Brain Death     By Dr Lily Ng

“Brain death” is a term initiated in l965 in London. This is a breakthrough concept in 1967 when Christian Barnard performed  the first heart transplant in Cape Town. Brain death is a medical term to denote death where there is IRREVERSIBLE (permanent) cessation of all functions of the ENTIRE BRAIN including the hardy brainstem. There is unresponsiveness, no spontaneous respiration and absent cranial reflexes. 

The first cadaveric renal transplant was carried out in Kuala Lumpur (KL) Hospital in 1977. University Hospital Brain Death format was developed in 1979, and endorsed by Islamic Fatwa Council in 1987. KL Hospital set guidelines in 1980s. Only in 1992 a National Brain Death Committee was formed which included physicians, anaesthetists and surgeons. National guidelines were formulated in 1993 and a Consensus Statement by specialists and  professional societies was made on 12/12/93.

Death occurs in two ways:  

1.  from cessation of cardiopulmonary (heart-lung) functioning. CARDIAC or RESPIRATORY ARREST is followed quickly by RESPIRATORY or CARDIAC ARREST, and BRAIN DEATH. (Pupils are always checked) and 

2.  from the permanent cessation of brain functioning. BRAIN DEATH which is associated with APNOEA (RESPIRATORY ARREST) is quickly followed by CARDIAC ARREST. 

Traditionally, diagnosing death by a doctor has always been (unknowingly) by brain death. He checks the pupils of a patient who is not breathing and has no heart beat. Fixed and dilated pupils confirm that the patient is death. 

Whatever the order in which the 3 events occur, the endpoint is the same i.e. death.

Without respiration, the heart soon stops after brain death as there is no spontaneous breathing. Advances in medicine and availability of anaesthesiologists and intensive care, enable artificial ventilation to be instituted immediately as a resuscitative measure, before a diagnosis of brain death from whatever  cause can be conclusively made. In brain death, with artificial ventilation, cardiac arrest can be delayed temporarily for some hours to days. However even if artificial ventilation is continued, the heart will inevitably stop beating because control and coordination from the brain is no longer present and the process of cell death has already started. 

Artificial ventilation initially buys  time for aggressive treatment and then time to diagnose brain death conclusively. Once diagnosis is made, ventilation will only serve to PROLONG DEATH, NOT PROLONG LIFE. 

From a medical point of view, death is a process of disintegration, rather than an event. Those ventilated the longest before cardiac arrest have brains that have the consistency of porridge (necrotic) and beyond recovery (a condition described as 'ventilator brain").

BRAIN DEATH IS DEATH. The body deteriorates as each day passes.  A Japanese Brain Death Study revealed that the average time to asystole was 4 days and 90% by 8 days (sometimes within a day, and rarely up to over 20 days). Without artificial ventilation, the heart of course would stop within minutes.

An analogy could be drawn between brain death and a broken car with  an engine that is beyond repair. It is vital for the public to appreciate that as long as artificial ventilation is instituted, for sometime before the heart stops naturally by itself, the body looks deceivingly “alive” for a few days. This unfortunately gives false hopes to relatives inspite of being told by doctors that their loved one is brain-dead. Families tend to request for futile ventilation to be continued.

Brainstem death must not be confused with types of coma where there is still some brain function. These patients are not dead.

Majority of brain death are due to supratentorial problems e.g. head injury or cerebrovascular accident. Progressive rise in pressure in the supratentorial compartment causes downward displacement of midbrain. Arteries are stretched and venous return blocked. This sets up a vicious circle which increases intracranial pressure (ICP) further. When ICP exceeds arterial perfusion pressure, cessation of cerebral blood flow and brain (including vital cardiorespiratory centres in the medulla) infarcts. 

Brain death is  an accepted medical, ethical, and legal principle. The standards for determining that someone is death are strict.

There are some preconditions that must be met. The patient is in DEEP COMA, APNOEIC and on ventilator, for at least 12 hours. Cause of coma is fully established and sufficient to explain the status of patient and there is IRREMEDIABLE STRUCTURAL BRAIN DAMAGE.

Exclusion of metabolic / endocrine disturbance, drug intoxication/ muscle paralysis, hypothermia, meningoencephalitis/encephalitis, Guillain Barre Syndrome and locked in state are needed before proceeding to confirmatory brainstem tests.

