Postmortem communication.

The phenomenon of near death and dying experiences has been both of popular interest and of scientific speculation. However, the reality of mental perception at the point of death is currently a subjective experience and has not been formally evaluated. While postmortem gene expression, even in humans, has been evaluated, restoration of postmortem brain activity has heretofore only been attempted in animal models, at the molecular and cellular levels. Meanwhile, progress has been made to translate brain activity of living humans into speech and images. This paper proposes two inter-related thought experiments. First, assuming progress and refinement of the technology of translating human brain activity into interpretable speech and images, can an objective analysis of death experiences be obtained by utilizing these technologies on dying humans? Second, can human brain function be revived postmortem and, if so, can the relevant technologies be utilized for communication with (recently) deceased individuals? In this paper, these questions are considered and possible implications explored.

Knowledge and practices of youth awareness on death and dying in school settings: a systematic scoping review protocol.

BACKGROUND: Awareness-raising and education have been identified as strategies to counter the taboo surrounding death and dying. As the favoured venue for youth education, schools have an essential role to play in informing future decision-makers. However, school workers are not comfortable addressing the subjects of death and dying, which, unlike other social issues, have no guidelines to influence awareness of these subjects in youth. OBJECTIVES: To systematically explore the knowledge and practices on raising awareness about death and dying in schools, the viewpoints of the people involved (young people, school workers; parents), and the factors that either promote or hinder awareness practices. METHOD: The scoping review method of Levac and Colquhoun (Implement Sci 5(1):69, 2010) will be used. Using a combination of keywords and descriptors, a body of literature will be identified through 15 databases and through grey literature searches, manual searches, consultation of key collaborators, and the list of relevant literature. Publications since 2009 will be selected if they relate directly to awareness-raising about death and dying in schools. Writings will be selected and extracted by two independent people, and conflicts resolved by consensus. The extracted data will be synthesized using a thematic analysis method. Experts from a variety of disciplines (health sciences, humanities, social sciences, and education) will be consulted to enhance the interpretation of the preliminary results. Results will be presented in narrative form and will include tables and diagrams. CONCLUSION: The results of this scoping review will contribute to the development of educational practices adapted to young people and to the identification of future avenues of research on awareness of death and dying.

Donation After Circulatory Death Heart Transplantation: A Narrative Review.

Heart transplantation is the definitive treatment for refractory, end-stage heart failure. The number of patients awaiting transplantation far exceeds available organs. In an effort to expand the donor pool, donation after circulatory death (DCD) heart transplantation has garnered renewed interest. Unlike donation after brain death, DCD donors do not meet the criteria for brain death and are dependent on life-sustaining therapies. Procurement can include a direct strategy or a normothermic regional perfusion, whereby there is restoration of perfusion to the organ before explantation. There are new developments in cold storage and ex vivo perfusion strategies. Since its inception, there has been a steady improvement in post-transplant outcomes, largely attributed to advancements in operative and procurement strategies. In this narrative review, the authors address the unique considerations of DCD heart transplantation, including withdrawal of care, the logistics of procuring and resuscitating organs, outcomes compared with standard donation after brain death, and ethical considerations.

Hormonal changes in northern white-cheeked gibbons (Nomascus leucogenys) after the death of a group member.

The small apes, gibbons and siamangs, are monogamous species with their social groups comprising of both parents and their offspring. Therefore, the loss of a member may elicit a stress response in the remaining members due to their strong bonds. Glucocorticoids (GCs) have been useful indicators of stress, but distinguishing between acute versus chronic stress may be limited when measuring these hormones alone. The adrenal hormone dehydroepiandrosterone-sulfate (DHEAS), a GC antagonist, has been implicated in the regulation of the stress response. Thus, the concomitant measurement of these hormones can help examine whether an event, such as the loss of a group member, elicited a stress response. In this brief report, we discuss the hormonal response of two zoo-housed northern white-cheeked gibbons (Nomascus leucogenys) (1 adolescent male and his mother) after the death of the adult male of the group. Baseline fecal samples were collected opportunistically from these two individuals 5 months prior, and 3 months following the death of their group member. A total of 25 samples were quantified for fecal GC metabolites (FGCMs) and DHEAS by enzyme immunoassay (EIA) to calculate the FGCMs:DHEAS ratio. Our results indicate an increase in FGCMs and FGCMs:DHEAS for the adolescent male, but not the adult female, following the death. Our findings suggest that the integration of FGCMs and DHEAS measurements can provide valuable information to interpret individual stress levels to the sudden change in the group's social structure.

