TKO Complexities Resulting From Difficulty in the Determination of Death

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Duquesne University School of Law

Complexities Resulting from Difficulty in the Determination of Death

Joseph Tkocs

LAWS C608-01

Spring 2010


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ABSTRACT

This paper investigates the issues that surround the care of individuals that have been

injured in a manner that makes the determination of death difficult. A brief history of the topic

will be covered along with some technical descriptions that will aid in the understanding of the

underlying physiological process that create the impaired state of being. The creation of

statutes as well as the actual statutes themselves will also be discussed. The importance of

advance directives will be stressed, as well as an example of what can occur when they do not

exist. This paper is focused towards practitioners of law in Pennsylvania and Pennsylvanians in

general.


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INTRODUCTION

Traditionally, the matter of discerning life from death was a relatively simple matter.

Overt body processes, such as breathing and consciousness, were easily detectable, and, with a

fair amount of accuracy, even a layman could determine if an individual was alive. Today, the

advancement of modern medicine now allows for the external maintenance of basal body

processes, blurring the lines between life and death. While the continuation of life is usually a

good thing, the technical determinations that it has forced the law to face have created much

confusion. Although this subject has not been clearly resolved, and has no signs of being

resolved in the near future1, an examination into the circumstances that surround this difficult

topic will prepare practitioners of law in Pennsylvania and Pennsylvanians in general for the

complexities that surround a person incapacitated in a state where the characteristics of life

and death converge.

DIFFICULTY IN THE DETERMINATION OF DEATH

Blacks Law Dictionary defines death as the ending of life; the cessation of all vital

functions and signs.2

Meanwhile, the Presidents Commission for the Study of Ethical

Problems in Medicine and Biomedical and Behavioral Research has concluded that proof of an

irreversible absence of functions in the entire brain, including the brainstem, provides a highly

reliable means of declaring death for respirator-maintained bodies.3

Alternatively, the

Pennsylvania Law Encyclopedia defines death as meaning the termination or cessation of life,

1Edward Lowenstein. Defining Brain Death: Motivations and Future Directions. 23(4) International

Anesthesiology Clinics 121 (Fall 2007)2

Blacks Law Dictionary. 428 (Bryan A. Garner ed., 8th ed., West 2004)3

Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.

Defining Death: Medical, Legal and Ethical Issues in the Determination of Death. 6 (Washington: GPO, 1981)


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or the state or condition of being dead; and from a medical standpoint it means a total

stoppage of the circulation of the blood, and a cessation of the animal and vital functions

consequent thereon, such as respiration, pulsation, etc.4

While most legal definitions of death reference cessation of body processes or the lack

of animal and vital5

functions, as seen in the report by the Presidents Commission for the

Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, there is a trend

towards recognizing the separation between physical death and brain death. This delineation

of death stems from the discrete physiological systems of the human body that contribute to

life. The three major physiological systems that are determinative of the presence of life are

the respiratory system, the circulatory system, and the neurological system. The first two

systems were previously the only way that death was able to be determined. Breathing was

evidence of a functioning respiratory system and a pulse was evidence of a functioning

circulatory system. Although one system can briefly function without the other, without the

resumption of functionality of the disabled system, death ensues in a short amount of time.

The neurological system differs significantly from the circulatory and respiratory

systems. Whereas the circulatory and respiratory systems perform what are basically

mechanical functions, the function of neurological system is more esoteric. While the spinal

cord and peripheral nervous system handles the more mechanical functions of the neurological

system in the conduction of neurological impulses, the brain is the primary object of the current

debate surrounding the determination of death. Among its many functions, the brain both

421 P.L.E. Death; Dead Bodies 1

5Blacks Law Dictionary. 488 (4th ed., West, 1968)


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regulates the circulatory and respiratory systems (via the brainstem) as well as forming

consciousness (via the cerebral cortex).

