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Technical (archive)
1

Hi All,

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.

The issues here involve 'statutory death', 'State Agency death', 'Judicial death' and
potentially 'extra-judicial' and 'extra-statutory death'. One also has the problem of
accumulating additional EHRs beyond some 'death state' to comply with a variety of
other policies, procedures, contracts, statutes and 'State Agency requirements'.

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.

Regards!

-Thomas Clark

2

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3

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

4

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:

5

Thomas, as stated in my previous mail, I am not quite aware of
the prevalent US laws. All that I stated are the generally
accepted objective medical criteria for 'Clinical' (somatic or
systemic) death and 'Brain' death ('wrap-up' phase criteria).
These are clear measureable/ demonstratable biological entities.

I suppose there are no legal angles to 99% of all deaths (viz.
clinical/ somatic/ systemic death). Some difficulties may arise
in few of the 'brain death' pronouncements, where the stated
biological criteria may not be fully established. Otherwise,
there should be no legal issues here too.

If legal and other considerations are to be entertained, a
pre-requisite would be to define the end points for such
additional legal criteria ... any proposals in this regard ?

Rgds,

Dr USM Bish
Bangalore

6

Hi,

Comments in text.

USM Bish wrote:

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.

Thomas, as stated in my previous mail, I am not quite aware of
the prevalent US laws. All that I stated are the generally
accepted objective medical criteria for 'Clinical' (somatic or
systemic) death and 'Brain' death ('wrap-up' phase criteria).
These are clear measureable/ demonstratable biological entities.

I suppose there are no legal angles to 99% of all deaths (viz.
clinical/ somatic/ systemic death). Some difficulties may arise
in few of the 'brain death' pronouncements, where the stated
biological criteria may not be fully established. Otherwise,
there should be no legal issues here too.

If legal and other considerations are to be entertained, a
pre-requisite would be to define the end points for such
additional legal criteria ... any proposals in this regard ?

1)The EHRs should indicate the legal entity or individual that has the authority to render
decisions regarding Healthcare issues during periods of Patient incapacity,
unresponsiveness and unavailability.

2)Competent legal jurisdictions where care rendered, e.g., (US+state+county+city)

3)Competent Court where court order issued affecting Patient, Practitioner, Facility

4)Police Authority or Emergency Medical Team where Patient unresponsive

5)Police Authority where Patient is in custody

6)Additional parties attempting to exercise some authority (see 3 above)

7)(really difficult) Civil Code, Court order or other jurisdictional order declaring or
permitting an assertion that the Patient is legally incompetent to make decisions regarding
their welfare.

8)Legal representatives (notified and on retainer)

All this and more is included in the more difficult conflicts.

-Regards!

-Thomas Clark