Brain stem death and organ transplantation anoxia fetal

Catholic medical quarterly volume 62(2) may 2012, 15-8 brain stem death and organ transplantation dr david evans, consultant cardiologist brain stem death

Brain

Stem death is a syndrome diagnosed by a specified series of bedside

Tests performed by specially qualified doctors at some time convenient

To them and others involved in the care of comatose patients whose brain

Damage appears to be mortal. It is obviously a different state from that

Long recognized as death. How, then, has this syndrome become accepted

By some of this country’s medical profession – we don’t know how many –

As equivalent to death?


For those who equate it with human death but

Object to the notion that there can be more than one kind of death, it

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Is death.

The answer requires consideration of concepts with their associated

Definitions – essentially a philosophical question but unavoidable if

Some different understanding of what death is and when it occurs is to

Be entertained. IN THE BEGINNING –

In 1976 – the rules for the identification of the brain stem death

Syndrome – unfortunately called ‘brain death’ at that time – were

Formally promulgated by a committee of the UK medical royal colleges[1].

The stated purpose was “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”. In accordance with good medical

Practice, identification of the syndrome required withdrawal of “further

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Artificial support” in order to spare relatives “from the further

Emotional trauma of sterile hope”.

While that wording suggests a purely prognostic use of the published

Criteria – providing common ground for the identification of a stage in

The dying process at which mechanical ventilation and other life-support

Measures should be discontinued so that the patient might be allowed to

Die with as much dignity as might remain – there was evidence of another

Interest, apart from that of the dying patient and his relatives. The

Preamble to the diagnostic criteria stated that they had been “written

With the advice of the sub-committee of the transplant advisory panel”.

THE FIRST OFFICIAL EQUATION OF BRAIN STEM DEATH WITH DEATH

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The first official equation of brain stem death with death was made

In a memorandum [2] published contemporaneously with the resumption of

Heart transplantation in the UK in 1979. The committee based that

Assertion on the concept that when “all functions of the brain have

Permanently and irreversibly ceased” a person “becomes truly dead”. That

Is, of course, the whole-brain definition, then widely accepted

Throughout the world, but ever more controversial at the present time.[3,4]

The reductionist UK version was rejected by the US president’s bioethics council [5] in 2008.

The published series of bedside brain stem tests – with no testing

For higher brain function or use of special investigatory techniques –

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Was, surprisingly, considered sufficient by this expert committee for

The safe diagnosis of total brain death and therefore of death on that

Concept. A prime purpose for the diagnosis and certification of death on

That basis became clear with the publication by the health departments

Of great britain and northern ireland, in 1983, of ‘cadaveric organs for

Transplantation – a code of practice including the diagnosis of brain

Death’ which authorized removal of organs from the living bodies – not

Cadavers, of course – of those diagnosed “brain dead” on their criteria.

BY 1995

There was so much published evidence of persisting brain function in

Patients diagnosed “brain dead” – including a very frank statement to

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That effect from christopher pallis [6] – that use of the term “brain

Death” to describe the state identified by the code of practice tests

Was officially discouraged [7] – the “more correct term brain stem

Death” being preferred. Thereafter the equation of that state with death

In accordance with the brain death concept was clearly untenable. But

That expert body wished to continue its support for the diagnosis of

Death for transplant purposes on essentially the same clinical criteria

And this necessitated the invention of yet another definition of human

Death deemed to be satisfied when “brain stem death” had been formally

Diagnosed.

The “suggested” new definition of death7 was “irreversible loss of

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The capacity for consciousness, combined with irreversible loss of the

Capacity to breathe”. Although there has been no noticeable general or

Within-professions discussion of this novel concept – or explanation

That “after my death” on NHS organ donor registration forms means death

So defined and not death as commonly understood – that has remained the

Concept upon which death diagnosis by brain stem testing has been based

Ever since [8]. THE NEW DEFINITION OF DEATH

Is essentially consciousness based. The requirement that the capacity

To breathe be lost too sits uncomfortably alongside and is not, as a

Matter of fact, satisfied by the prescribed tests which do not challenge

The respiratory centre to the ultimate anoxic drive stimulus.Anoxia fetal

The permanent loss of consciousness is an essential feature of death,

Of course. When that state is diagnosed on the traditional criteria,

Still those by which almost all deaths are diagnosed universally these

Days, its permanent loss is guaranteed by the cessation of blood flow

Through all parts of the brain and the passage of sufficient time

Thereafter to ensure that irreversible necrosis of the whole brain is

Under way but do the prescribed tests of some brain stem functions

Suffice for the certain diagnosis of the permanent loss of consciousness

In patients whose hearts are beating and still perfusing their bodies –

And, for all we know, parts of their brains – with oxygenated blood?