The efficacy of modern medical equipment now allows the external maintenance of

functions performed by the majority of the circulatory and respiratory systems. There is no

correlating external support system for the brain, however. Since the circulatory and

respiratory systems are no longer dependent upon the neurological system for internal

regulation, the severe impairment or destruction of the brain does not necessarily mean the

end of the mechanical functioning of the body. Medical machines can indefinitely prolong the

existence of the body, even when the brain is irreparably damaged. As the brain is the organ

that initializes locomotion, maintains memory, determines personality, and originates

consciousness, the body that remains does so in a basically static state, save for reflexive

processes that act automatically through the autonomic nervous system. It is this state in

which the determination of death is up to interpretation. The physical body of a person exists,

but the spark of life that defines an individual as a human being is lost. This loss of self

manifests in two main categories: coma and vegetative state.

COMA VS. (PERSISTENT) VEGETATIVE STATE

When the brain suffers a trauma and there is impairment to higher brain functions,

there is a continuum of resultant outcomes. Injuries to the brain that are on the severe end of

that spectrum result in the aforementioned static existence of a human body. The two main

results in such a situation are comas and vegetative states.

A coma is a state in which the cerebral cortex or higher brain functions of a person are

impaired, resulting in profound loss of consciousness, inability to be aroused, and no response


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to external stimuli such as pain, sound, touch, or light. If lower brain centers are damaged, a

respirator may be required for the person to breathe. The ultimate result of a coma can be

anywhere from a full recovery to death.6

Most comas last from a few days to a few weeks. A

significant indicator of the outcome of a coma occurs at twenty four hours after the patient

enters the coma. According to the Glasgow Coma Scale,7

if the best scale is 3 to 4 after twenty-

four hours, 87% of those individuals will either die or remain in a vegetative state; only 7% will

had a moderate disability or good recovery.8

In contrast to a coma, a vegetative state exists when a person is able to have sleep-wake

cycle, however, when the individual is awake, they are totally unaware. A person in a

vegetative state can no longer think, reason, relate meaningfully with his/her environment,

recognize the presence of loved ones, or feel emotions or discomfort. The higher levels of

the brain are no longer functional. A vegetative state is called persistent if it lasts for more

than four weeks.9

The four week milestone with vegetative state is just as significant as the

twenty-four hour milestone with coma patients; after this point, chances of a successful

recovery significantly decline. Approximately 44% of patients that showed signs of recovery in

the first month made successful recoveries, compared with approximately 4% of patients that

made a successful recovery after showing signs of improvement after the first three months.10

6American Hospice Foundation. Coma and Persistent Vegetative State: An Exploration of Terms.

http://www.americanhospice.org/index.php?option=com_content&task=view&id=50&Itemid=8 (last accessed

April 10, 2010)7

Graham Teasdale & Bryan J. Jennett. Assessment of Coma and Impaired Consciousness. A Practical Scale.

2(7872) Lancet 81 (July 13, 1974)8

braininjury.com. Coma: Some Facts. http://www.braininjury.com/coma.html (last accessed April 12, 2010)9

American Hospice Foundation. Coma and Persistent Vegetative State: An Exploration of Terms.

http://www.americanhospice.org/index.php?option=com_content&task=view&id=50&Itemid=8 (last accessed

April 10, 2010)10

braininjury.com. Vegetative State. http://www.braininjury.com/coma.html (last accessed April 12, 2010)


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It is important to note that the main determinant in either of these categories is brain

activity. A patient can be in a coma, yet have significant higher brain function, while a person in

vegetative state has negligible brain activity. Scans using magnetic resonance imaging (MRI),

positron emission tomography (PET), computed axial tomography (CAT), or

electroencephalography (EEG) can assist in detecting brain damage and activity, though no

methods are absolutely determinative of the potential outcome of every individuals recovery.

To combat such ambiguity, the National Conference of Commissioners on Uniform State Laws

(NCCUSL), as well as the individual states themselves, has acted to advance legislation that

codifies the determination of death.

