of neuronal death, however, suggests that trophic interactions among neurons may also be involved. Current work is focused on the fate of a pair of motor neurons, the MN-12 cells, in the third abdominal ganglion. Isolation of this ganglion from the thoracic ganglia can prevent the death of these cells at the time when they would normally die in response to removal of ecdysteroids. The factors mediating this effect may act in concert with the ecdysteroid decline to specify the exact time of death for individual neurons.