Two Consultants, usually an anaesthesiologist, physician or surgeon are eligible to perform the tests but they must not have any interest in the recipient.

Brain death is an accepted medical, ethical, and legal principle. The standards for determining that someone is brain dead are strict. Withdrawal of ventilatory support should be considered once brain death is confirmed because if continued, it will deny an individual of a dignified death. Deterioration of the body (e.g. puffing up) occurs with each day. Also unnecessarily prolonging agony and misery of the next of kin and misusing limited resources which may be fruitfully utilised on other patients with better prospects of recovery.

BRAINSTEM TESTS

1) Pupillary Light Reflex

2) Oculocephalic Reflex (Doll’s sign)

3) Corneal Reflex

4) Motor Response in Cranial Nerve Distribution (Grimacing to Deep Pain)

5) Vestibulo-ocular Reflex (Caloric test)

6) Oropharyngeal Reflex (Gag)

7) Tracheobronchial Reflex (Carinal)

8) Apnoeic Test

At the third International Conference of Islamic Jurists (OIC) in Amman 1986, brain death was equated with cardiac death. "It is permissible to take the person off resuscitation apparatus, even if the function of some organs e.g. heart, are still artificially maintained".

At Persidangan Akademi Fiqh Islam Ke-10 in Mecca in 1987, it was ruled that a patient who is on life-support machine, once ascertained by specialists to be brain dead and with no hope of recovery, he can be disconnected from the machine even though the heart is still beating.

The diagnosis of brain death TAKES AWAY PRIORITY FOR FURTHER CARE IN THE ICU. It will be simply doing something useless to someone who is already dead, and the only exception is for organ donation because "Care of the recipients begin with care of the donor".

Withdrawal of ventilatory support should be considered once brain death is confirmed because if continued, it will deny an individual of a dignified death. deterioration of the body (e.g. puffing up) will occurs with each day. Also unnecessarily prolonging agony and misery of the next of kin and misusing limited resources which may be utilised on other patients with better prospect of recovery. Lastly it is demoralising to medical staff who have to attend to the cadaver.

Tissues like eyes and bones from a dead body without a heartbeat or circulation are useable. However, organs e.g. kidneys, liver need to be donated from a heart-beating but brain-dead body. Otherwise without circulation or blood flow prior to removal and preservation, the organs are of no use and cannot be transplanted for functioning in the recipients. 

In Saudi Arabia between 1986 - 1995, the number of brain death cases reported was 1727, out of which 1146 of them were confirmed to be brain dead. The number who were subsequently harvested was 375 which is 23.35 of total brain death cases reported. Hence Saudi Arabia has a very vigorous transplant program in contrast to the situation in Malaysia.

This is what the Director General of Health, Tan Sri Dato Dr. Abu Bakar Suleiman, has to say on the subject," Unfortunately in this country, kidney transplantation relies mainly on living related donors. Many patients with endstage renal failure (ESRF) do not have a suitable or willing donor. It is important therefore, that a concerted effort be made to develop a viable cadaveric (dead body) organ donation program. With greater awareness through public education activities, it is hoped that more of such organs will be available. The Ministry Of Health has produced guidelines to assist doctors in managing a potential cadaveric donor”. 

We have just entered a new millennium, when technology and medical expertise is flourishing, yet an already established and successful form of medical treatment for endstage organ failure, that is, transplantation cannot progress if cadaveric organ donation does not take place on a large scale. 

Survey carried out showed that APATHY and IGNORANCE of MEDICAL STAFF was a MAJOR OBSTRUCTION to the progress of transplant program. ATTITUDE OF MEDICAL STAFF NEED TO CHANGE. Health care professionals need to consider the issue of organ procurement as a standard aspect of patient care. The impact of this shift in the mind-set of health care professionals could result in a substantial increase in the number of transplantable organs. At present many organs and tissues are lost each year because potential donor are not identified and donation not requested.

When every donated organ might represent life saved, IS IT NOT UNETHICAL ON OUR PART NOT TO DO MORE? Organs can only be made available if we can on our part convince society that it is caring and beneficial to donate.

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