UNIFORM DETERMINATION OF DEATH ACT

The NCCUSL, an organization similar to the American Law Institute (ALI), discusses and

debates areas of law that should be uniform among the states. The NCCUSL also drafts

model/uniform acts that are proposed to the various jurisdictions. The Uniform Determination

of Death Act is one of those acts. The Uniform Determination of Death Act is based on the

NCCUSLs previous Uniform Brain Death Act, which was in turn based on the American Bar

Associations (ABAs) Model Definition of Death Act.11

Most jurisdictions have adopted the Uniform Determination of Death Act. The Uniform

Determination of Death Act states an individual who has sustained either irreversible cessation

of circulatory and respiratory functions, or irreversible cessation of all functions of the entire

11University of Pennsylvania. Uniform Determination of Death Act.

http://www.law.upenn.edu/bll/archives/ulc/fnact99/1980s/udda80.htm (last accessed April 12, 2010)


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brain, including the brain stem, is dead. A determination of death mustbe made in accordance

with accepted medical standards.12

Pennsylvania has adopted the Uniform Determination of Death Act. It is codified at 35

P.S. 10201-10203. Similar to the model act, the Pennsylvania Uniform Determination of

Death Act states that a determination of death must be made in accordance with accepted

medical standards when there is irreversible cessation of circulatory and respiratory functions,

or irreversible cessation of all functions of the entire brain, including the brain stem.13

In both cases, the criteria for the determination of death would require total brain

death; severe impairment that would result in a persistent vegetative state would not support a

determination of death by either the model act or by Pennsylvanias statute. Therein lies the

dilemma of diagnosing death; a person could be irreparably incapacitated, where death would

ensue without the external aid of machines, and yet the persons status would still elude the

technical statutory definition of death.

ADVANCE DIRECTIVES

In cases where the line between life and death is blurred, an individual may not want to

continue to exist where they derive no benefit from the sustenance of life, are a financial

burden, and whose suffering creates emotional pain in others. On the other hand, loved ones

may disregard the chances that the person will not recover, and, hanging on to the faintest

glimmer of hope, will not want to have the sustaining medical devices removed. If an individual

12American College of Legal Medicine Foundation. Medicolegal Primer. 121 (Cyril H. Wecht & Harold L. Hirsch ed.,

1st

ed., American College of Legal Medicine Foundation 1991)13

35 P.S. 10203


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has pre-formed opinions about what should happen to them, they should prepare advance

directives.

Pennsylvania defines advance health care directives as a health care power of attorney,

living will or a written combination of a health care power of attorney and living will.14

A

medical power of attorney is the advance directive where an individual selects a person they

trust to make decisions about their medical care if they are temporarily or permanently unable

to communicate and make decisions on their own. This includes not only decisions at the end

of ones life, but also in other medical situations. This document is also known as a health care

proxy, appointment of a health care agent, or durable power of attorney for health care.

This document goes into effect when a physician declares that an individual is unable to make

their own medical decisions. The person that is selected can also be known as a health care

agent, surrogate, attorney-in-fact, or health care proxy.15

A living will is an advance directive

that guides family members and medical professionals about the medical treatment that one

desires if they are unable to communicate their wishes. A living will goes into effect only when

a person is no longer able to make their own decisions.16,

17

Pennsylvanias legislative stance to self-determination in conjunction with advance

directives is that:

individuals have a qualified right to make decisions relating to their own health

care. This right is subject to certain interests of society, such as the maintenance

of ethical standards in the medical profession and the preservation and

1420 Pa.C.S.A. 5422

15Caring Connections. Understanding Advance Directives.

http://www.caringinfo.org/userfiles/file/PDFs/Understanding_Advance_Directives.pdf (last accessed April 20,

2010)16

Id.17

A sample durable power of attorney and living will are included in Appendices A and B.