The Effect of Life Stages on the Experience of Those Who Have Received an Unexpected and Violent Death Notification: A Qualitative Study.

BACKGROUND: How individuals are informed of the traumatic loss of a loved one can influence their grieving process and quality of life. OBJECTIVE: This qualitative study aimed to explore, through thematic analysis, how life stages might influence the experience and feelings of those who have received communication of a traumatic death from police officers or healthcare professionals. METHOD: Recruited through social networks and word of mouth, 30 people participated in the study. Subjects were divided into three groups according to age (Group 1: ten participants aged between 20 and 35 years; Group 2: ten participants aged between 45 and 55 years; and Group 3: ten participants aged 60 and over). Participants completed an ad hoc questionnaire online. Atlas.ti software 8 was used to perform thematic analysis. RESULTS: The three age groups had the following four key themes in common: (a) emotional reactions; (b) subjective valuation of the notification; (c) support; and (d) needs. Subtle differences emerged between age groups; yet the quality of the reactions and main themes did not vary greatly between the groups considered. CONCLUSIONS: The communication of an unexpected and violent death seems to provoke rather similar effects in survivors of different life stages. A few differences were noted in sub-themes (increased need for professional training in younger recipients; absence of suicidal ideation in older adults); perhaps quantitative designs could provide further details in future investigations.

The Unified Brain-Based Determination of Death Conceptually Justifies Death Determination in DCDD and NRP Protocols.

Organ donation after the circulatory determination of death requires the permanent cessation of circulation while organ donation after the brain determination of death requires the irreversible cessation of brain functions. The unified brain-based determination of death connects the brain and circulatory death criteria for circulatory death determination in organ donation as follows: permanent cessation of systemic circulation causes permanent cessation of brain circulation which causes permanent cessation of brain perfusion which causes permanent cessation of brain function. The relevant circulation that must cease in circulatory death determination is that to the brain. Eliminating brain circulation from the donor ECMO organ perfusion circuit in thoracoabdominal NRP protocols satisfies the unified brain-based determination of death but only if the complete cessation of brain circulation can be proved. Despite its medical and physiologic rationale, the unified brain-based determination of death remains inconsistent with the Uniform Determination of Death Act.

Ethical and Equity Guidance for Transplant Programs Considering Thoracoabdominal Normothermic Regional Perfusion (TA-NRP) for Procurement of Hearts.

Donation after circulatory determination of death (DCDD) is an accepted practice in the United States, but heart procurement under these circumstances has been debated. Although the practice is experiencing a resurgence due to the recently completed trials using ex vivo perfusion systems, interest in thoracoabdominal normothermic regional perfusion (TA-NRP), wherein the organs are reanimated in situ prior to procurement, has raised many ethical questions. We outline practical, ethical, and equity considerations to ensure transplant programs make well-informed decisions about TA-NRP. We present a multidisciplinary analysis of the relevant ethical issues arising from DCDD-NRP heart procurement, including application of the Dead Donor Rule and the Uniform Definition of Death Act, and provide recommendations to facilitate ethical analysis and input from all interested parties. We also recommend informed consent, as distinct from typical "authorization," for cadaveric organ donation using TA-NRP.

An Ethics Committee's Evaluation of Normothermic Regional Perfusion (NRP) in 2018-Unsatisfactory Answers Then-and Now.

An adult university hospital ethics committee evaluated a proposed TA-NRP protocol in the fall of 2018. The protocol raised ethical concerns about violation of the Uniform Determination of Death Act and the prohibition known as the Dead Donor Rule, with potential resultant legal consequences. An additional concern was the potential for increased mistrust by the community of organ donation and transplantation. The ethics committee evaluated the responses to these concerns as unable to surmount the ethical and legal boundaries and the ethics committee declined to endorse the procedure. These concerns endure.

Chinese older adults' prior-to-death disability profiles and their correlates.

BACKGROUND: Disability prior to death complicates end-of-life care. The present study aimed to explore the prior-to-death disability profiles of Chinese older adults, the profiles' links to end-of-life care arrangements and place of death, and predictors of the profiles. METHODS: In total, data were extracted from the records of 10,529 deceased individuals from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Latent profile analyses, bivariate analysis, and multivariate logistic regression were applied to identify prior-to-death disability profiles, explore the profiles' links to end-of-life care arrangements and place of death, and examine predictors in the profiles, respectively. RESULTS: Three prior-to-death disability profiles, namely, Disabled-Incontinent (37.6%), Disabled-Continent (34.6%), and Independent (27.8%), were identified. Those with the Independent profile were more likely to live alone or with a spouse and receive no care or care only from the spouse before death. Disabled-Continent older adults had a higher chance of dying at home. Being female, not "married and living with a spouse", suffering from hypertension, diabetes, stroke or cerebrovascular disease (CVD), bronchitis/emphysema/pneumonia, cancer, or dementia, and dying in a later year were associated with more severe prior-to-death disability patterns. Not having public old-age insurance predicted lower chances of having a Disabled-Incontinent profile, and advanced age increased the chance of having a Disabled-Continent profile. CONCLUSIONS: Three prior-to-death disability patterns were identified for Chinese adults aged 65 years and older. These profiles were significantly linked with the end-of-life caregiving arrangements and place of death among older adults. Both demographic information and health status predicted prior-to-death disability profiles.

