On the way to school Oliver and Edward were walking next to the Liten Burial Ground, a local cemetery located in Basingstoke in south central England.

They walked along their daily route to school, but this time, something unusual caught their attention: The boys heard a faded screaming voice coming from one of the graves, but it was too quiet understand the words.

“Do you hear that or am I just going crazy?!” Oliver asked Edward in disbelief.

“Bloody Mary! I do! It sounds like somebody shouting through a glass jar,” said Edward, “What should we do?”

“If we go explore the cemetery now, we’ll be late for class and get in trouble. Let’s tell the headmaster about this. Adults always know what to do.” Said Oliver.

Oliver and Edward ran quickly to their school and approached their school headmaster.

“Mr. Thomson, there are voices coming out from the graveyard!” Oliver cried out to his teacher.

“That’s nonsense! Young men should not be running around and telling lies about the deceased.” Said Mr. Thomson, “For our next class, read the remainder of book of Exodus and then present a summary of it in front of the entire class. Edward, you look guilty, so you’ll help Oliver.” Mr. Thomson added angrily.

“But, Mr. Thomson, we are not lying! There REALLY are voices coming from the cemetery.” Said Oliver with tears in his eyes.  

“You should know better than that. Discussion is over!” Said Mr. Thomson to Oliver and Edward and the boys walked away.

***

The boys were not lying – the screaming was the voice of Mrs. Blunden, who had the misfortune of being buried before she was actually dead in Basingstoke England, in mid-July of 1674. Several people that day repeated Oliver’s and Edward’s claims, but by the time the grave was re-opened it was too late. Mrs. Blunden’s nails were covered with blood and her coffin was scratched from the inside in her attempts to escape.

Historically, it was often difficult to tell if somebody was dead or in a coma and, as a consequence, many people have been buried prematurely and Mrs. Blunden’s story is one of many. In the 18^th and 19^th centuries in Europe, the fear of being buried alive was such a common problem that wealthy and wary could purchase fancy coffins that had bells inside – in the case you woke up, you could ring for help.

So, how do we tell if somebody is really dead? This should be a simple answer, right? When one is dead, one is dead. But, death is defined in many ways, not necessarily by medical sciences, but by law. In the United States, there are two main criteria for determining if someone is medically “dead:” cardiopulmonary death (cessation of breathing and heart beat) and brain death (no neuronal activity present). Intriguingly, “brain death” is a much more recent addition to the medical criteria for death and its diagnosis is primarily determined by a clinician. To determine whether somebody is brain dead, a clinician tests for brain stem reflexes such as loss of pupillary reflexes (pupils don’t constrict when you shine light into the eyes), lack of heartbeat, and lack of respiratory movements (aka an apnea test). Ethically, these are interesting criteria for determining death because a brain-dead individual whose heart is still beating, lungs are still expanding and whose body is still pink and warm is just as “dead,” legally speaking, as an individual whose heart stopped beating and whose body has turned stiff and cold.

When do you call the time of death for someone? This is by far the most important question in our current era of clinical organ transplantation and there is ton of controversy between the relationship of determining the time of death and organ donation. Obviously, if a patient is an organ donor, you want to call it sooner rather than later, because with each second ticking by in a deceased donor, the organ viability decreases tremendously.

Currently, the so-called “Dead Donor Rule” (DDR) is the gold standard of current organ procurement. The name is misleading because the DDR is not a rule nor a regulation but rather an ethical norm that has become widely adapted in the medical community. The DDR basically says that it’s wrong to kill person (by, say, removing their vital organs) to save a life of another. Thus, before vital organs are removed, the person must be either brain dead or assessed for cardiopulmonary death. Physicians challenge the DDR rule all the time, however, such as when a family requests that a physician withdrawals life-support from a patient who is brain dead: technically the cessation of life-support causes death, not the underlying disease.

And what about the more obvious dead folks, the cold cases, the stiffs? Their time of (cardiopulmonary) death is usually determined by a pathologist. Surprisingly, the first thing a pathologist might check is whether the deceased is wearing a watch. Especially, if the watch is broken, because this would give insight on the time of death as a result of traumatic injury, such as death caused by a car accident or a fall. Other methods used to determine the physiological time of death include measuring the body temperature (the body, normally about 37 C, loses 1.5 C per hour until it reaches the temperature of its surrounding environment) and by… insects! The study of when and how various species of insects enter dead bodies is called “forensic entomology” and pathologists are able to estimate the time of death by looking at the life cycle stage of certain insects that are present in the human flesh. And place of death doesn’t matter – whether you die in your apartment or get murdered in a cornfield, they can assess your death looking at the life cycles of house flies or flesh flies/horse flies. Insects are everywhere! (No matter how clean your house is.)

In the case of Mrs. Blunden, she wasn’t feeling so well, so she went to the doctor for poppy water, which she consumed for its narcotic effect. After drinking it, she had fallen so deeply asleep that a physician mistakenly diagnosed her with cardiopulmonary death. Fortunately, today in Western countries people are rarely prematurely buried. Before the 1930s, when a person was dying, family, friends, relatives, clergy and neighbors would gather at their home and try to spend the last moments comforting the person who is dying. Now, most people die in a professionalized medical environment instead of in their homes and this transition of your location of dying is called by historians the “Invisible Death,” simply because we started hiding our “deaths” within the hospital walls, rather than experiencing it as part of everyday community interaction. Also, considerable advances in medical technology such as breathing machines and feeding tubes have helped people live longer. It’s less likely to be prematurely buried when you have a team of medical professionals in a hospital constantly monitoring your heartbeat and breathing patterns.

Objectively speaking, there is only one kind of death, whether a patient is brain-dead or diagnosed with cardiopulmonary death, the outcome is the same – you’re dead and there is irreversible absence of circulation. But, policy, ethics, law, and medicine all define death differently, categorizing it or breaking it down to different types of deaths, adding another moral and legal layer of complexity in defining death.

References:

1. Robert M. Sade BRAIN DEATH, CARDIAC DEATH, AND THE DEAD DONOR RULE. J S C Med Assoc. 2011 August
2. Determining time of death: http://www.exploreforensics.co.uk/estimating-the-time-of-death.html