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protection of human life. Modern medical technological procedures make

possible the prolongation of human life beyond natural limits. The application of

some procedures to an individual suffering a difficult and uncomfortable process

of dying may cause loss of dignity and secure only continuation of a precarious

and burdensome prolongation of life. It is in the best interest of individuals

under the care of health care providers if health care providers initiatediscussions with them regarding living wills and health care powers of attorney

during initial consultations, annual examinations, at diagnosis of a chronic illness

or when an individual under their care transfers from one health care setting to

another so that the individuals under their care may make known their wishes to

receive, continue, discontinue or refuse medical treatment in the event that they

are diagnosed with an end-stage medical condition or become permanently

unconscious. Health care providers should initiate such discussions, including

discussion of out-of-hospital do-not-resuscitate orders, with individuals under

their care at the time of determination of an end-stage medical condition and

should document such discussion in the individual's medical record.18

RAMIFICATIONS OFNOT HAVING ADVANCE DIRECTIVES

Advance directives play a pivotal role in the litigation of cases involving incapacitated

persons in a state between life and death. While there is significant Pennsylvania litigation

surrounding the issue of determining the medical procedure to be performed on individuals

who have been incompetent since birth, and have never had the ability to create advance

directives,19

the most contentious cases nationwide occur when loved ones disagree on what

types of life-extending measures are to be performed. The most prominent instance of such a

situation in recent times is the voluminous litigation surrounding Terri Schiavo.

The facts surrounding the Schiavo cases are as follows: Terri Schiavo, a resident of

Florida, suffered from an undetermined cardiac arrest. She was later revived by paramedics,

but the period of time without oxygen left her with significant brain damage. Her brain damage

1820 Pa.C.S.A. 5423 See also In re Fiore, 543 Pa. 592, 673 A.2d 905 (Pa. 1996)

19See In re D.L.H., 967 A.2d 971 (Pa.Super. 2009) and Halderman v. Pennhurst State Sch. & Hosp., 1997 U.S. Dist.

LEXIS 20504


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presented as a persistent vegetative state. After a significant period of time without any signs

of improvement, her husband first requested a do not resuscitate order (DNR), and then later

filed a petition to have her feeding tube removed. Schiavos parents opposed the removal of

the feeding tube, and pursued legal action against it. The resulting litigation involved multiple

court cases, intervention from Floridas legislature, Floridas governor, and eventually, Congress

and the President. The litigation was ultimately decided in favor of Schiavos husband.

The Schiavo line of litigation20

is important to Pennsylvanians, as Floridas statute21

on

the appointment of a health care proxy when there is no advance directive is very similar to

Pennsylvanias.22

Both statutes state a priority list based on order of relatedness to an

individual. In both statutes, the spouse is listed as having a superior interest in performing

duties as a health care proxy over parents. While the statute would normally trump most intra-

familial conflicts, this situation was complicated by a possible coloring of Schiavos husbands

intent due to a possible inheritance, and the Schiavos parents allegation that her religion as a

Roman Catholic would prohibit the quasi-euthanasia aspect of the removal of the feeding tube.

This complication was compounded by Schiavos husband later having a child with another

woman.

CONCLUSION

This paper has examined the physiological classifications of states of existence that

make the determination of death difficult. A brief history statutory formulation and actual

20Schiavo ex rel. Schindler v. Schiavo, 357 F. Supp.2d 1378 (M.D. Fla. 2005), Schiavo ex rel. Schindler v. Schiavo,

403 F.3d 1223 (11th

Cir. Fla. 2005), and Schiavo ex rel. Schindler v. Schiavo, 403 F.3d 1261 (11th

Cir. Fla. 2005) et. al21

Fla. Stat. 765.40122

20 Pa.C.S.A. 5461


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Pennsylvania statutes were also discussed, as was the impact of advance directives. In addition,

the circumstances surrounding Terri Schiavo were examined, as Pennsylvanias laws are

substantially the same as Floridas in the area of health care proxies. Pennsylvanians should

take the unseemly litigation as a learning point, and, regardless of personal views on the

continuation of life in such circumstances, plan to have some type of advance directive, if only

to prevent their own loved ones from the same type of distress.


