Medical futility: When does death occur?

I wish I knew honestly. It's always heart-wrenching to be faced with a patient in whom medical interventions amount to maintaining the status quo which is already not good and whose family members don't seem to understand that there is no going back to better or going back to something that most will call "living".

This really isn't a discussion on the rights of the disabled, that is if you consider someone who is in a persistent vegetative state to be disabled. Nor am I going to attempt to answer the question as to at what time death occurs. I think we would have to agree on when life begins and what life is in order to tackle defining death.

But it isn't that rare an occurence. Whether it is grandfather who has been ailing for a long while, but always seems to bounce back after each critical illness, but this time has a devastating stroke, and there is no coming back according to the physicians, no getting off the ventilator, no more memories of "once upon a time, back in 1930..."; or whether it's that young mother struck down by breast cancer who courageously faced bilateral mastectomy and chemotherapy only to develop metastasis after metastasis each time moving forward only to be set back and now she has had one metastasis too many and she too is at that crossroad where physicians are saying no more, it isn't that rare an occurrence. And I am thankful that I don't have to be the one to tell a family member over and over and over again that our medical care is futile.

How do you tell someone holding out for a miracle that there is no miracle to be had? How do you tell someone that the patient in the bed under the BAIRHugger to keep them warm, on pressors to keep the heart beating, on mechanical ventilation to keep them breathing, on the dialysis machine to filter the blood, is not simply asleep. How do you argue with faith? I can't. As an infectious disease physician I am often consulted on these "dead but alive on the machine" patients for a fever here and there or an abnormal white count, or presence of bacteria in their urine (after having a catheter in their bladder for several days) or in their sputum (after having a tube in their throat for several days). And I treat them regardless of whether I think they are dead or not because the status is "full press on - do anything and everything", and it has not been officially expressed or determined or accepted that we have reached the point of medical futility. Why? Because how am I supposed to be the one rouge physician who decides not to do something that is obvious to us all is futile. I'm not God either. 

But if I'm asked directly by an already heartbroken family member how I think their loved one is doing, or whether I think the antibiotics will help, I plainly state my truth. The patient is actively dying...I don't think antibiotics are going to be of much help...they might make the bacteria in the sputum go away, but they won't help the lungs themselves. And if I notice that they are still listening to me, I may take my chance and add in to the chorus they've probably heard already about the poor/grim prognosis overall and how maybe we should start thinking abou the patient's comfort and dignity.

It's not easy.