319:
that satisfaction of the criteria sufficed for the diagnosis of the death of the brain as a whole, despite the persistence of demonstrable activity in parts of the brain. In 1995, that claim was abandoned and the diagnosis of death (acceptable for legal purposes in the UK in the context of organ procurement for transplantation) by the specified testing of brainstem functions was based on a new definition of death – the permanent loss of the capacity for consciousness and spontaneous breathing. There are doubts that this concept is generally understood and accepted and that the specified testing is stringent enough to determine that state. It is, however, associated with substantial risk of exacerbating the brain damage and even causing the death of the apparently dying patient so tested (see "the apnoea test" above). This raises ethical problems which seem not to have been addressed.
172: – and advanced a new definition of human death as the basis for equating this syndrome with the death of the person. The suggested new definition of death was the "irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe". It was stated that the irreversible cessation of brainstem function will produce this state and "therefore brainstem death is equivalent to the death of the individual".
2112:
2122:
361: – the 'respiratory centre'. In the UK, establishing a neurological diagnosis of death involves challenging this centre with the strong stimulus offered by an unusually high concentration of carbon dioxide in the arterial blood, but it is not challenged by the more powerful drive stimulus provided by
318:
The diagnostic criteria were originally published for the purpose of identifying a clinical state associated with a fatal prognosis (see above). The change of use, in the UK, to criteria for the diagnosis of death itself was protested immediately. The initial basis for the change of use was the claim
327:
which lie within the brainstem (there are elements also within the wider brain). Knowledge of this arousal system is based upon the findings from animal experiments as illuminated by pathological studies in humans. The current neurological consensus is that the arousal of consciousness depends upon
121:
but showing no signs of recovery. The
Conference sought "to establish diagnostic criteria of such rigour that on their fulfilment the mechanical ventilator can be switched off, in the secure knowledge that there is no possible chance of recovery". The published criteria – negative responses to
384:
A small minority of medical practitioners working in the UK have argued that neither requirement of the UK Health
Department's Code of Practice basis for the equation of brainstem death with death is satisfied by its current diagnostic protocol and that in terms of its ability to diagnose de facto
305:
Published studies of patients meeting the criteria for brainstem death or whole brain death – the
American standard which includes brainstem death diagnosed by similar means – record that even if ventilation is continued after diagnosis, the heart stops beating within only a few hours or
345:(serving sight and smell) which are not tested when diagnosing brainstem death but which were described in cats in 1935 and 1938. In humans, light flashes have been observed to disturb the sleep-like EEG activity persisting after the loss of all brainstem reflexes and of spontaneous respiration.
322:
It has been argued that sound scientific support is lacking for the claim that the specified purely bedside tests have the power to diagnose true and total death of the brainstem, the necessary condition for the assumption of permanent loss of the intrinsically untestable consciousness-arousal
112:
The United
Kingdom (UK) criteria were first published by the Conference of Medical Royal Colleges (with advice from the Transplant Advisory Panel) in 1976, as prognostic guidelines. They were drafted in response to a perceived need for guidance in the management of deeply comatose patients with
340:
appears, on the basis of electroencephalographic (EEG) studies, to be awaiting the command or ability to function. The role of diencephalic (higher brain) involvement is stated to be uncertain and we are reminded that the arousal system is best regarded as a physiological rather than a precise
353:
raising thoughts about the "plasticity" of the nervous system. Other theories of consciousness place more stress on the thalamocortical system. Perhaps the most objective statement to be made is that consciousness is not currently understood. That being so, proper caution must be exercised in
180:
In the UK, the formal rules for the diagnosis of brainstem death have undergone only minor modifications since they were first published in 1976. The most recent revision of the UK's
Department of Health Code of Practice governing use of that procedure for the diagnosis of death reaffirms the
130:
factors and drug effects – were held to be "sufficient to distinguish between those patients who retain the functional capacity to have a chance of even partial recovery and those where no such possibility exists". Recognition of that state required the withdrawal of further
372:
No testing of testable brain stem functions such as oesophageal and cardiovascular regulation is specified in the UK Code of
Practice for the diagnosis of death on neurological grounds. There is published evidence strongly suggestive of the persistence of brainstem
81:. The premise of this is that a person is dead when consciousness and the ability to breathe are permanently lost, regardless of continuing life in the body and parts of the brain, and that death of the brainstem alone is sufficient to produce this state.