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APPENDIX A

Sample Durable Power of Attorney23

2320 Pa.C.S.A. 5471


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I, __________, of __________ County, Pennsylvania, appoint the person named below to be my

health care agent to make health and personal care decisions for me.

Effective immediately and continuously until my death or revocation by a writing signed by me

or someone authorized to make health care treatment decisions for me, I authorize all health

care providers or other covered entities to disclose to my health care agent, upon my agent'srequest, any information, oral or written, regarding my physical or mental health, including, but

not limited to, medical and hospital records and what is otherwise private, privileged, protected

or personal health information, such as health information as defined and described in the

Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191, 110 Stat.

1936), the regulations promulgated thereunder and any other State or local laws and rules.

Information disclosed by a health care provider or other covered entity may be redisclosed and

may no longer be subject to the privacy rules provided by 45 C.F.R. Pt. 164.

The remainder of this document will take effect when and only when I lack the ability to

understand, make or communicate a choice regarding a health or personal care decision as

verified by my attending physician. My health care agent may not delegate the authority to

make decisions.

MY HEALTH CARE AGENT HAS ALL OF THE FOLLOWING POWERS SUBJECT TO THE HEALTH CARE

TREATMENT INSTRUCTIONS THAT FOLLOW IN PART III (CROSS OUT ANY POWERS YOU DO NOT

WANT TO GIVE YOUR health care AGENT):

1. To authorize, withhold or withdraw medical care and surgical procedures.

2. To authorize, withhold or withdraw nutrition (food) or hydration (water) medically supplied

by tube through my nose, stomach, intestines, arteries or veins.

3. To authorize my admission to or discharge from a medical, nursing, residential or similar

facility and to make agreements for my care and health insurance for my care, including

hospice and/or palliative care.

4. To hire and fire medical, social service and other support personnel responsible for my care.

5. To take any legal action necessary to do what I have directed.

6. To request that a physician responsible for my care issue a do-not-resuscitate (DNR) order,including an out-of-hospital DNR order, and sign any required documents and consents.

APPOINTMENTOFHEALTH CAREAGENT

I appoint the following health care agent:

Health care agent: ____________________ (Name and relationship)


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Address:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Telephone Number: Home __________ Work __________

E-mail: ____________________

IF YOU DO NOT NAME A HEALTH CARE AGENT, HEALTH CARE PROVIDERS WILL ASK YOUR

FAMILY OR AN ADULT WHO KNOWS YOUR PREFERENCES AND VALUES FOR HELP IN

DETERMINING YOUR WISHES FOR TREATMENT. NOTE THAT YOU MAY NOT APPOINT YOUR

DOCTOR OR OTHER HEALTH CARE PROVIDER AS YOUR HEALTH CARE AGENT UNLESS RELATED

TO YOU BY BLOOD, MARRIAGE OR ADOPTION.

If my health care agent is not readily available or if my health care agent is my spouse and an

action for divorce is filed by either of us after the date of this document, I appoint the person or

persons named below in the order named. (It is helpful, but not required, to name alternative

health care agents.)

First Alternative Health Care Agent: __________ (Name and relationship)

Address:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


E-mail: ____________________

Second Alternative Health Care Agent: ____________________ (Name and relationship)

Address:

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________


E-mail: ____________________

GUIDANCEFOR HEALTH CAREAGENT(OPTIONAL)


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GOALS

If I have an end-stage medical condition or other extreme irreversible medical condition, my

goals in making medical decisions are as follows (insert your personal priorities such as comfort,

care, preservation of mental function, etc.):______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

SEVERE BRAIN DAMAGE OR BRAIN DISEASE

If I should suffer from severe and irreversible brain damage or brain disease with no realistic

hope of significant recovery, I would consider such a condition intolerable and the application

of aggressive medical care to be burdensome. I therefore request that my health care agent

respond to any intervening (other and separate) life-threatening conditions in the same manner

as directed for an end-stage medical condition or state of permanent unconsciousness as I have

indicated below.

