When is Death Irreversible? A Resuscitation M.D. Explains Why It’s Evolving

Hypothesis and Emerging Research

Some early observations support this concept (or parts of the theory), and there is scientific interest in elucidating exactly what’s at work.

When is Death Irreversible? A Resuscitation M.D. Explains Why It’s Evolving

As the director of resuscitation research and an assistant professor of critical care medicine at The State University of New York at Stony Brook, Sam Parnia, M.D. is almost singularly focused on the chasm of irreversible death—and how to bring people back. In Erasing Death: The Science that Is Rewriting the Boundaries Between Life & Death, he provides a wide survey of how the prognosis for patients who have cardiac arrests outside of hospitals varies widely depending on zip code: Depending on the city, your chances of survival can swing from 4 percent to 17 percent. This is due, in large part according to Parnia, to a lack of a single, international gold standard for resuscitation, and accordingly, no guidelines to study, and no way to measure and compare the success of hospital programs from around the world. In some places, practices like putting the body into a hypothermic state to delay the deterioration of brain cells is put into place; in others, it’s not.

Below, he explains what death means from a medical and scientific state, the technology that is currently available to revive it, how to be an advocate for yourself and those you love, as well as the science of death—when it’s reversible, when it’s not, and the scientific mining expeditions we need to undertake to understand what happens when we die.

A Q&A with Sam Parnia, M.D.

Who in your mind is setting the standard for resuscitation medicine, and why? What are the current rates of resuscitation both in “winning lottery” areas, and places where it could be improved?

The honest answer is that there isn’t one place that can be singled out: There are very small pockets of people in different centers in the world who are trying to enhance the method of resuscitation so it can be implemented across the globe for people who suffer from cardiac arrest. (Ultimately, we will all suffer from cardiac arrest.) The reality is that in the US, what is currently understood to be the gold standard has been poorly adopted and poorly implemented, whether that’s in the ambulance level or at the hospital level.

Here are some realities: General survival rates of cardiac arrest outside of the hospital are always lower than they are in the hospital. In the hospital, we witness the events and can respond immediately. So typically, cardiac arrest survival rates in the community range from 4 to 9 percent, where the general survival rate in the hospital is 20 to 25 percent (see more on post-resuscitation care, below).

Seattle is a good example of a community who works very hard to do bystander CPR training to ensure that citizens know how to deliver good-quality chest compressions. A few years ago they were quoting 17 percent as their survival rate for cardiac arrest in the community.

So there is an enormous variation, which the American Heart Association recognizes—these variations are not due to differences in the patient population, but are due to the lack of implementation of the basics of resuscitation.

What do you think needs to be done in terms of instituting international and national standards to raise the bar for our resuscitation success rates?

The community needs to demand that hospitals adhere to the American Heart Association guidelines, both for resuscitation care, and also for post-resuscitation care. Their guidelines are simply there to guide—they are not enforceable, and so most of them are not read. The American Heart Association cannot make it mandatory for hospital staff to learn them, or to educate physicians on up-to-date best practices.

So what we find is that even within hospitals, there isn’t an absolute standard for doctors who are receiving patients in emergency rooms. I liken it to planes flying without standardized protocols, air traffic control, etc. Ultimately, the regulatory agencies need to mandate a standard. In the US, and elsewhere, the state and federal authorities are responsible for the maintenance of standards in hospitals—they’ve just never put down a basic standard to measure the quality of resuscitation. It doesn’t exist.

You write about some incredible technology that is becoming available in some parts of the world. What do you think should be standard in every ambulance and hospital?

Resuscitation was born in 1960, which from a treatment standpoint, makes it more than a half-century old—and it hasn’t been updated much since. There’s really no other medical treatment protocol that we use today that hasn’t evolved in more than 50 years. But for cardiac arrest—the most life and death affliction—the treatment is still what it was in 1960. That’s a big problem. What makes it worse is that we don’t deliver the 1960 treatment effectively.

We’ve all taken CPR courses, but even a human who has had the very best training cannot deliver CPR for a prolonged period of time very effectively. It’s important to remember that basic CPR is not intended to restart the heart, it is intended simply to keep the blood flowing to the brain and other organs—it needs to be done at a very specific cadence and pressure, and sustained for a significant amount of time. On a basic level, every hospital and ambulance should be supplied with mechanical CPR devices so we can take away human variation and deliver effective compressions, i.e., just doing the 1960’s-version correctly. For the 21st century, I think that at the very least, we should be able to offer an ECMO machine—which takes blood out of the body, oxygenates it, and redelivers it—so that we can deliver much better quality oxygen to the brain and other organs. This machine gives doctors the gift of time to understand what it is that caused someone to die, and repair the issue.

