Testing for Brain Death in Hospitals
Properly Diagnosing Brain Death
“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” according to the American Academy of Neurology Guidelines for determining brain death in adults that doctors use. Brain Death is normally determined only by a bedside determination without using any evidence based ancillary testing.
Of the 5 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
The Wikipedia definition for brain stem death points out that the concept of brain stem death is the “reductionist” diagnosis and certification of death as permitted in the United Kingdom on the premise that:
“A person is dead when consciousness and the ability to breathe are permanently lost, regardless of continuing life and parts of the brain, and that death of the brain stem alone is sufficient to produce this state.”
The Uniform Determination of Death Act (UDDA) definition considers “irreversible cessation of the brain stem” to be brain death. In the UK they say “death of the brain stem,” which is the essentially the same definition as the UDDA.
Determination of death should only be performed in the absence of confounding factors and after excluding the effects of drugs and other conditions and abnormalities that can mimic brain death by preventing neurologic responses. Specifically, medical professionals should test for:
- Overdose levels of poisons and tranquillizers, including muscle relaxers used with a ventilator, illegal drugs, and other chemical agents
- HypothermiaMetabolism conditions and/or abnormalities such as diabetes and insulin levels resulting in diabetic coma, due to too much glucose in the patient’s bloodLiver disease caused by alcoholism
- Obesity, a non-alcoholic disease causing a fatty liver
- Disfunction in peripheral nerves or muscles
Finally, observation wait times should occur at long enough intervals to establish a diagnosis beyond a reasonable doubt. Is confirmatory testing standardly applied? In most hospitals such testing is up to the doctor and is still optional, and subject to individual hospital standardized protocol. Most doctors will follow this observation criteria when the examinations are not reliable.
Diagnosis of brain death requires multiple testing. The 2010 American Academy of Neurology (AAN) guidelines require only a six hour interval between repeated tests. Families of potentially brain dead patients can also ask for these tests if they have doubts about the original clinical findings. However, doctors and hospitals are not required to perform these tests and they are used only if the doctor orders them.
According to the Annals of Intensive Care, spring of 2012 research of American Neurologists state:
“The standard medical, ethical, and legal tests for brain death require only clinical bedside tests; EEG, brainstem evoked potential, brain blood flow, or pituitary hormone testing are not required or recommended. In addition, brain pathology is not obtained as part of the diagnosis of brain death.”
The new Affordable Health Care Act puts more pressure on doctors to control costs. To counter-balance that pressure, a family’s integrity and protection of their loved one will become increasingly important. You should absolutely verify the prognosis of brain death through confirmatory testing.
Neurologist Dr. Steven Novella states that determination of brain death within 36 hours of a severe head injury to the brain is not an appropriate observation period. Many neurologists require 24 hours or more to be sure there are no changes in the condition of the patient.
Any uncertainty or confounding factors require ancillary testing, such as:
- 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 neurological examination to determine brain death cannot be established by evidence-based methods.
It is important to have a base understanding of what healthy and brain dead waves look like. Below are some links of normal and brain dead brain waves:
Life support is used because it is ethically and legally in the patient’s best interest. “The brain can no longer conduct the body’s various instruments,” states Gary Greenberg of The New Yorker.
It is a medical professional’s job to reverse or cure the patient’s current underlying medical condition, as well as to stabilize the patient, providing a chance for recovery and life. Below is a list of medical treatments commonly used to sustain life:
- Artificial Ventilation (machine aided breathing)
- Nutrition to sustain the building blocks for life
- Artificial hydration, also known as IV fluids, to prevent death by dehydration
- Dialysis to take pressure off the kidneys and aid in preventing kidney failure
- Antibiotics and chemotherapy to prevent infection and/or the progressive spread of disease
All of these treatments are performed to prolong and sustain the life of the patient regardless of whether the patient needs short or long life-sustaining medical measures.
The questions then becomes, is it permissible under the hippocratic oath of “do no harm” to risk any harm to a deep coma patient, who is said to be legally dead by individual state statute, yet, as Organtransplant states, has “never become brain dead because they retain some minor brain stem function.” Use of a ventilator interrupts the death process before it becomes a final event where the organs can no longer sustain the body as an integrated whole. Why? Because death by cardiac arrest causes the brain to die after the heart stops pumping blood flow to the brain. Death of the brain stem by loss of control of basic function and no blood flow to the brain is the standard under the whole brain death definition, as defined in the dead donor rule and the intent and interpretation of the UDDA.
Once loss of the elastic recoil and elasticity of the lungs and chest stop after true death, neither respiration assisted by a ventilator nor chest compressions provided by medical intervention will work to reverse or slow the death process for the patient. The respiration and circulation stop, the patient’s organs become seismic, and the body corps will begin immediately to break down and begin decomposition.
Deep Coma in Relation to Mammal Hibernation
The use of a brain death patient’s organs for organ transplant at this stage becomes statically less successful for the organ transplant recipient due to ischemia. It is similar to the way that an organ from an organ donor who dies outside of the hospital becomes a non-candidate for organ donation even if he/she is registered to be an organ donor.
At the point where there can be no respiration, the ventilator will only be able to move air. Any success achieved through ventilation is due to the continued presence of life and its unity with the body. Thus, brain death, and brain stem death—which is the main control center of the brain which controls heart rate, breathing, temperature and all other bodily functions—ends all activity, resulting in total death of the body. So, it is reasoned that there is no possibility of recovery from brain death.
In a commentary by C. Pallis in the Journal of Medical Ethics, Pallis questions whether death is a process or an event measured in terms of the “clinical significance (of) death of the organism as a whole (a definition where only part of the organism is purportedly dead) or, death of the whole organism,” which is the measure of traditional real death of the whole person.
One must also look at the changes and results of the current research. In September 2013, research showed that brain cells continue to live weeks after decapitation and found that a new definition of brain death is needed. Also, a look at the research on deep coma and a 2013 study on mammal hibernation, a form of deep coma, showed the new ability to turn off and on mammal hibernation at will, which scientist now say is a state much like that of the medically induced (deep) coma.
This new research raises the following questions:
- How are we alive if we are in deep coma and are not conscious?
- Who are we when we can no longer remain aware and are in a severely impaired conscious state known as deep coma (coma de ‘passé)?
- Is this state possibly (locked in) arousal without awareness?
These are important questions to consider when determining the definition of brain death.