Diagnosing Brain Death
When is the right time to turn off life support? True brain death under the UDDA law is permanent and irreversible, families of those who are brain dead will often decline to keep the patient on life-sustaining care. In casual terms, this is often called “pulling the plug,” because the machines are disconnected from the patient, and his or her body is allowed to shut down.
True brain death is essentially death, a diagnosis of the medical condition is extremely important. The article “Case for Caution in the Definition of Brain Death” cites several criteria that must be met in order for someone to be considered brain dead.
According to the American Academy of Neurology Guidelines for determining brain death in adults that doctors use, states “Many of the details of the clinical neurologic examination to determine brain death cannot be established by evidence-based methods…It must be emphasized that this guidance is (physician) opinion-based. (Commonly known as an educated guess.) Alternative protocols may be equally informative.” Brain Death is normally determined only by a bedside determination without using any evidence based ancillary testing.
Of the five major recommendations by the AAN Guidelines, as published by the Department of Health and Human Services, used to determine brain death, 4 out of 5 are rated Level U as inadequate and conflicting.
Note: The following tests may or may not be performed by the doctor.
1. The patient must not have any brainstem reflexes. Brainstem reflexes are automatic reactions of the brain that occur without cognitive thought. For example, if a flashlight is shined into your eyes, the pupils in your eye should constrict automatically without you having to make an effort to cause them to constrict. If the pupils do not constrict, then this is a sign of brain death.
Doctors normally test the pupillary reflex (contraction of the pupils due to light) Note: blindness can affect outcome, as well as the gag reflex, the corneal reflex and the oculocephalic reflex. The corneal reflex causes you to blink if your eye is touched with water. The oculocephalic reflex involves moving the head from side to side to see if the eyes fixate. If the patient does not gag, blink or move his eyes, then the patient can be considered brain dead.
2. The patient must have completely lost consciousness and the loss of consciousness must be permanent and irreversible. It is essential to distinguish between a severe coma and brain death. Knowing the cause of the unconsciousness is the key to making this determination. For example, someone who has had a severe stroke might have permanent brain death, while a person who has taken a drug may be in a deep coma, but will eventually emerge from that coma as the body heals.
3. The patient must be unable to breathe on his/her own. To test this function, the patient’s ventilator is turned off. At some point, when the level of carbon dioxide reaches levels that stimulate breathing, the body would automatically make an attempt to breathe. If no such attempt is made, this is a sign of brain death.
4. Ancillary Testing
- Pet Scan
- Transcranial Doppler Ultrasonography EEG (Research from 2013 indicates that EEG flat wave is deep coma and does not indicate death of the brain according to the UDDA and AAN guidelines for testing.)
- Somatosensory Evoked Potentials
- Cerebral Angiography
- Apnea Test
- Cerebral Perfusion Scintigraphy: Note: AAN Guidelines state that many of the details of the clinical meurologic examination to determine brain death cannot be established by evidence-based methods.”
Planning for Brain Death
When a patient is diagnosed as brain dead and these tests along with the ancillary testing conclusively prove beyond all reasonable doubt that the brain and the brain stem have lost all function and there is no hope of recovery, the patient will need to be removed from life support. It is often best for all involved if the patient has a living will, advanced medical directive or a life guardian card in place to indicate his or her wishes regarding being kept alive when experiencing deep coma brain death.
If the patient made clear he or she did not want to live on a ventilator or other machines, this can save the family from having to make a tough decision about when to pull the plug.
Ancient wisdom says, “It’s not what happens to us in life that matters; it’s what we choose to do about it that matters.”
By living our lives with purpose and integrity through the challenges and mysteries of life, as well as its hardships and difficult times, we are able to overcome the brokenness that end-of-life issues bring by remaking ourselves, with God’s help, into a better, stronger and loving being.