Setting aside the problem of defining consciousness in any precise

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Sense, the answer for pragmatic purposes depends upon their adequacy for

The ascertainment of permanent loss of function in those elements of the

Brain essential for its generation. THE SCIENTIFIC UNDERSTANDING OF CONSCIOUSNESS

There is, to date, no truly scientific understanding of consciousness

And it has been said that science cannot address the problem [9], though

Several nobel laureates have tried to do so. The old idea that its

Generation depends upon an arousal system predominantly located within

The brain stem – a theory based upon the animal experiments of moruzzi

And magoun [10] some 60 years ago – still seems to hold sway in the

Field of clinical neurology [11,12] and appears to be the theory

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Underpinning the 1995 working group’s claim, repeated by the 2008

Working party, that the irreversible cessation of brain stem function

“will produce” the permanently unconscious state. However, there have

Always been caveats about the reticular activating system (RAS) – best

Regarded as a physiological rather than a precise anatomical entity11,

Or even as “little more than a metaphor” [13] – and about the possible

Rôle of inputs from the first and second cranial nerves. More recently

There has been concern about the permanence of coma associated with

Brain stem lesions [14], perhaps engendered by new understanding of the

Plasticity of the nervous system.

In light of such uncertainty it may be thought significant that

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Neither the 1995 working group nor its successors have quoted scientific

Evidence in support of their assertions that “brain stem death” is a

State of permanent unconsciousness. DO THE TESTS SUFFICE?

Do the tests suffice for the diagnosis of death on the stated

Premise? The answer must be “no”. The RAS is not directly testable. Its

Brain stem elements can be said to be permanently out of action only

When the brain stem is totally dead. The purely bedside tests lack the

Power to establish that state as a matter of fact [15]. They do not test

For remaining blood pressure and heart-rate control by medullary

Centres, which may be evident during organ procurement surgery

Subsequently [16,17], nor for oesophageal motility control, and the

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Brain stem respiratory centre is not subjected to stringent testing

(which may exacerbate brain damage or even cause death [18]).

In the era of evidence-based medical practice, it is no longer

Possible to maintain that brain stem death, as diagnosed by the

Officially prescribed clinical testing, is death. The clinical syndrome

So identified, fails to meet the requirements of either of the two novel

Concepts and definitions of human death proposed by the medical royal

Colleges2,7 in 1979 and 1995.

It cannot now be considered good medical practice to seek to diagnose

This syndrome for organ procurement purposes. The prescribed series of

Tests – particularly the caloric test and disconnection of the

Ventilator without sedation – must risk causing suffering in at least

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Some of those so tested. ORGAN TRANSPLANTATION

The retrieval of organs from the so-called “brain stem dead” must now

Be seen as a pre-mortal surgical procedure upon a paralysed patient who

Is not certainly permanently unconscious. Protection against the legal

Consequences may be offered by the official codes of practice

The retrieval of organs from the so-called

“brain stem dead” must now be seen as a pre-mortal surgical procedure

Upon a paralysed patient who is not certainly permanently unconscious.Governing

This activity and attending anaesthetists may cover the possibility of

Suffering by administration of general anaesthesia [19]. Prospective

Organ donors and those asked to give consent to the removal of their

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Children’s organs after diagnosis of death by brain stem testing ,

Should surely be given all the relevant facts about that diagnosis and

Procedure – and the option to specify general anaesthesia to cover it.

Other sources of organs have been sought as organ procurement from

The “brain stem dead” has decreased. One popular source is healthy

(related or altruistic unrelated) donors. Another is those declared dead

After brief periods of cardiac arrest induced by stage-managed

Withdrawal of life-support. In the latter case there may be prior

Cannulation and perfusion of the admittedly potentially-sentient dying

Patient in the interests of the wanted organs. The required observation

Period after what appears to be the last heartbeat is usually of the

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Order of a few minutes – perhaps long enough to say that there will not

Thereafter be spontaneous resumption of coordinate cardiac action but

Not long enough to guarantee irreversibility, surely an essential

Feature of death. I have personally resuscitated many patients after

Much longer observed periods of cardiac arrest – the longest 40 minutes,

That courageous neurologist returning to work soon afterwards.

