Blog dedicated primarily to randomly selected news items; comments reflecting personal perceptions

Thursday, January 07, 2016

The Ultimate Insecurity

"This is truly one of those matters of life and death, and we want to make sure this is done right every single time."
"There are very few things in medicine that should be black and white, but this is certainly one of them [medical determination of death]."
Neurologist David Greer, Yale University

"The brain is the person, the evolved person, not the machine person. ...We are not one living cell. We are the evolution of a very large group of systems into the awareness of self and the environment."
Neurologist Fred Plum, Cornell University

"If one hospital is using a testing method that's different from another hospital, people might wonder: 'Are they really dead'?"
Dr. Leslie Whetstine, bioethicist, Walsh University, Ohio

An individual is dead when he or she "has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem."
Uniform Determination of Death Act 
The Lower Brain -- where the top of the spinal cord goes up through our necks and into our brains -- regulates body functions such as spontaneous breath, reflexes, our heartbeat, body temperature and sleep/wake cycles.
The Upper Brain is behind all the "higher" functions in a person's nervous system. This gives us the ability to use our senses -- to see, taste, smell, hear and feel.
"Brain death" means both the upper and lower part of the brain are not functioning. That command center of the body that regulates the central nervous system is unable to perform. However, some function, such as a heartbeat, may linger. 
In 2010, the American Academy of Neurology issued guidelines meant for hospitals and medical personnel to use in determining whether brain death has occurred. Brain death is the condition that is lawfully recognized as crossing from life into death. The painstaking discussion among medical experts to find agreement on what constitutes fully and absolutely the end of life was occasioned because of horror stories where patients have been declared death when death has not in fact occurred.

The basic statement above taken from the Uniform Determination of Death Act allows for no errors in identifying the state of death having occurred. Dr. Greer, who among others was responsible for establishing that standard is disturbed that though the guidelines were published in the journal JAMA Neurology the standard has not been universally adopted. Of close to 500 American hospitals that Dr. Greer and colleagues studied over a period of three years, most had no requirement that an expert in neurology of neurosurgery be involved in the declaration of brain death.

The individual tasked to make that declaration did not have to be the patient's attending physician at more than half of the hospitals surveyed. Most hospitals did not require doctors to test for hypotension (abnormally low blood pressure) or hypothermia, both conditions capable of suppressing brain function, and as a result the patient on examination could conceivably appear to be brain dead.

At St.Joseph's Hospital Health Center in Syracuse, N.Y. Colleen Burns who had been in a deep coma for days post-drug overdose, and declared brain dead was being prepped in an operating room for the removal of her organs for transplant purposes. A scan of brain electrical activity indicated brain death and her family was urged to agree to harvesting her organs for transplant. Despite the OR bright lights attending staff failed to note the 41-year-old's symptoms of life.

Her lips and tongue moved, she was beginning to breathe on her own, and her nostrils were flaring. Doctors had diagnosed cardiac arrest inaccurately, and they failed to determine whether her system still harboured drugs. A mere 32 percent of the hospitals that Dr. Greer's team surveyed even required that drug tests be routinely undertaken to rule out toxic levels present capable of mimicking the loss of primitive reflexes commonly associated with brain death.

When Ms. Burns opened her eyes, she was taken directly back into the ICU where doctors resumed treatment to restore her to full consciousness. She recovered and was later discharged. The consequences had her body not reasserted its autonomic function and given evidence that her brain was still functioning, would have been final and irreversible. The situation brought into stark living colour that age-old question: when is a person no longer alive?

There is a brief window of opportunity when organs can be taken from a person hovering between life and death. Only when it can be certified that death has occurred can those organs be viably extracted and rushed to another operating theatre where a potential recipient for a replacement organ awaits a donor's demise. Begin the extraction process prematurely and the risk is that someone who might have lived has been sacrificed; initiate the extraction too late and the organ may no longer be viable.

According to a 1968 definition arrived at by an ad hoc Harvard Medical School committee and published in the Journal of the American Medical Association, a human being can be declared dead once the heart and lungs no longer operate. But locking in on the brain and its continuing function is seen as truly critical to identifying the arrival of death since without a brain, without thought and identity, there is no life.

So can one be assured that the matter is now settled and universally recognized? Hardly; in spite of legal medial and moral issues that led to the determination of brain death no universally recognized procedure has been standardized declaring brain death with full assurance that life has ceased has occurred. There are expert guidelines that neurologists are confident identify the end of life and the entrance of death. On the other hand, there is the issue of whether hospitals accept the guidelines and apply them.

Signs of brain death

Some of the signs of brain death include:
  • The pupils don’t respond to light.
  • The person shows no reaction to pain.
  • The eyes don’t blink when the eye surface is touched (corneal reflex).
  • The eyes don’t move when the head is moved (oculocephalic reflex).
  • The eyes don’t move when ice water is poured into the ear (oculo-vestibular reflex).
  • There is no gagging reflex when the back of the throat is touched.
  • The person doesn’t breathe when the ventilator is switched off.
  • An electroencephalogram test shows no brain activity at all.

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