An 82-year-old woman who was recently pronounced dead at a New York nursing home was later discovered by funeral home workers. This comes after a similar incident in Iowa, where a 66-year-old woman with dementia praecox was pronounced dead by a nurse, only to be found gasping for air when funeral staff unzipped her body bag.
Fortunately, these events are very rare. But their fear is visceral, which may explain an ancient naval custom. When sewing the canvas shroud for a dead sailor, the sailboat would make the last stitch on the deceased’s nose. Presumably having a sailcloth needle up your nose was a stimulus potent enough to wake up any sailor still alive.
Confirmation of death these days is thankfully much less brutal.
The absence of heart and breath sounds over a period of time, the presence of fixed and dilated pupils, and the inability to respond to any stimuli must mean that the person has passed away. All doctors are taught to do this, and everyone is aware of their duties.
Unfortunately, there have been cases where death has been confirmed by this process, but the patient has shown signs of life afterwards.
Over the years I have seen this happen. One day, in a hospital, a colleague declared the death of an elderly woman, but a short time later she started breathing again and her pulse was briefly restored.
In another unforgettable incident, the emergency medical team was called with the words: “Cardiac arrest. Funerary. This is not a joke!” A woman had taken an overdose of barbiturates prescribed for her epilepsy. She had been seen by a general practitioner who certified that she was dead.
But when he got to the morgue, one of his legs was shaking. Excruciating embarrassment all around. And if I remember correctly, she recovered.
Failure to carry out the death confirmation procedure correctly explains some cases of people incorrectly declared dead. A cursory examination while distracted can easily lead to a failure to hear heart sounds and detect shallow and infrequent breathing. It pays to be thorough. However, some medications we give patients can make the task more difficult.
Drugs, toxins and cold water
Sedative drugs are thought to somehow protect the brain from damage and this is used in anesthesia for major surgical procedures, especially if circulation needs to be stopped for a while.
Less useful and potentially alarming, an overdose of sedatives reduces responsiveness and depresses breathing and circulation, leading to the impression of death while protecting the brain from hypoxia (lack of oxygen). Later, as the drug is cleared from the body, the person may wake up.
Diazepam (brand name Valium) and alprazolam (brand name Xanax) have caused people to be mistakenly declared dead.
Certain toxins can have a similar effect. Voodoo practitioners called Bokors apparently administered powders to their victims to make them appear dead. These powders supposedly contained small doses of pufferfish tetrodotoxin to paralyze the victim, who was presumably kidnapped before burial and enslaved. Could neurological damage from the “zombification” process explain the popular image of the zombie?
Immersion in cold water can also lead to the illusion of death due to its effect on lowering the heart rate. Survival after considerable periods of time in water is well documented.
In emergency medicine, it has long been taught that a drowning patient is not considered dead until he is warmed. Good neurological recovery has been reported after periods of immersion in cold water of up to 70 minutes
Fainting can also fool the certifying physician. Activation of the vagus nerve (the longest cranial nerve in the body) occurs during fainting, slowing the heart and lowering blood pressure.
This may explain a very sad case reported in Honduras. A pregnant teenager is believed to have died of shock after hearing gunshots in her neighborhood. She was heard screaming inside her tomb the day after her funeral. It is quite possible that she woke up after a prolonged blackout.
Many cases appear to originate outside Europe. Geographic variation in the medical confirmation of the death procedure may explain this. Perhaps the errors arise when people are least likely to afford a doctor’s costs.
Whatever the cause, these cases appear in the media because they are sensational and attract sensational attention, but ultimately they are very rare.
Stephen HughesSenior Lecturer in Medicine, Anglia Ruskin University
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