Diagnosing brain death without a neurologist
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7352.1471 (Published 22 June 2002) Cite this as: BMJ 2002;324:1471All rapid responses
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EDITOR - Altruistic organ donors (and potential donors) have never
had explained to them the implications of the process of donation, as is
required for fully informed consent. The Editorial by Baumgarten and
Gerstenbrand(1) does little to clarify the situation. They still retain
the term "brain death" which has long been replaced by "brain stem death",
and more recently "death for transplant purposes" has been used by the
Department of Health. At the very least it should be made clear precisely
what the (potential) donor understands by death. Without that
understanding, consent will surely be invalid.
If it is only neurologists who should apply the tests for the "fatal
syndrome" of death, have we been negligent for 25 years in allowing any
practitioners of five years seniority to apply the tests? Can those who
are prepared to make the critical diagnosis of death on the brain stem
test criteria not be considered as "part of the transplant team"? Is it
understood that the apnoea test itself can cause further brain damage or
even death, as has been clearly demonstrated by Coimbra(2)?
Anaesthetists are uneasy with the diagnosis of death. There is a
division of practice amongst anaesthetists(3). Some give full anaesthesia
to organ donors (because they respond to surgery much like any other
patient), whilst others withold anaesthesia (which might look like an
admission that the donors are still alive), but suppress the responses to
surgery by other means.
A recent Australian opinion(4) is that "Rather than redefining those
who are 'brain dead' as 'dead' it may be more honest to acknowledge that
such individuals are not dead and that removing their organs is in fact
killing them" and "The long term viability of the transplantation
programmes is likely to be better served by telling the truth than by
trading in fiction". This surely must be a better approach than writing
that "We should not disturb the current pragmatic consensus that lets the
brain dead be dead"(1). Honesty is still the best policy.
(1) Baumgarten H Gerstenbrand F Diagnosing brain death without a
neurologist. Br Med J 2002:324 1471-2
(2) Coimbra CG Implications of ischaemic penumbra for the diagnosis
of brain death. Braz J Med Biol Res 1999; 32:1479-87
(3) Young PJ Matta BF Anaesthesia for organ donation in the
brainstem dead - why bother? (Editorial) Anaesthesia (2000 February);
55:105-6
(4)Kerridge IH Saul P Lowe M McPhee J Williams D Death, dying and
donation: organ transplantation and the diagnosis of death J Med Ethics
2002;28:89-94
Competing interests: No competing interests
Editor - in their editorial, Baumgartner and Gerstenbrand conclude
that "determination of brain death without a neurologist should never be
done for transplantation purposes". However, this is exactly what is
carried out daily by consultant anaesthetists and intensivists in
Intensive Care Units throughout the UK. Without this practice we would
hardly have a transplant programme at all. An essential feature of the
criteria used in the UK for diagnosis of brainstem death is that a
neurologist is not required.
Competing interests: No competing interests
I recently enjoyed reading the BMJ editorial “Diagnosing brain death
without a neurologist”, by Baumgartner and Gerstenbrand.
In Dr. Matthews’ response to this editorial, he suggested that
Baumgartner and Gerstenbrand confounded the concept of brain death with
brainstem death, because “patients who are truly brainstem dead become
asystolic after 211 hours at the latest”. I have recently discussed the
three main brain oriented formulations of death: the 'whole brain', the
'brainstem' and the 'higher brain' standards, proposing a new standard of
human death.1 Some authors had defended that brainstem death predicted an
inevitable asystole within a few hours or days.2 Nonetheless, some recent
reports have shown that some brain dead patients do not develop an
inevitable cardiac arrest within a short while.3,4 Shewmon has recently
presented a detailed review of prolonged survivals in about 156 braindead
patients.5 This author presented a unusual video during the III
International Symposium on Coma and Death (Havana, 2000), of a boy who was
kept under ventilator during 16 years, since he became BD at age 4,
showing a complete liquefied of the whole brain (including the brainstem).
