Brain Death - Research Paper Example

Brain Death: Interrelated Medical and Ethical Issues Introduction Advances in the field of medicine have created a new entity in death, the “brain death”. This concept mainly arose for 2 purposes: organ donation and discontinuation of unnecessary ventilator support. However, declaration of brain death is associated with several medical, ethical and legal issues and many religious groups do not consider it equal to death. Even among Catholics, brain death is a much debated topic with some acknowledging it equal to death, while others questioning its validity (Shewmon, 2009). In this essay, medical and ethical issues of brain death will be discussed. Brain death Brain death is a condition in which there is "irreversible loss of all functions of the brain, including the brainstem" (Goila and Pawar, 2009). According to Machodo (2010), "brain death should be understood as the ultimate clinical expression of a brain catastrophe leading to a complete and irreversible neurological stoppage, characterized by irreversible coma, absent brainstem reflexes, and apnea." The 3 characteristic features of brain death are coma, absence of reflexes of the brain stem and apnoea. It is very important to ascertain brain death because, a patient who is brain dead is legally and clinically dead (Goila and Pawar, 2009). The diagnosis of brain death is basically clinical. If a detailed clinical examination has proven brain death, no other tests need to be done to ascertain the diagnosis of brain death. To clinical determine brain death, 2 separate assessments of reflexes of brain stem and one apnoea test is confirmatory (Goila and Pawar, 2009). Medical issues Brain death certification is a process and involves the following procedures (Goila and Pawar, 2009): 1. A detailed history must be taken and complete physical examination must be performed to ascertain the etiology of brain death. Some of the common causes of irreversible coma are severe head injury, aneurysmal subarachnoid hemorrhage, hypertensive intracerebral hemorrhage, fulminant hepatic failure and hypoxic ischemia. The diagnosis must be consistent with neuroimaging findings or clinical history (Goila and Pawar, 2009). 2. Certain conditions must be ruled out before arriving at a diagnosis of brain death because these can confound brain stem function examination findings. They are hypothermia of less than 32 degree centigrade, shock, Gullian-Barre syndrome, brain stem encephalitis, intake of drugs which alter the function of brain stem function like anesthetic drugs, methaqualone, neuroparalytic drugs, barbiturates, amitryptiline, benzodiapines, bretylium, alcohols, trichloroethylene and meprobamate, severe hypophosphatemia and hepatic encephalopathy related uremia and hyperosmolar coma (Goila and Pawar, 2009). 3. Complete neurological examination is mandatory; including brain stem reflexes tests and apnoea test. When contemplating organ donation and continuation of ventilatory support, there are several other medical-related issues that have to be evaluated and managed. This is because; brain death is associated with several endocrine, metabolic and hemodynamic dysfunctions which can ultimately lead to major complications and affect the process of organ doantion (Ali et al, 2006). Ethical issues Physicians have several responsibilities for determining brain death. The facility must inform the closest relative that process of determining brain death is on the way. Though there is no need to take consent for performing the tests, any moral or religious objections from the family members must be taken into consideration. After the first clinical examination for brain death, repeat examination must be done after 6 hours for all individuals above one year of age. For individuals less than one year of age, more gap must be provided. The second clinical examination for brain stem reflexes must also be done in detail and must be documented. Confirmatory tests are not indicated except in conditions like cardiovascular instability and cervical or skull injuries. These tests may also be done to assure the family members and staff about brain death. Tests useful for this purpose are brain angiography, radionuclide angiography, cerebral arteriography, nuclear brain scanning, electroencephalography and transcranial doppler ultrasonography (Goila and Pawar, 2009). The certificate of brain death can be issued by a single physician. However, for the purpose of organ donation certain state laws have to be followed. According to the New York State law, "the time of brain death must be certified by the physician who attends the donor at his death and one other physician, neither of whom shall participate in the process of transplantation." Such a law makes sure that all the evaluations pertaining to brain death are as per the medical standards and also ensures that all participants have confidence in the determinants of brain death and no suspicion of involvement of extraneous factors is there (Goila and Pawar, 2009). There must be proper documentation of all phases of brain death determination. The documentation must include the etiology of the irreversible coma, lack of response to pain, "absence of brainstem reflexes during two separate examinations separated by at least 6 hours", lack of respiration with pCO2>60mmHg and also documentations of any tests that have been done (Goila and Pawar, 2009). Following, the confirmation of brain death, ventilatory support must be discontinued. During this time, the family must be treated with sensitiveness and respect. Family members must be given an opportunity to stay besides the patients during discontinuation of ventilatory support. According to Willatts et al (cited in Goila and Pawar, 2009), "family members should be prepared for the possibly disturbing clinical activity that they may witness when organ donation is contemplated, ventilatory support will conclude in the operating room and family attendance is not appropriate." Religion-related issues Though medically, scientists equal brain death to death; religiously, the perception is different by different proponents. Among Catholics too there are different opinions of thought with regard to brain death and organ donation based on that diagnosis and many debates have occured as to whether brain death is eaual to death. In 2000, Pope John Paul II addressed the 18th International Congress of the Transplantation Society and stated that “Vital organs which occur singly in the body can be removed only after death; that is, from the body of someone who is certainly dead ... the death of a person is a single event consisting in the total disintegration of that unity and integrated whole that is the personal self ... The death of a person is an event which no scientific technique or empirical method can identify directly ... the ‘criteria’ for ascertaining death used by medicine today should not be understood as the technical scientific determination of that exact moment of a person’s death, but as a scientifically secure means of identifying the biological signs that a person has died.” The Pope however concluded that the criterion adopted in more recent times for ascertaining the fact of death - namely the complete and irreversible cessation of all brain activity - if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology.” In 2003, the Pope opined that "It is never licit to kill one human being in order to save another.” This debate was reopened by him in 2006 when several protestors argued that brain death was not equal to death. However, based on reports from the Pontifical Academy for the Sciences, the chancellor of the academy, Bishop Sanchez declared that "brain death was equivalent to the death of a person." Conclusion Declaration of brain death is connected with several religious, medical and ethical issues. By law, brain death is equal to death and removal of ventilator support to an individual with brain death is absolutely legal. However, in some religious groups, brain death is not considered equal to death and approval for organ donation and withdrawal from cardiorespiratory support becomes difficult in such cases. Physicians have many responsibilities which certifying brain death and they must certify brain death in accordance with ethical and medical policies connected with it. References Ali, S., Matthew, M., Carlos, B., et al. (2006). Complications of brain death: Frequency and impact on organ retrieval. JOM, 72(5), 377- 381. Goila, A.K., and Pawar, M. (2009). The diagnosis of brain death. Indian J Crit Care Med., 13, 7-11. Machado, C. (2010). Diagnosis of brain death. Neurology International, 2(2), 6-10. Shea, J.B. (2007). Organ donation: The inconvenient truth. Bioethics. Retrieved on December 3rd, 2010 from http://catholicinsight.com/online/bioethics/article_747.shtml Shewmon, A. (2009). Brain Death: Can It Be Resuscitated? The Hastings Center Report, 39(2), 18-24. Read More