Medical Science Progress, Regression

"The implication is less brain death equals less organ donors, frankly. This is at a time when the need for organ transplants is at an all-time high. A patient has a horrible brain injury. Everybody agrees the prognosis is horrible. But they're not brain-dead -- their brain hasn't swollen to this point where they've actually progressed to being brain-dead.
"Doctors aren't always completely unanimous about things. In most cases, it's clear that the prognosis is hopeless. But, what if there isn't complete agreement?
Dr. Andreas Kramer, Calgary critical-care doctor, medical director of Southern Alberta Organ and Tissue Donation Program
 
"The question that people have is, is it possible for somebody to suffer after their heart stops? Can they feel anything? The data that we have is that, in fact, in most instances the brain stops working before the heart stops in ICU patients who are dying.
"So, the answer to the question is no -- patients cannot feel or suffer or be awake. They are completely and irreversibly unconscious within seconds after their heart stops beating."
Dr. Sam Shemie, McGill University medical director for donation at Canadian Blood Services

The incidence of "brain-dead" declarations leading to the recently deceased's body parts becoming a useful tool enabling others whose organs have collapsed due to disease, accident or medical mishap, to receive a lease on a longer life than anticipated is controversial. One man's death is another man's chance at prolongation of life. A finding just published in the Canadian Medical Association Journal announces a "stagnant or even declining rate of deceased organ donation".

The finding results from a ten-year study of almost three thousand brain-injured adults in southern Alberta. The proportion of the total who succumbed to their condition leading to a diagnosis of "brain -death" has plummeted from 8% in 2002 to 4% by 2012 (lower still in 2010 at 2.2%). This is a reflection of fewer traffic deaths and non-fatal accidents. Advances in treating head trauma also plays a part in the diminished incidence of "brain-death".

"Patients get their CT scans more quickly, they go to the operating room more quickly", explained lead author of the study, Dr. Andreas Kramer, medical director of the Southern Alberta Organ and Tissue Donation Program, a Calgary critical-care doctor. Thanks also to greater emphasis within the medical community "on protecting the brain in this vulnerable state when it's injured." Good news for the injured, sad news for the patient awaiting organ transplantation.

Brain death is recognized as complete and irreversible loss of all brain function. Even though a patient's heart remains beating and a ventilator circulates air in and out of their lungs, they can be legally declared death. A patient normally halts the breathing process when the brain no longer functions. Life support, however, can maintain oxygen and blood circulation through the heart, lungs, liver, kidneys and other organs.

If a family makes a decision to halt life support, the organs can be retrieved in five minutes after the heart has stopped beating. All the patient's organs with the exception of the heart can be harvested for transplant. "When the decision to consider organ donation is made, the patient isn't dead yet", observed Dr. Kramer. There is controversy over how long doctors should wait to retrieve organs.

In Canada, Australia and the United Kingdom, the wait is a minimum of five minutes. It can be twice as long in some other countries. The knowledge is there that the longer doctors wait to retrieve the organs the more deterioration of potential functionality sets in. In some American jurisdictions the ait is 2 minutes before declaring death.

Never, cautioned Dr. Shamie, should thought of organ donation influence the decision to withdraw life support. "That's sacrosanct. Transplant doctors can have no role in the care of dying patients -- they can have no role in the determination of death prior to organ donation. ... That is a legal and moral and strict separation in all our work."

And thank heavens for that.