Debate grows over when brain dead really means dead
February 6th 2010 20:53
Signature Tune
From: National Post
The 10-month-old Edmonton boy had been left alone in his bathtub for only a few minutes. By the time a caregiver returned, however, the child was floating face down and motionless, drowned in a few inches of water.
Forty-two hours later, doctors declared the baby brain dead, a frantic battery of treatments from CPR to drastic cooling of the child's body having failed to revive him. And yet, that was not the end of the story: 15 hours after death was diagnosed at Stollery Children's Hospital, signs of life suddenly reappeared.
"People at the bedside noticed what they first thought were hiccups," recalled Dr. Ari Joffe, the intensive-care specialist summoned to investigate the unusual case. "It was obvious the baby was making breathing efforts."
The infant eventually died, but the earlier, spontaneous breathing showed that some brain function had returned. In a recently published report, Dr. Joffe says the case calls into question the very concept of brain death and whether it truly represents a person's permanent demise, adding fuel to a heated medical and philosophical debate over how to determine a life has ended.
The 10% of ICU patients who are declared brain dead are crucial to the supply of viable organs for transplant. But the drowning case underlines the "urgent" need to at least revisit the guidelines for diagnosing it, some specialists say.
"Society is very supportive of transplantation and organ donation, but I think that support is predicated on the diagnosis of death," said Dr. David Zygun, a neurological critical-care physician at the University of Calgary. "If someone did not meet criteria for death accepted by everyone, that would raise huge concerns about organ retrieval."
A major U.S. government panel also addressed the issue several months ago. A leading Canadian expert, however, says the science around the concept is rock solid and calls the Alberta case study an "irresponsible" attempt to bend the facts to fit Dr. Joffe's well-known anti-brain death slant.
"It's very easy to scare people if you are not diligent about what you report," said Dr. Sam Shemie, a Montreal intensive-care specialist. "What we need in this area is dispassionate, objective reporting, rather than reporting things that support a bias."
It used to be that someone was considered dead simply when their heart stopped beating. The concept of brain death - an irreversible loss of all brain function - emerged in the 1960s in answer to modern medical technology that could keep the heart and lungs functioning mechanically during treatment. With blood continuing to flow through the body, it also presented prime conditions for removing organs for transplant.
After the Edmonton case - which occurred about a year ago but has only now been reported in the journal Pediatric Neurology - Dr. Joffe and colleagues unearthed several other, similar cases worldwide of people declared brain dead, only to seemingly come alive again. Most died soon after, but one 60-year-old man in 1976 recovered fully, while a newborn had a "good outcome" and two were left in permanent vegetative state, though alive.
Dr. Joffe rejects the original justification for the brain death idea: that the brain is a master organ, ensuring the body is an "integrated organism" and not just a collection of cells. Brain-dead bodies kept alive on life-support machines have been known to give birth, develop through puberty, fight infection and heal wounds, he notes.
A U.S. presidential panel, concerned about such arguments, came up with a new rationale in a report released last January. It talks of brain death ending a person's "engagement" with the outside world.
Dr. Joffe responds that brain-dead bodies on life support can react to outside stimuli, with heart rates and blood pressure climbing in reaction to cuts, and the body processing oxygen and food.
"My own view is that brain death is a dismal state, it is a very poor prognosis. But I don't think that it is death," he said. "People, I think, want to be called dead when they really are dead.... For me it's important that we're honest and don't stretch the rules, because if we do, it's tempting to stretch them even further."
Dr. Joffe says it is reasonable to withdraw life support from patients declared brain dead and says that organ harvesting can still take place. But families in some cases would have to be told that - while death was imminent - their relative was technically still alive.
Dr. Shemie says that position is the exception in the medical community and cites a "consensus forum" of top experts in intensive care, neurology, transplantation and ethics that he chaired in 2003, which confirmed the brain death idea and developed guidelines for diagnosing it.
"The metaphor would be, you are decapitated: Your brain no longer functions and no longer has the ability to direct the body in any way," he said. "That does not mean you cannot keep the body working by using technology. You can keep a decapitated body working."
Putting aside the question of whether brain death equals end of life, Dr. Joffe says his case suggests the guidelines for declaring it should be revised. Doctors probably ought to do two separate exams to diagnose the state, separated by as much as 48 hours, he said.
Dr. Shemie, however, said the Edmonton case proves nothing. The problem was that the baby was subjected to 24 hours of hypothermia, a cooling of the body designed to limit brain injury, which can also mimic the symptoms of brain death. Had the doctors waited another 24 hours before testing for brain death to avoid that "confounding factor," there would have been no problem, he argued.
Regardless, Dr. Zygun said the case does at least raise questions about the validity of the current protocol. He also cited a case in Calgary, being prepared for publication, that might cast more doubt over the process. A brain scan indicated blood flow to the brain had stopped - considered a sure-fire confirmation of brain death - but clinical tests suggested there was still life.
Dr. Chip Doig, another Calgary intensive-care physician and part of the forum that came up with the current guidelines, said he supports the brain-death diagnosis and also has questions about the case study, but he welcomes the controversy around a topic Canadians have generally overlooked.
"If Ari is raising an issue that is stimulating public attention and public debate, that is a good thing," he said.
National Post
Read more: Really Long Link
The National Post is now on Facebook. Join our fan community today.
| 48 |
| Vote |
Add To: 
subscribe to this blog