The declaration of death (for transplant purposes) after 2-5 minutes

Is made on the basis that skilled resuscitation will not be undertaken

Thereafter, not that it cannot be achieved. OBFUSCATING HUMAN DEATH

Why is there so much obfuscation, and manipulation of thought, about

So fundamental a matter as human death?Anoxia fetal there was never need for it as a

Consequence of the development of life-support techniques per se. When

We recognized that further, extraordinary, life-support measures were

Pointless and unkind, there was no difficulty about their

Discontinuation to allow our patients to die. We saw that as our duty

And last service to them – and that was later endorsed as good medical

Practice[1].

The answer is to be found in the advent of organ transplantation, for

Which purpose death has been redefined variously since 1968. No other

Purpose is served by these redefinitions which are now recognized as

Biologically incoherent and mere legal fictions3. CONCLUSION

The practice of human organ transplantation

Raises very serious ethical concerns, with consequences for that trust

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In the medical profession which is of fundamental importance to good

Medical practice.

In my view it is wrong, because the procurement of viable complex organs

Necessitates abuse of the dying or harming the healthy – activities in

Which doctors should not be involved. Evil

Committed for a good purpose remains evil.

Even when it succeeds?

Above all when it succeeds. That is not the current view of

The populace which is, we are often told, overwhelmingly in favour of

Transplantation, but I wonder if that would be the case if it were fully

And fairly informed about organ procurement practice.

It may be timely to remember the quotation from victor hugo with which the

Late richard nilges – a neurosurgeon who saw through “the crassly

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Utilitarian concept of brain death” – prefaced his article in this

Journal[20] in 1990 :-

Evil committed for a good purpose remains evil.

Even when it succeeds?

Above all when it succeeds.

REFERENCES

• conference of medical royal colleges and their faculties in the UK

(1976). Diagnosis of brain death. BMJ, 1187-88. 2.

• conference of medical royal colleges and their faculties in the UK

(1979). Memorandum on the diagnosis of death. BMJ, 1, 332.

• shah, S.K., truog R.D., miller F.G. (2011). Death and legal fictions. J

Med ethics, 10.1136/jme.2011.045385.

• henderson D.S. (2011). Death and donation (ISBN: 978-1-60899-622-3).

Pickwick publications, eugene, OR 97401.

• president’s council on bioethics (2008). Controversies in the

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Determination of death (a white paper). Washington, DC.

Www.Bioethics.Gov

• pallis C. (1985). Defining death. BMJ, 291, 666.

• RCP working group, endorsed by the conference of medical royal colleges

(1995). Criteria for the diagnosis of brain stem death. J roy coll

Physns, london, 29, 381-2.

• academy of medical royal colleges (2008). A code of practice for the

Diagnosis and confirmation of death. Wimpole street, london.

• pippard, B. Personal communication.

• moruzzi, G. Magoun H.W. (1949). Brain stem reticular formation and

Activation of the EEG. Electroencephalography and clinical

Neurophysiology, 1, 445-473.

• goetz C.G. (2003). Textbook of clinical neurology, 2nd edn. Elsevier

Science.

• bleck T.P. (2007).Anoxia fetal ibid, 3rd edn.

• roth, M. Personal communication.

• parvizi J. Damasio A.R. (2003). Neuroanatomical correlates of

Brainstem coma. Brain, 126, 1524-36.

• evans D.W. Hill D.J. (1989). The brain stems of organ donors are not

Dead. Catholic medical quarterly, 40, 113-121.

• evans D.W. (2000). The demise of ‘brain death’ in britain. In beyond

Brain death – the case against brain based criteria (ISBN:

1-4020-0366-8). Eds. Potts M., byrne P.A, nilges R.G. Kluwer academic

Publishers, dordrecht, pp. 139-158.

• hill D.J. (2000). Brain stem death : a united kingdom anaesthetist’s

View. Ibid, pp. 159-169.

• coimbra C.G. (1999). Implications of ischemic penumbra for the diagnosis

Of brain death. Braz J med biol res, 32, 1479-87.Anoxia fetal

• hill D.J. (2011). Death and donors. Western mail, 29th august.

Http://www.Walesonline.Co.Uk/news/letters-to-the-editor/western-mail-letters/2011/08/29/western-mail-letters-monday-29-august-2011-91466-29319355/

• nilges R.G. (1990). The death of the brain. Catholic medical quarterly,

57, 26-29.