Hence, if life support is not withdrawn, some bodies with destroyed brains
(brain dead patients) could be kept “alive” for years, if they are not
suitable as organ donors.1,6
I will now target my discussion on the question: Is the neurologist
the only competent physician to diagnose BD? Most physicians who are not
specialists either in neurology or neurosurgery are not trained during
their pre or postgraduate education to make detailed neurological
examinations in comatose patients. Although in Cuba, we have enough
neurologists in all provinces of the country, we have obtained very good
results by training intensive care specialists for applying BD diagnostic
criteria. It is clear that physicians will only face brain-dead cases in
an intensive care environment. Moreover, we give special emphasis in the
medical career curriculum to teach the diagnosis of death on neurological
grounds.1,6,7
I completely agree with that BD can’t be expanded to consider such
syndromes categorized as persistent or permanent vegetative state, the
chronic apallic syndrome, or the minimally conscious state. I have also
recently discussed these states based on the physiopathological mechanisms
of consciousness generation in human beings.1,6 Again, Dr. Matthews made
an incredible mistake, wondering that Prof Baumgartner and Prof.
Gerstenbrand, are beginners in this area of Neuroscience.8
REFERENCES
1.Machado C. Consciousness as a definition of death: its appeal and
complexity. Clin Electroencephalogr 1999; 30(4):156-164.
2.Pallis C. Brainstem death: the evolution of a concept. Semin Thorac
Cardiovasc Surg 1990; 2(2):135-152.
3.Beca JP, Wells W, Rubio W. [Maternal brain death during pregnancy].
Rev Med Chil 1998; 126(4):450-455.
4.Spike J. Brain death, pregnancy, and posthumous motherhood. J Clin
Ethics 1999;10(1):57-65.
5.Shewmon DA. Chronic "brain death": meta-analysis and conceptual
consequences. Neurology 1998; 51(6):1538-1545.
6.Machado C. Is the concept of brain death secure? In Zeman A,
Emanuel L, eds. Ethical Dilemmas in Neurology, vol. 36. London, W. B.
Saunders Company, 2000:193-212.
7.Edición Ordinaria del 21 de Septiembre del 2001. 9-21-2001. La
Habana, Ministerio de Justicia. Gaceta Oficial de la República de Cuba.
Resolución No. 90 de Salud Pública.
8.Vos PE, Battistin L, Birbamer G, Gerstenbrand F, Potapov A, Prevec
T, Stepan ChA, Traubner P, Twijnstra A, Vecsei L, von Wild K. EFNS
guideline on mild traumatic brain injury: report of an EFNS task force.
Eur J Neurol 2002; 9(3):207-219.
Correspondence:
Calixto Machado, MD, Ph.D
Instituto de Neurología y Neurocirugía
Apartado Postal 4268
Ciudad de La Habana 10400
Cuba
E-mail: braind@infomed.sld.cu
Competing interests: No competing interests
I agree with the authors arguments.Brain or brainstem death is death
at all - since the surprising Barnard brothers transplantation,the Harvard
ad hoc Comitee until now.Here,in Brazil,we have fine hospitals,medical
centers and ICUs in the South states,as Sao Paulo,Rio de Janeiro,Rio
Grande do Sul,Minas Gerais,etc.And huge problems in the North:in the
enormous Amazon rain forest states,there are only three neurologists board
certified !By other hand,intensivists could make proper brain death
certification,observed by the ethics principles,like don't make part of
transplantation teams.However,if there are few neurologists and proper
useful ICUs,like in Amazon,why do we concern about the brain death
criteria ?In this places,transplantations cannot be performed !And the
euthanasia issue in forbidden in Brazil.In resume,even in the more
developed areas of Brazil,there is a extreme necessity to explain to the
society the scientific and ethical purposes of declaring brain death as
death itself.And probably there are the same patterns in countries like
Brazil.
Competing interests: No competing interests
Sirs,
notoriously, in day-to-day practice even general practitioners should be
able to diagnose brain death, due to the fact that they must recognise
such pathological condition under a lot of difficult circumstances, when
neurological experts are not available. In order to recognize brain death
as well as patients really dead, doctors need at the bed side a reliable
clinical tool, which allows them to ascertain without any doubt such
conditions. In my opinion, to aim this goal, general practioners should
know, at first, that “life” is the trajectory of the biological
systems strange attractor and, then, they should be able to assess it in
a “quantitative” way in all tissues of patient’s body, in order to avoid
dreadful complications (1).