What Italian PICU Healthcare Providers Think About Donation After Cardiocirculatory Determination of Death: A National Survey.

BACKGROUND: Italy presently does not have a pediatric organ donation program after cardiocirculatory determination of death (pDCDD). Before implementing a pDCDD program, many centers globally have conducted studies on the attitudes of pediatric intensive care unit (PICU) staff. This research aims to minimize potential adverse reactions and evaluate the acceptance of the novel donation practice. METHODS: We conducted an electronic and anonymous survey on attitudes toward pDCDD among healthcare professionals (HCPs) working at eight Italian PICUs. The survey had three parts: (I) questions about general demographic data; (II) 18 statements about personal wishes to donate, experience of discussing donation, and knowledge about donation; (III) attitudinal statements regarding two pediatric Maastricht III scenarios of organ donation. RESULTS: The response rate was 54.4%, and the majority of respondents were nurses. Of those who responded, 45.3% worked in the Center, 40.8% in the North, and 12.8% in the South of Italy. In total, 93.9% supported pediatric organ and tissue donation, 90.3% supported donation after neurological determination of death (DNDD), 78.2% supported pDCDD, and 69.7% felt comfortable about the idea of participating in pDCDD on Type III patients, with a higher percentage of supportive responses in the Center (77.2%) than in the North (65.1%) and South (54.5%) of Italy (p-value < 0.004). Concerning scenarios, 79.3% of participants believed that organ retrieval took place in a patient who was already deceased. Overall, 27.3% considered their knowledge about DCDD to be adequate. CONCLUSIONS: Our study provides insight into the attitudes and knowledge of PICU staff members regarding pDCDD in Italy. Despite a general lack of knowledge on the subject, respondents showed positive attitudes toward pDCDD and a strong consensus that the Italian legislation protocol for determining death based on cardiocirculatory criteria respects the "dead donor rule." There were several distinctions among the northern, central, and southern regions of Italy, and in our view, these disparities can be attributed to the varying practices of commemorating the deceased. In order to assess how practice and training influence the attitude of PICU staff members, it would be interesting to repeat the survey after the implementation of a program.

Psychosocial distress among spouses of persons with dementia before and after their partner's death.

BACKGROUND: Spouses of persons living with dementia may face heightened psychosocial distress in the years immediately before and after their partner's death. We compared the psychosocial needs of spouses of partners with dementia with spouses of partners with non-impaired cognition nearing and after the end of life, focusing on loneliness, depression, life satisfaction, and social isolation. METHODS: We used nationally representative Health and Retirement Study married couples data (2006-2018), restricting to spouses 50+ years old. We included 2098 spouses with data on loneliness and depressive symptoms 2 years before and after the partner's death. We additionally examined a subset of spouses (N = 1113) with available data on life satisfaction and social isolation 2 years before their partner's death. Cognitive status of partners was classified as non-impaired cognition, cognitive impairment not dementia (cognitive impairment), and dementia. We used multivariable logistic regression to determine: 1) the change in loneliness and depression for spouses pre- and post-partner's death, and 2) life satisfaction and social isolation 2 years before the partner's death. RESULTS: Spouses were on average 73 years old (SD: 10), 66% women, 7% Black, 7% Hispanic non-White, 24% married to persons with cognitive impairment, and 19% married to partners with dementia. Before their partner's death, spouses married to partners with dementia experienced more loneliness (non-impaired cognition: 8%, cognitive impairment: 16%, dementia: 21%, p-value = 0.002) and depressive symptoms (non-impaired cognition: 20%, cognitive impairment: 27%, dementia: 31%, p-value < 0.001), and after death a similar prevalence of loneliness and depression across cognitive status. Before their partner's death, spouses of partners with dementia reported less life satisfaction (non-impaired cognition: 74%, cognitive impairment: 68%; dementia: 64%, p-value = 0.02) but were not more socially isolated. CONCLUSION: Results emphasize a need for clinical and policy approaches to expand support for the psychosocial needs of spouses of partners with dementia in the years before their partner's death rather than only bereavement.