Initials __________ I agree

Initials __________ I disagree


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APPENDIX B

Sample Living Will24

24Id.


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The following health care treatment instructions exercise my right to make my own health care

decisions. These instructions are intended to provide clear and convincing evidence of my

wishes to be followed when I lack the capacity to understand, make or communicate my

treatment decisions:

IF I HAVE AN END-STAGE MEDICAL CONDITION (WHICH WILL RESULT IN MY DEATH, DESPITETHE INTRODUCTION OR CONTINUATION OF MEDICAL TREATMENT) OR AM PERMANENTLY

UNCONSCIOUS SUCH AS AN IRREVERSIBLE COMA OR AN IRREVERSIBLE VEGETATIVE STATE AND

THERE IS NO REALISTIC HOPE OF SIGNIFICANT RECOVERY, ALL OF THE FOLLOWING APPLY

(CROSS OUT ANY TREATMENT INSTRUCTIONS WITH WHICH YOU DO NOT AGREE):

1. I direct that I be given health care treatment to relieve pain or provide comfort even if such

treatment might shorten my life, suppress my appetite or my breathing, or be habit forming.

2. I direct that all life prolonging procedures be withheld or withdrawn.

3. I specifically do not want any of the following as life prolonging procedures: (If you wish to

receive any of these treatments, write I do want after the treatment)

heart-lung resuscitation (CPR)_____________________________________________________

mechanical ventilator (breathing

machine)____________________________________________

dialysis (kidney machine)_________________________________________________________

surgery________________________________________________________________________

chemotherapy__________________________________________________________________

radiation treatment______________________________________________________________

antibiotics_____________________________________________________________________

Please indicate whether you want nutrition (food) or hydration (water) medically supplied by a

tube into your nose, stomach, intestine, arteries, or veins if you have an end-stage medical

condition or are permanently unconscious and there is no realistic hope of significant recovery.

(Initial only one statement)

TUBE FEEDINGS

__________ I want tube feedings to be given


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OR

NO TUBE FEEDINGS

__________ I do not want tube feedings to be given.

HEALTH CAREAGENT'S USEOFINSTRUCTIONS

(INITIAL ONE OPTION ONLY)

__________ My health care agent must follow these instructions.

OR

__________ These instructions are only guidance. My health care agent shall have final say and

may override any of my instructions. (Indicate any exceptions)

______________________________________________________________________________

If I did not appoint a health care agent, these instructions shall be followed.

LEGALPROTECTION

Pennsylvania law protects my health care agent and health care providers from any legal

liability for their good faith actions in following my wishes as expressed in this form or in

complying with my health care agent's direction. On behalf of myself, my executors and heirs, I

further hold my health care agent and my health care providers harmless and indemnify them

against any claim for their good faith actions in recognizing my health care agent's authority orin following my treatment instructions.

ORGANDONATION

(INITIAL ONE OPTION ONLY)

__________ I consent to donate my organs and tissues at the time of my death for the purpose

of transplant, medical study or education. (Insert any limitations you desire on donation of

specific organs or tissues or uses for donation of organs and tissues.)

____________________________________________________________________________________________________________________________________________________________

OR

__________ I do not consent to donate my organs or tissues at the time of my death.

SIGNATURE


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Having carefully read this document, I have signed it this__________day of__________, 20___,

revoking all previous health care powers of attorney and health care treatment instructions.