469:
289:
With due regard for the cause of the coma, and the rapidity of its onset, testing for the purpose of diagnosing death on brainstem death grounds may be delayed beyond the stage where brainstem reflexes may be absent only temporarily – because the
142:
In 1979, the
Conference of Medical Royal Colleges promulgated its conclusion that identification of the state defined by those same criteria – then thought sufficient for a diagnosis of brain death – "means that the patient is dead".
76:
can be certified on the basis of a formal diagnosis of brainstem death, so long as this is done in accordance with a procedure established in "A Code of
Practice for the Diagnosis and Confirmation of Death", published in 2008 by the
348:
There is also concern about the permanence of consciousness loss, based on studies in cats, dogs and monkeys which recovered consciousness days or weeks after being rendered comatose by brainstem ablation and on human studies of
582:
Shewmon DA. 'Brain body' disconnection : implications for the theoretical basis of 'brain death'. In Finis Vitae – is brain death still life? Ed. De Mattei R. Consiglio
Nazionale delle Richerche. Rubbettino, 2006, pp.
563:
Coimbra CG. Are 'brain dead' (or 'brain stem dead') patients neurologically recoverable? In Finis Vitae – 'brain death' is not true death. Eds. De Mattei R, Byrne PA. Life
Guardian Foundation, Oregon, Ohio, 2009, pp.
276:
Two doctors, of specified status and experience, are required to act together to diagnose death on these criteria and the tests must be repeated after "a short period of time ... to allow return of the patient's
450:
622:
Evans DW. The demise of 'brain death' in Britain. In Beyond brain death – the case against brain based criteria for human death. Eds. Potts M, Byrne PA, Nilges RG. Kluwer Academic Publishers, 2006, pp.
268:
is ensured by pre-oxygenation and diffusion oxygenation during the disconnection (so the brainstem respiratory centre is not challenged by the ultimate, anoxic, drive stimulus). This test – the
104:
made it clear, for example, in its White Paper of December 2008, that the British concept and clinical criteria are not considered sufficient for the diagnosis of death in the United States.
92:. Elsewhere in the world, the concept upon which the certification of death on neurological grounds is based is that of permanent cessation of all function in all parts of the brain –
298:
alive and capable of recovery. There has recently been renewed interest in the possibility of neuronal protection during this phase by use of moderate hypothermia and by correction of the
2158:
260:
No observed respiratory effort in response to disconnection of the ventilator for long enough (typically 5 minutes) to ensure elevation of the arterial partial pressure of
122:
bedside tests of some reflexes with pathways through the brainstem and a specified challenge to the brainstem respiratory centre, with caveats about exclusion of
336:. It is said that the midbrain reticular formation may be viewed as a driving centre for the higher structures, loss of which produces a state in which the
2304:
692:
Zwarts MJ, Kornips FHM. Clinical brainstem death with preserved electroencephalographic activity and visual evoked response. Arch Neurol 2001;58:1010
281:
and baseline parameters to the pre-test state". These criteria for the diagnosis of death are not applicable to infants below the age of two months.
2151:
523:
Coimbra CG. Implications of ischemic penumbra for the diagnosis of brain death. Brazilian Journal of Medical and Biological Research 1999;32:1479–87
1101:
147:
on those criteria has continued in the United Kingdom (where there is no statutory legal definition of death) since that time, particularly for
1162:
306:
days. However, there have been some very long-term survivals and it is noteworthy that expert management can maintain the bodily functions of
1126:
162:, the Conference of Medical Royal Colleges formally adopted the "more correct" term for the syndrome, "brainstem death" – championed by
1096:
2144:
1398:
749:
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101:
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78:
365: – although the effect of that ultimate stimulus is sometimes seen after final disconnection of the ventilator in the form of
653:
Lindsley DB et al. Effect upon the EEG of acute injury to the brain stem activating system. EEG Clin Neurophysiol 1949;1:475–8627
1634:
1086:
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anatomical entity. There should, perhaps, also be a caveat about possible arousal mechanisms involving the first and second
2299:
1182:
860:
635:
G, Magoun HW. Brain stem reticular formation and activation of the EEG. Electroencephalog Clin neurophysiol 1949;1:455–73
545:
Saposnik G et al. Problems associated with the apnea test in the diagnosis of brain death. Neurology India 2004;52:342–45
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155:
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Powner DJ, Bernstein IM. Extended somatic support for pregnant women after brain death. Crit Care Med 2003;31:1241–49
554:
Yingying S et al. Diagnosis of brain death : confirmatory tests after clinical test. Chin Med J 2014;127:1272–77
532:
Coimbra CG. The apnea test – a bedside lethal 'disaster' to avoid a legal 'disaster' in the operating room. In
243: – no eye movements following the slow injection of at least 50ml of ice-cold water into each ear in turn (the
2167:
723:
Wetzel RC et al. Hemodynamic responses in brain dead organ donor patients. Anesthesia and Analgesia 1985;64:125–28
644:
Ward AA. The relationship between the bulbar-reticular suppressor region and the EEG. Clin Neurophysiol 1949;1:120
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A Code of Practice for the Diagnosis and Confirmation of Death. Academy of Medical Royal Colleges, London, 2008
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There should be no doubt that the patient's condition – deeply comatose, unresponsive and requiring
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1411:
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148:
84:
This concept of brainstem death is also accepted as grounds for pronouncing death for legal purposes in
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often occurs within a few days, although it may continue for weeks if intensive support is maintained.