Exploring the influence of the impending death discharge tradition on home death rate in Taiwan.

BACKGROUND: As modern societies witness a shift from home deaths to hospital deaths, the compromise practice of impending death discharge (IDD) in response to Chinese traditions and changing times deserves further exploration. METHODS: Using the Longitudinal Generation Tracking Database 2005, a validated cohort of two million randomly sampled National Health Insurance (NHI) beneficiaries, we conducted a retrospective analysis on the places of death for 123 832 individuals from 2008 to 2017. RESULTS: Approximately 47.4% of the residents died in hospitals, 45.6% died in their own homes, and 2.4% died in long-term care facilities. Of those who died at home, 27 809 (49.2%) had undergone an IDD and were classified in the IDD group. Over the past decade, there has been a noticeable trend of decreasing home death rates. This trend is mainly due to the decline in the IDD group, which decreased from 29.6% in 2008 to 16.0% in 2017. The percentage of non-IDD group deaths that occurred at home ranged from 21.4% to 24.7%. The logistic regression analyses of all patients admitted to hospital before death revealed that individuals with IDD tend to be women, middle-aged individuals (aged between 50 and 79 years), married, and those residing outside of the six municipalities. Furthermore, the choice for IDD varied with the cause of death, with conditions like sepsis and malignancy recording higher rates as opposed to pneumonia. Patients who were discharged from hospice care were less likely to choose IDD. No association was found between choosing IDD and receiving hospice home care or emergency room visits in the year before death. CONCLUSION: This study investigates factors associated with IDD, informing healthcare professionals on end-of-life care in Chinese culture. Future qualitative or prospective research can offer deeper insights into family dynamics, patient preferences, and other unmeasured factors influencing IDD utilization.

Changes Due to Patient Deaths: Medical Students' Expectations vs. Health Professionals' Experiences.

CONTEXT: Preparing healthcare professionals for inevitable encounters with patient deaths is crucial to preventing maladaptive professional bereavement outcomes. OBJECTIVES: This study aimed to explore the discrepancies between medical students' pre-patient death expectations and healthcare professionals' post-patient death experiences regarding accumulated global changes due to patient deaths (AGC), identify heterogeneous expectation patterns among students, and reveal risk factors for worthy-of-concern expectation patterns. METHODS: Cross-sectional survey data from 231 professional caregivers and 405 medical and nursing students were used. Independent t tests and analyses of covariance were run for staff-student AGC comparisons. Latent profile analysis (LPA) among students was followed by logistic regression. RESULTS: The students scored higher than did the staff in two AGC factors: more acceptance of limitations and more death-related anxiety. LPA identified four latent expectation patterns, with the "overoptimistic" (27.8%) group being worthy of concern, as students overestimated positive changes and underestimated negative changes. The overoptimistic pattern was predicted by students' motivations to study medicine, which were driven by "interests," "career opportunities," and "improving medical services in the hometown," rather than "by chance," and higher scores on the death attitude of "neutral acceptance." CONCLUSION: In general, students tend to overestimate the long-term impacts of patient deaths. However, approximately 1/4 of students hold overly optimistic expectations, which are predicted by motivations to study medicine and death attitudes.

Beyond troubled and untroubled positions - an intersectional analysis of siblings who are bereaved by drug-related deaths' meaning-making stories about their deceased brothers and sisters.

PURPOSE: This study investigates how social categories work and intersect in siblings bereaved by drug-related deaths' (DRDs) stories about their relationships to their deceased brother or sister. The sociocultural embedded process of making meaning of the relationship with the deceased individual is essential in adapting to the loss. However, insight into such experiences of siblings bereaved by a DRD is scarce. Previous research has suggested that DRDs may be stigmatized life experiences for bereaved family members, and this paper furthers understanding of the experiences and issues involved in losing a sibling in a stigmatized death. METHODS: An intersectional analysis is applied to interviews with 14 bereaved siblings. By investigating and displaying how different categories intertwine, various positionings are identified. FINDINGS: Categorization of the deceased siblings as "addicts" constructs a troubled position. However, when "addict" intersects with the categories "unique," "sibling," and "uncle," the troubled subject's position as an "addict" can be concealed. CONCLUSIONS: Normative conceptions of addiction and DRDs produce troubled subject positions. By intermingling the category of "addict" with other categories, less problematic positions are created. Still, intersections of categories can also construct further complexities of remorse and self-blame for the bereaved siblings.