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Antea Worldwide Palliative Care Conference

Rome, 12-14 November 2008


Presenting author TITOLO: Thresholds in the dying process
Carlo Alberto Defanti
Authors (max 6, presenting author included): Carlo Alberto Defanti
The fundamental fact we face is that death today is almost never an event, but mostly a process,
Phone more or less lengthy, profoundly modified by the medical intervention. We can distinguish several
thresholds and we try to describe them in a schematical way.
A first threshold is loss of consciousness: the coma state, long ago antechamber of death, now a
Mobile phone possible transient stage both toward death itself and awakening and life.
A second threshold is the vegetative state (VS), which can be a phase precedent death in the
course of progressive central nervous diseases, but usually is a transient condition following
coma after an acute brain damage. VS can evolve toward awakening or minimally conscious
Please underline the most state, but sometimes become a stable condition: the permanent vegetative state (PVS), defined by
appropriate category for your some cortical death.
abstract A third, most important threshold is “irreversibile coma” or brain death. Along with some
scholars I maintain that – contrarily to the common opinion – it doesn’t coincide with the death
• Pain and other symptoms
of the organism as a whole (only cardiocirculatory arrest is a good candidate for this), but
• Palliative care for cancer patients certainly is a “point of no return”.
• Palliative care for non cancer A fourth threshold is cardiocirculatory arrest, the “old” cardiac death.
patients A possible fifth threshold is the temporal threshold of vitality of organs and tissues after cardiac
• Paediatric palliative care arrest, clearly a very important point for the sake of transplantation.
After this description of the stages of the dying process, we have to tackle with the moral problem
• Palliative care for the elderly
raised by the treatment of the dying person during the various steps. Obviously in the coma state,
• The actors of palliative care
when prognosis is not clear, our duty is to aggressively treat the patient in order to make it
• Latest on drugs possible for him/her to recover. Long ago this attitude was mandatory in each case, but now, at
• Pain least when strong prognostic signs announcing death or PVS are present, the correct attitude is to
withdraw life- sustaining treatments.
• Illness and suffering through In VS patients with favorable prognostic signs the full treatment has to be given.
media In the case of PVS, the withdrawal of life-sustaining treatments and especially artificial nutrition
can be discussed, according to a possible advance directive executed by the patient.
• Marginalisation and social stigma
Brain death clearly justify withdrawal of life-sustaining treatments and harvesting organs when
at the end of life
the person agreed or at least not dissented with this.
• Palliative care advocacy projects In the case of sudden and unexpected cardiac arrest, a trial of resuscitation is mandatory and its
• Prognosis and diagnosis possible failure shows that the condition is irreversible and death can be declared. If cardiac
communication in arrest happens during the course of a disease with fatal prognosis, no resuscitation is mandatory
different cultures and death can be declared.
Sometimes, when the dying process is due to a progressive brain disease and (cardiac) death is
• Communication between doctor- foreseeable, organs can be harvested a very short time after cardiac arrest, with consent of the
patient and patient- legal representative, according to the so-called Pittsburgh protocol.
• Religions and cultures versus
suffering, death and
• Public institution in the world:
palliative care policies
and law
• Palliative care: from villages to metropolies

• Space, light and gardens for the terminally ill patient
• End-of-life ethics
• Complementary therapies Session: Neurology & palliative care
• Education, training and research
• Fund-raising and no-profit Chair of the session: Dott. Ignazio R. Causarano
• Bereavement support
• Volunteering in palliative care
• Rehabilitation in palliative care
• Neurology & palliative care