“Resuscitation was born in 1960, which from a treatment standpoint, makes it more than a half-century old—and it hasn’t been updated much since.”

So, for example, if you have a thirty-nine-year-old who suddenly dies, you need to be able to hook them up to this machine so that the kidney, brain, heart, and liver are being given enough oxygen to buy time for the cardiologist to understand why the heart stopped in the first place. If it’s not possible or appropriate to resuscitate the patient after that time, then we know that we’ve given them every chance, thanks to resuscitation of perfect quality.

Can you explain the phases of resuscitation meditation, and where a lot of errors are made, specifically why post-resucitation medicine is so essential?

Besides the basics of resuscitation, there is another very important component, which is post-resuscitation care. Most brain damage happens after the heart has been restarted. It’s paradoxical, but when you put oxygen back into the system after it’s been deprived for 30 minutes or more, it reacts with toxic waste product that has built up in the brain, and causes inflammation and massive cell death.

The next big intervention is to find ways to reduce the likelihood of cell damage at that time in the ICU. That includes cooling people down (hypothermia), and giving drugs that will protect the brain from oxygen toxicity. There’s a whole cocktail of drugs that can be given, as well as measures to optimize the correct amount of blood that is allowed into the brain. Otherwise, if there is ongoing inflammation and damage, hearts will stop for a second or third time. Or, the patient might develop ongoing brain damage.

“Besides the basics of resuscitation, there is another very important component, which is post-resuscitation care. Most brain damage happens after the heart has been restarted.”

If you take an example of one hundred cardiac arrest events, we may be able to restart the heart in forty to fifty of them with old-fashioned CPR. Two-thirds of those people then die after we’ve restarted the heart, so the overall survival rate is 10 percent. All the effort doesn’t get us anywhere because they end up with a secondary injury. So we’re trying to hit both of those curves in resuscitation medicine. In an ideal world, we’d have ECMO machines to ensure that we are restarting the heart more effectively and hitting rates of 80-90 percent, and then we’d also find ways to reduce injury after the heart restarts, and thus minimize the amount of brain disorders, or disorders of consciousness that are inadvertently created.

As a patient and/or patient advocate, what are things that you should request? Is there training beyond typical CPR that you would recommend to the average citizen?

What people need to ask for is that the communities they live in enhance the delivery of CPR in the first place, like in their ambulance crews. Ask about whether they carry mechanical CPR devices. When you get to the hospital, make sure that the hospital has developed a strategy for post-resuscitation care.

You believe that there are serious medical advances to be made in terms of understanding where consciousness goes with brain death, and what its relationship might be to the brain since it’s impossible to trace, at this point, the origin of thoughts. Do you see a breakthrough coming?

We were never designed to be able to reverse death—so that’s why we have this perception that death is irreversible. You could do nothing, for millennia. And so in that time, we explored important essential questions about the nature of the human self and what happens when we die—the self was called the psyche, which was translated into the word soul in common English. We have different opinions about what it is, and what happens to it when it dies. We now call the psyche consciousness—it is our thoughts, our feelings, shared experiences that bring us together.

Unfortunately, every single one of us will have a cardiac arrest—it’s the one thing that will happen to everyone. We need to understand the biology, but also the nature of consciousness, not only to understand what will happen to our own minds and consciousness when we go through death, but also to avoid resuscitating people who are husks, with no consciousness at all.

“The source of consciousness is undiscovered in the same way that electromagnetic waves have been around for millions of years, but it’s only been recently that we created a device to record them and show them to other people.”

What the evidence suggests is that the soul, the self, the psyche, whatever you want to call it, does not become annihilated, even though the brain has shut down. This suggests that part of what makes us who we are—a part that is very real—is not produced by the brain. Instead, the brain is acting like a mediator. Like anything that has been undiscovered, because we can’t touch and feel it, we choose to ignore it. The reality, though, is that human thought exists, we communicate through thoughts—so it is a real phenomena. The source of consciousness is undiscovered in the same way that electromagnetic waves have been around for millions of years, but it’s only been recently that we created a device to record them and show them to other people.

So in short, we haven’t got the tools yet, or a machine that’s accurate enough to pick up your thoughts and show them to me. In the next couple of decades, I believe it will be discovered that we continue to exist after death, and that consciousness is in fact an independent entity.