________________________________________________________

(SIGN FULL NAME HERE FOR HEALTH CARE POWER OF ATTORNEY AND HEALTH CARETREATMENT INSTRUCTIONS)

WITNESS: ________________________________________________________

WITNESS: ________________________________________________________

Two witnesses at least 18 years of age are required by Pennsylvania law and should witness

your signature in each other's presence. A person who signs this document on behalf of and at

the direction of a principal may not be a witness. (It is preferable if the witnesses are not your

heirs, nor your creditors, nor employed by any of your health care providers.)

NOTARIZATION (OPTIONAL)

(Notarization of document is not required by Pennsylvania law, but if the document is both

witnessed and notarized, it is more likely to be honored by the laws of some other states.)

On this__________day of __________, 20___, before me personally appeared the aforesaid

declarant and principal, to me known to be the person described in and who executed the

foregoing instrument and acknowledged that he/she executed the same as his/her free act and

deed.

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County

of__

________, State of Pennsylvania, the day and year first above written.

__________________________________________

__________________________________________

Notary Public

__________________________________________

__________________________________________

My commission expires


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REFERENCES

Statutes

Fla. Stat. 765.401

20 Pa.C.S.A. 5422

20 Pa.C.S.A. 5423

20 Pa.C.S.A. 5461

20 Pa.C.S.A. 5471

35 P.S. 10203

Cases

Halderman v. Pennhurst State Sch. & Hosp., 1997 U.S. Dist. LEXIS 20504

In re D.L.H., 967 A.2d 971 (Pa.Super. 2009)

In re Fiore, 543 Pa. 592, 673 A.2d 905 (Pa. 1996)

Schiavo ex rel. Schindler v. Schiavo, 357 F. Supp.2d 1378 (M.D. Fla. 2005)

Schiavo ex rel. Schindler v. Schiavo, 403 F.3d 1223 (11th

Cir. Fla. 2005)

Schiavo ex rel. Schindler v. Schiavo, 403 F.3d 1261 (11th

Cir. Fla. 2005)

Cruzan v. Dir., Mo. Dep't of Health, 497 U.S. 261 (1990)

Other Authorities

American College of Legal Medicine Foundation. Medicolegal Primer. 121 (Cyril H. Wecht &

Harold L. Hirsch ed., 1st

ed., American College of Legal Medicine Foundation 1991)


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American Hospice Foundation. Coma and Persistent Vegetative State: An Exploration of Terms.

http://www.americanhospice.org/index.php?option=com_content&task=view&id=50&I

temid=8 (last accessed April 10, 2010)

Blacks Law Dictionary. 488 (4th ed., West, 1968)

Blacks Law Dictionary. 428 (Bryan A. Garner ed., 8th ed., West 2004)

braininjury.com. Coma: Some Facts. http://www.braininjury.com/coma.html (last accessed

April 12, 2010)

braininjury.com. Vegetative State. http://www.braininjury.com/coma.html (last accessed

April 12, 2010)

Alexander Morgan Capron and Leon R. Kass. Statutory Definition of the Standards for

Determining Human Death: An Appraisal and a Proposal. 121 U. Pa. L. Rev. 87 (1972)

Caring Connections. Understanding Advance Directives.

http://www.caringinfo.org/userfiles/file/PDFs/Understanding_Advance_Directives.pdf (last

accessed April 20, 2010)

Edward Lowenstein. Defining Brain Death: Motivations and Future Directions. 23(4)

International Anesthesiology Clinics 121 (Fall 2007)

21 P.L.E. Death; Dead Bodies 1

Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical and

Behavioral Research. Defining Death: Medical, Legal and Ethical Issues in the

Determination of Death. (Washington: GPO, 1981)

Graham Teasdale & Bryan J. Jennett. Assessment of Coma and Impaired Consciousness. A

Practical Scale. 2(7872) Lancet 81 (July 13, 1974)


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University of Pennsylvania. Uniform Determination of Death Act.

http://www.law.upenn.edu/bll/archives/ulc/fnact99/1980s/udda80.htm (last accessed

April 12, 2010)

TKO Complexities Resulting From Difficulty in the Determination of Death

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