1991:
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50:
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Pennefather SH, Dark JH, Bullock RE. Haemodynamic responses to surgery in brain-dead organ donors.
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accepting a diagnosis of its permanent loss before all cerebral blood flow has permanently ceased.
324:
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89:
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is inadequate to support synaptic function, although there is still sufficient blood flow to keep
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Parvizi J, Damasio AR. Neuroanatomical correlates of brainstem coma. Brain 2003;126:1524–36
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Bleck TP. In Textbook of clinical neurology, 3rd Edn. Ed. Goetz CG. Elsevier Science, 2007
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Criteria for the diagnosis of brain stem death. J Roy Coll Physns of London 1995;29:381–82
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to at least 6.0 kPa (6.5 kPa in patients with chronic carbon dioxide retention). Adequate
214:
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Tononi G. An information integration theory of consciousness. BMC Neuroscience 2004;5:42
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Conference of Medical Royal Colleges and their Faculties in the UK. BMJ 1976;2:1187–88
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is a clinical syndrome defined by the absence of reflexes with pathways through the
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Conference of Medical Royal Colleges and their Faculties in the UK. BMJ 1979;1:332.
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Potentially reversible circulatory, metabolic and endocrine disturbances likewise.
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Hall GM et al. "Hypothalamic-pituitary function in the 'brain dead' patient".
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Pallis C, Harley DH. ABC of brain stem death. BMJ Publishing Group, 1996, p.30
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The ability to breathe spontaneously depends upon functioning elements in the
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Textbook of clinical neurology, 2nd Edn. Ed. Goetz CG. Elsevier Science, 2003
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so that death is allowed to occur, thus "sparing relatives from the further
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34:
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2006:
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Pallis, C. From Brain Death to Brain Stem Death, BMJ, 285, November 1982
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to bronchial stimulation or gagging response to pharyngeal stimulation.
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Fixed pupils which do not respond to sharp changes in the intensity of
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The Transplantation of Human Organs Act, 1994. Act No.42 of 1994. s. 2
57:-dependent patient. Identification of this state carries a very grave
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1723:
1493:
1361:
1285:
927:
210:
159:
96: – with which the British concept should not be confused. The
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1609:
1589:
1530:
1328:
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269:
221:
With these pre-conditions satisfied, the definitive criteria are:
151:
purposes, although the conceptual basis for that use has changed.
85:
73:
2198:
333:
2140:
758:
601:
Evans DW, Lum LC. Cardiac transplantation. Lancet 1980;1:933–34
203:
as the cause of unconsciousness must have been excluded, and
189: – is due to irreversible brain damage of known cause.
754:
310:
brain dead women for long enough to bring them to term.
192:
There should be no evidence that this state is due to
618:
616:
37: – the "stalk" of the brain, which connects the
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2239:
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1602:
1464:
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1243:
1232:
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799:
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328:reticular components which reside in the midbrain,
154:In 1995, after a review by a Working Group of the
610:Evans DW, Lum LC. Brain death. Lancet 1980;2:1022
302:abnormalities commonly seen in this early stage.
181:preconditions for its consideration. These are:
2152:
770:
534:Finis Vitae – is brain death still life?
