Permanent or Irreversible: What Difference Does It Make?

January 26, 2024 • Posted in Blog

D. Joy Riley, M.D., M.A.
Executive Director

A number of years ago, I was out of town when we had significant flooding at home. There was some leaking of water into the basement, and one of our then-teenage sons decided to make sure I would be aware of where exactly the leaks had appeared. He used a hot pink permanent marker to delineate the problem on the drywall for me. When my husband arrived home at the end of a full day, he became rather “excited” about our son’s decision. Thankfully, an older son found a solution to remove evidence of the marker, so that “permanent” was not also “irreversible.” The “permanent” markings were actually reversible and indeed, invisible, when I returned home. In fact, I didn’t learn about this escapade until some years later.

The difference between “permanent” and “irreversible” is a difference that matters. The dictionary definitions of these are

Permanent – “lasting or remaining without essential change”; and

Irreversible – “not reversible; incapable of being changed.”

The difference between these two words in the world of medicine can mean the difference between life and death – at least brain death.

The American Academy of Neurology (AAN) recently released new guidelines for the determination of brain death/death by neurologic criteria (BD/DNC). They advised, “The terms irreversible and permanent have both been used to describe the extent of loss of function that must be present to determine BD/DNC. The panel chose to use the term permanent to mean function was lost and (1) will not resume spontaneously, and (2) medical interventions will not be used to attempt restoration of function. This terminology was also used in the World Brain Death Project” (1114).

Point #2 above, that medical intervention will not be used to attempt to restore function, is worthy of consideration. It is a decision made – ostensibly a decision borne of clinical training and expertise – but a decision, nonetheless. It can also be a self-fulfilling prophecy: medical intervention will not be used, and the patient will progress to brain death. It seems that an abundance of caution would be needed in this situation. As we all know, and as the National Kidney Foundation makes clear in their online brochure on brain death, “After brain death is declared, organ and tissue donation becomes a possibility.

A story from India yields a cautionary tale. Mr. Darshan Singh, an 80-year-old with a chronic heart condition, was recently admitted to a private hospital. On a Thursday, his son was notified that Mr. Singh’s heart had stopped and he was declared dead. Mr. Singh’s younger son, Baldev Singh, “rushed” to bring his father’s body home, but the trip did not proceed as expected. Baldev Singh describes what happened: “When the ambulance was near Dhand in Kaithal, its tires hit a big pothole on the bumpy road, which jolted the vehicle. Suddenly, I noticed a movement in my father’s hand. When I checked I found his heart was beating.” Mr. Singh was immediately taken to another private hospital, from which he was referred on to yet another medical institution. There, Dr. Netra Pal is treating him. Mr. Singh required a ventilator for less than 24 hours, reported Dr. Pal.

Prominent Indian newspaper, The Print, quoted remarks by cardiac physician Dr Viney Singla about this “rare” case:

“It will be difficult to comment on this particular case unless one knows how the doctor who declared the patient dead concluded that the patient was dead,” he said.

“Normally, when doctors declare a patient dead, they first look at the pupils. If the pupils are dilated, it means the patient is brain dead. Also, the doctors look at the cardiac activity. Most of the doctors would certainly do an ECG to be sure that cardiac activity has stopped,” said Sangla.

The doctor added: “The ECG will show a straight line in the report in that case. Once there is no cardiac activity, there will be no pulmonary activity (respiration) too. And if the brain doesn’t get oxygen for a few seconds, it will be almost impossible for the patient to revive.”

What exactly happened to Mr. Singh in the first hospital and in the ambulance as it encountered the pothole is not clear. Yet, it appears that what was thought to be a permanent situation was not. Neither was it irreversible. Language matters. Truth matters.



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