Fortunately, nowadays we can use a new
physical semeiotics, based upon the evaluation of biological systems
deterministic chaos: Biophysical Semeiotics (2, 3, 4) (See the site
HONCode ID. N° 233736 http://digilander.iol.it/semeioticabiofisica and the
Page, I hold in italian site www.Katamed.it).
Sergio Stagnaro MD., Active Member NYAS.
1) Lo B, Dornbrand L, Wolf LE, Groman M. The Wendland case
withdrawing life support from incompetent patients who are not terminally
ill. N Engl J Med 2002; 346: 1489-1493[Full Text].
2) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica del torace, della
circolazione ematica e dell’anticorpopoiesi acuta e cronica. Acta Med.
Medit. 13, 25, 1997.
3) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica: valutazione
clinica del picco precoce della secrezione insulinica di base e dopo
stimolazione tiroidea, surrenalica, con glucagone endogeno e dopo
attivazione del sistema renina-angiotesina circolante e tessutale – Acta
Med. Medit. 13, 99, 1997.
4) Stagnaro-Neri M., Moscatelli G. Stagnaro S., Biophysical Semeiotics:
deterministic Chaos and biological Systems. Gazz. Med. It. Arch. Sc. Med.
155, 125,1996.
Competing interests: No competing interests
I have read with interest the Editorial by Baumgartner and
Gerstenbrand but feel that it is clumsy and confused, with no clarity
regarding their recommendations. Firstly, in an area where precise
definitions are imperative, to use the term "brain death" without
explaining what is meant begs the question about whether the authors have
clearly thought through their arguments. I presume they mean "brainstem
death," but then the statement "some bodies whose brains presented with
all the diagnostic criteria of brain death have been kept alive for years"
suggests that maybe they don't; patients who are truely brainstem dead
become asystolic after 211 hours at the latest. Again, to use the term
persistant vegetative state when the correct term is "permanent"
vegetative state again makes me wonder if authors have adequately
researched this area.
My main point of contention, however, is the sentence "Determination
of brain death without a neurologist should never be done for
transplantation purposes.." Firstly brainstem death testing is performed
to establish whether the patient is legally dead. If they are then life
support may be continued with a view of possible organ donation. The tests
are NOT performed primarily "for transplantation purposes." Secondly, and
more importantly, there can be no justification for the statement that
neurologists should be required to perform the tests. No evidence is
provided that neurologists are better qualified to perform the test or,
put another way, that there has ever been a problem with other suitably
experienced specialists performing the tests. Indeed, it could be argued
that as neurologists have very litle understanding about Intensive Care
Medicine, including the pathophysiology and pharmacological practices used
that need to be taken into account prior to testing, they may be one of
the least qualified to lead the tests.
The authors have missed an opportunity to raise some interesting
points for discussion in an Editorial that is filled with confused
reasoning and a paucity of evidence, thereby rendering its recommendations
as unjustified and at times semi-hysterical.
Competing interests: No competing interests
Diagnosing Brain Stem Death without a Neurologist
Dear Sir
The article by Baumgartner and Gerstenbrand on "Diagnosing brain
stem death without a neurologist" (BMJ 324, 22nd June, 1471), discussed
the diagnosis of brain stem death from an international perspective but
failed to describe the well established principles used in UK clinical
practice. We would like to place on record the following points:
*In the UK, the criteria for the diagnosis of brain stem death and
the clinical method of confirming it have been accepted for many years.
*There is no need for the obligatory involvement of a neurologist;
properly trained doctors of appropriate seniority of any specialty can
perform the tests and make the diagnosis.
*It is established practice that the medical staff making the
diagnosis must be separate from those involved in the recovery and
transplantation of donor organs.
*The guidelines concerning management of an organ donor, including
the mechanism for establishing brain stem death were published by the
Intensive Care Society in June 1999. These guidelines are available from
the Society (www.ics.ac.uk).
Yours sincerely
Peter Hutton
President, Royal College of Anaesthetists and Chairman, Academy of Medical
Royal Colleges
Peter Nightingale
President, Intensive Care Society
Saxon Ridley
President Elect, Intensive Care Society
Alaistair Short
Chairman, Intercollegiate Board for Training in Intensive Care Medicine
Competing interests: No competing interests