8:
631:
629:
519:
517:
451:Controversies In The Determination Of Death
272: – is dangerous, and may prove lethal.
217:and cervical cord injury, must be excluded.
2159:
2145:
2137:
1240:
1229:
796:
777:
763:
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661:
659:
440:Human Tissue Transplant Act 2000. s. 19(1)
750:Great Ormond Street Hospital for Children
498:
496:
486:
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482:
213:(dependence on the ventilator), such as
394:
404:
402:
400:
398:
1127:List of ways people dishonor the dead
418:
416:
414:
250:No response to supraorbital pressure.
7:
385:brainstem death it falls far short.
1132:List of ways people honor the dead
323:function of those elements of the
25:
1163:Gompertz–Makeham law of mortality
209:Potentially reversible causes of
166:in a set of 1982 articles in the
79:Academy of Medical Royal Colleges
2305:Health law in the United Kingdom
2120:
2111:
2110:
475:from the original on 2018-05-17.
458:President's Council on Bioethics
108:Evolution of diagnostic criteria
102:President's Council on Bioethics
2121:
53: – in a deeply comatose,
1:
1183:Maternal mortality in fiction
460:. December 2008. p. 66.
117:who were being kept alive by
1097:Expressions related to death
1050:Medical declaration of death
456:(Report). Washington, D.C.:
2189:Persistent vegetative state
1117:Preventable causes of death
156:Royal College of Physicians
61:for survival; cessation of
2321:
2168:Disorders of consciousness
2184:Minimally conscious state
2106:
1484:Consciousness after death
1407:
971:
351:brainstem stroke syndrome
2295:Medical aspects of death
1885:Personification of death
1107:People by cause of death
285:Prognosis and management
241:oculovestibular reflexes
1962:Death-positive movement
1807:Post-mortem photography
1087:Causes of death by rate
1015:Death by natural causes
169:British Medical Journal
1997:Fascination with death
1635:Reincarnation research
1630:Out-of-body experience
1092:Notable deaths by year
933:Immunogenic cell death
849:Temporal lobe necrosis
187:artificial ventilation
119:mechanical ventilators
1802:Post-mortem chemistry
1615:Near-death experience
1511:Desecration of graves
1447:Postmortem caloricity
1412:Beating heart cadaver
856:Programmed cell death
824:Liquefactive necrosis
149:organ transplantation
90:Trinidad & Tobago
2300:Anatomical pathology
1992:Festival of the Dead
1890:Dying-and-rising god
1845:Chinese burial money
1734:Prohibition of dying
1686:Death-qualified jury
1452:Post-mortem interval
1112:Premature obituaries
819:Coagulative necrosis
279:arterial blood gases
51:cerebral hemispheres
2052:Philosophy of death
1917:Death from laughter
1217:Perinatal mortality
958:Mitotic catastrophe
938:Ischemic cell death
881:Intrinsic apoptosis
829:Gangrenous necrosis
325:reticular formation
292:cerebral blood flow
245:caloric reflex test
145:Death certification
2274:Locked-in syndrome
2098:Thanatosensitivity
2002:Hierarchy of death
1942:Death notification
1850:Coins for the dead
1782:Forensic pathology
1666:Capital punishment
1620:Near-death studies
1212:Mortality salience
844:Fibrinoid necrosis
814:Avascular necrosis
139:of sterile hope".
133:artificial support
2282:
2281:
2254:Vasovagal episode
2134:
2133:
1870:Death anniversary
1865:Death and culture
1709:Dying declaration
1691:Death certificate
1598:
1597:
1460:
1459:
1312:Neuropreservation
1102:Natural disasters
1073:
1072:
94:whole brain death
27:Clinical syndrome
16:(Redirected from
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2161:
2154:
2147:
2138:
2124:
2123:
2114:
2113:
2094:
2079:Assisted suicide
1977:Death trajectory
1792:Mortuary science
1787:Funeral director
1778:
1744:Suspicious death
1516:Eternal oblivion
1302:Cryopreservation
1241:
1230:
1168:Infant mortality
1158:Excess mortality
1060:Terminal illness
1045:Lazarus syndrome
1030:End-of-life care
981:Accidental death
834:Caseous necrosis
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215:muscle relaxants
137:emotional trauma
21:
18:Brain stem death
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2176:Unconsciousness
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2102:
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2032:Museum of Death
1982:Dignified death
1937:Death messenger
1912:Death education
1828:
1772:
1758:
1696:Declared death
1644:
1594:
1551:Online mourning
1456:
1422:Cadaveric spasm
1403:
1348:
1290:
1281:Skeletonization
1221:
1153:Child mortality
1148:Birthday effect
1136:
1069:
1065:Unnatural death
996:Brainstem death
967:
906:Pseudoapoptosis
788:
783:
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741:
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736:1993;48:1034–38
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31:Brainstem death
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1599:
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1595:
1593:
1592:
1587:
1582:
1577:
1576:
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1560:
1555:
1554:
1553:
1543:
1538:
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1513:
1508:
1503:
1498:
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1491:
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1476:
1470:
1468:
1462:
1461:
1458:
1457:
1455:
1454:
1449:
1444:
1439:
1434:
1432:Death erection
1429:
1424:
1419:
1414:
1408:
1405:
1404:
1402:
1401:
1396:
1391:
1386:
1381:
1376:
1375:
1374:
1369:
1367:Natural burial
1358:
1356:
1350:
1349:
1347:
1346:
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1336:
1331:
1326:
1321:
1316:
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1227:
1223:
1222:
1220:
1219:
1214:
1209:
1208:
1207:
1200:Mortality rate
1197:
1192:
1185:
1180:
1178:Maternal death
1175:
1170:
1165:
1160:
1155:
1150:
1144:
1142:
1138:
1137:
1135:
1134:
1129:
1124:
1122:Unusual deaths
1119:
1114:
1109:
1104:
1099:
1094:
1089:
1083:
1081:
1075:
1074:
1071:
1070:
1068:
1067:
1062:
1057:
1055:Organ donation
1052:
1047:
1042:
1037:
1032:
1027:
1022:
1017:
1012:
1011:
1010:
1003:Clinical death
1000:
999:
998:
988:
983:
978:
972:
969:
968:
966:
965:
960:
955:
950:
945:
940:
935:
930:
925:
920:
915:
914:
913:
908:
903:
898:
893:
888:
883:
878:
873:
868:
863:
853:
852:
851:
846:
841:
836:
831:
826:
821:
816:
805:
803:
794:
790:
789:
784:
782:
781:
774:
767:
759:
753:
752:
745:
744:External links
742:
739:
738:
725:
716:
703:
694:
685:
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667:
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637:
625:
612:
603:
594:
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575:
566:
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547:
538:
525:
513:
504:
492:
478:
442:
433:
424:
410:
393:
392:
390:
387:
375:blood pressure
343:cranial nerves
315:
312:
300:neuroendocrine
286:
283:
274:
273:
262:carbon dioxide
258:
251:
248:
237:
234:corneal reflex
230:
227:incident light
219:
218:
207:
204:
197:
190:
177:
174:
109:
106:
70:United Kingdom
26:
24:
14:
13:
10:
9:
6:
4:
3:
2:
2317:
2306:
2303:
2301:
2298:
2296:
2293:
2292:
2290:
2275:
2272:
2271:
2269:
2267:
2266:consciousness
2264:Alteration of
2261:
2255:
2252:
2250:
2247:
2246:
2244:
2242:
2238:
2232:
2229:
2225:
2222:
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2119:
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2025:
2023:
2020:
2018:
2015:
2013:
2010:
2008:
2005:
2003:
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1896:
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1886:
1883:
1882:
1881:
1878:
1876:
1875:Death anxiety
1873:
1871:
1868:
1866:
1863:
1861:
1860:Darwin Awards
1858:
1856:
1853:
1851:
1848:
1846:
1843:
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1825:
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1818:
1817:Biostratinomy
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1729:Necropolitics
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1564:
1563:Reincarnation
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1466:Other aspects
1463:
1453:
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1443:
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1417:Body donation
1415:
1413:
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1397:
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1384:Dismemberment
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1329:Mummification
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1286:Fossilization
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1276:Decomposition
1274:
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1251:Pallor mortis
1249:
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129:
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107:
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99:
98:United States
95:
91:
87:
82:
80:
75:
71:
66:
64:
60:
56:
52:
48:
44:
40:
36:
32:
19:
2249:Heat syncope
2203:
1972:Death threat
1855:Dark tourism
1797:Necrobiology
1739:Right to die
1697:
1656:Abortion law
1580:Resurrection
1568:Palingenesis
1465:
1427:Coffin birth
1334:Plastination
1295:Preservation
1271:Putrefaction
1266:Rigor mortis
1261:Algor mortis
1256:Livor mortis
1233:
1189:Memento mori
1187:
1040:Lazarus sign
1020:Death rattle
995:
963:Suicide gene
948:Karyorrhexis
839:Fat necrosis
733:
728:
719:
711:
706:
697:
688:
679:
670:
649:
640:
606:
597:
588:
578:
569:
559:
550:
541:
533:
528:
507:
466:10822/559343
445:
436:
427:
383:
379:organ donors
371:
367:agonal gasps
356:
347:
330:diencephalon
321:
317:
304:
288:
275:
255:cough reflex
220:
179:
167:
153:
141:
126:influences,
115:brain damage
111:
83:
67:
30:
29:
2194:Obtundation
2089: [
2047:Necrophobia
2042:Necrophilia
2012:Immortality
1967:Death squad
1947:Death panel
1932:Death march
1927:Death knell
1907:Death drive
1880:Death deity
1824:Thanatology
1773: [
1719:Legal death
1698:in absentia
1676:Civil death
1521:Examination
1506:Crematorium
1389:Excarnation
1226:After death
1025:Dysthanasia
991:Brain death
923:Autoschizis
901:Phenoptosis
896:Parthanatos
886:Necroptosis
793:In medicine
734:Anaesthesia
714:1980;2:1259
377:control in
296:brain cells
270:apnoea test
266:oxygenation
201:hypothermia
39:spinal cord
2289:Categories
2224:Somnolence
2017:Last rites
1987:Extinction
1957:Death pose
1952:Death poem
1922:Death hoax
1902:Death camp
1895:Psychopomp
1770:Death tech
1625:Necromancy
1603:Paranormal
1585:Underworld
1437:Dissection
1399:Resomation
1394:Promession
1372:Sky burial
1339:Prosection
1324:Maceration
1035:Euthanasia
953:Karyolysis
911:Pyroptosis
891:Paraptosis
801:Cell death
536:pp. 113–45
389:References
194:depressant
55:ventilator
47:cerebellum
2231:Cataplexy
2062:Sacrifice
2057:Predation
2022:Longevity
1812:Taphonomy
1749:Trust law
1704:Death row
1489:Afterlife
1442:Gibbeting
1379:Cremation
1344:Taxidermy
1319:Embalming
1195:Micromort
1141:Mortality
918:Autolysis
876:Autophagy
871:Apoptosis
314:Criticism
176:Diagnosis
128:metabolic
124:endocrine
63:heartbeat
59:prognosis
43:mid-brain
35:brainstem
2116:Category
2086:Thanabot
2037:Necronym
2007:Homicide
1558:Obituary
1546:Mourning
1536:Internet
1479:Cemetery
1354:Disposal
1307:Cryonics
976:Abortion
943:Pyknosis
809:Necrosis
470:Archived
308:pregnant
199:Primary
2241:Syncope
2126:Outline
2074:Suicide
1714:Inquest
1681:Coroner
1573:Saṃsāra
1541:Midwife
1526:Funeral
1501:Customs
1474:Carrion
1173:Karoshi
986:Autopsy
866:Anoikis
359:medulla
239:Absent
113:severe
68:In the
41:to the
2209:Stupor
2027:Martyr
1763:Fields
1724:Murder
1640:Séance
1610:Ghosts
1494:Tukdam
1362:Burial
1244:Stages
928:Eschar
712:Lancet
623:139–58
583:211–50
564:313–78
363:anoxia
338:cortex
211:apnoea
196:drugs.
164:Pallis
160:London
2219:Sleep
2214:Sopor
2093:]
2067:human
1833:Other
1777:]
1649:Legal
1590:Vigil
1531:Grief
1079:Lists
786:Death
473:(PDF)
454:(PDF)
86:India
74:death
2199:Coma
1754:Will
1235:Body
1205:RAMR
861:AICD
334:pons
332:and
88:and
49:and
1008:DOA
462:hdl
253:No
232:No
158:of
2291::
2091:ca
1775:pt
658:^
628:^
615:^
516:^
495:^
481:^
468:.
413:^
397:^
381:.
369:.
247:).
100:'
72:,
45:,
2160:e
2153:t
2146:v
778:e
771:t
764:v
464::
236:.
229:.
20:)
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