Brain Death & Ethical Brain Death & Ethical issuesissues

Dr. Ashraf HussainDr. Ashraf Hussain

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What is death?What is death? History of deathHistory of death Clinical death, brain deathClinical death, brain death Islamic perspective of deathIslamic perspective of death Ethical issuesEthical issues

When a human being is dead? Why it is important?

When the entity that integrates rest of the organism dies, the organism dies with it

Advances in medical Sciences Advances in medical Sciences have made the determination of have made the determination of the time of person’s death less the time of person’s death less simple than it used to be simple than it used to be

Death is a process not an eventDeath is a process not an event

History of death

Before 1816, physicians were not well trusted in their ability to diagnose death

Fear of being buried alive

In ancient Rome

Call out deceased person’s name 3 times If no response-- finger amputated If no bleeding– declared deceased

Fear to be buried alive

In 14th century Duke of Lancaster left instructions to keep his

body in bed for 40 days If doctors still believed he was dead then to be

buried

Magic words (1790)

written on mirrors in invisible ink (silver nitrate)Decomposed body produced hydrogen sulfide, writing

became visible as silver sulfide was produced

““I am dead”I am dead”

Patented Coffin to alert (1897)

If death was misdiagnosed If presumed deceased awoke from sleep

beneath the ground A device was rigged to light a lantern, raise a

flag and ring a bell

Clawed forceps

By French physician Designed to clamp around the nipple of the

presumed corpse to confirm death No response---dead

“…I know when one is dead, and when one lives. She is dead as earth. Lend me a looking glass. If that her breath will mist or stain the stone, why then she lives”

King Lear; Act V, Scene III

William Shakespeare

Invention of stethoscope (1816) Physician were began to be trusted in their

ability to diagnose death

Primary modes of confirming deathPrimary modes of confirming death

Respiration Respiration Heart sound Heart sound pulsepulse

Death criteriaDeath criteria

In beginning of 20In beginning of 20thth century century Cardiorespiratory criteria Cardiorespiratory criteria

Clinical DeathClinical Death Cessation of blood circulation and breathingCessation of blood circulation and breathing

ChangeChange

Change started in 1952 with an outbreak of Change started in 1952 with an outbreak of polio in Copenhagen, 12 year old girl under polio in Copenhagen, 12 year old girl under went tracheostomy & put on ventilatorwent tracheostomy & put on ventilator

Pierre Mollaret (French) in 1957 reported on Pierre Mollaret (French) in 1957 reported on patients who had developed brain injury and patients who had developed brain injury and were on mechanical ventilationwere on mechanical ventilation

No brainstem reflexes were present and post No brainstem reflexes were present and post mortem examination revealed brain mortem examination revealed brain liquefactionliquefaction

A new diagnosis of deathA new diagnosis of death

In 1968 Harvard Brain Death Committee In 1968 Harvard Brain Death Committee published report on how to diagnose death on published report on how to diagnose death on new criterianew criteria

Criteria proposed that patient could have no Criteria proposed that patient could have no brainstem or spinal cord reflexes.brainstem or spinal cord reflexes.

A confirmatory test was also required i.e. EEGA confirmatory test was also required i.e. EEG In essence, committee said In essence, committee said a person is dead if a person is dead if

the brain is deadthe brain is dead

DeathDeath

Clinical deathClinical death Brain deathBrain death

Clinical DeathClinical Death

Cessation of blood circulation and breathingCessation of blood circulation and breathing When the heart stops beating in a regular When the heart stops beating in a regular

rhythm. Condition is called cardiac arrestrhythm. Condition is called cardiac arrest The absence of blood circulation and vital The absence of blood circulation and vital

functions related to blood circulation was functions related to blood circulation was considered to be the definition of considered to be the definition of death death

““Clinical death is now seen as a medical Clinical death is now seen as a medical condition that Precedes death rather than condition that Precedes death rather than actually being death”actually being death”

During clinical death, all tissues and organs During clinical death, all tissues and organs in the body steadily accumulate a type of in the body steadily accumulate a type of injury called Ischemic injuryinjury called Ischemic injury

Factors for changeFactors for change

Increasing availability of mechanical Increasing availability of mechanical ventilation—legal implications of ventilation—legal implications of disconnectiondisconnection

Rapidly advancing field of organ Rapidly advancing field of organ transplantationtransplantation

DeathDeath

Permanent and irreversible cessation Permanent and irreversible cessation of vital functions of heart, brain and of vital functions of heart, brain and lungslungs

((C.K. Parikh; Text book of forensic medicine and toxicology)C.K. Parikh; Text book of forensic medicine and toxicology)

If we have a human body being ventilated on a respirator, but in which there is no sign of brain activity, ought we to regard that person dead or alive?

How should we regard a person in permanent coma?

When should we cease to persist with life prolonging treatment?

Under what circumstances can patients decline life-saving measures?

TYPES OF BRAIN INJURY

Coma Brain death Vegetative state Locked-in state Minimally conscious state

ComaComa

Prolonged state of unconsciousness, in which Prolonged state of unconsciousness, in which patient is alive, but unable to move or respond patient is alive, but unable to move or respond to environment.to environment.

Coma

Most serious brain injuries begin with a coma “Eyes-closed unconsciousness.” It is as if the patient is sleeping but cannot be

aroused. Coma is usually not permanent. Some patients go on to become brain dead;

others enter the vegetative stage, become “locked in,” or enter the minimally conscious state; still others recover completely

Brain death

Irreversible loss of the clinical function of the whole brain:

The cortex (responsible for motor and cognitive function)

The midbrain (which might be thought of as integrating higher and lower centers in the brain)

Brain stem (responsible for vegetative functions such as sleep-wake cycles and breathing).

Brain death is a product of modern technology, made possible by mechanical ventilators and cardiopulmonary resuscitation

Brain death criteriaBrain death criteria

Absence of eye openingAbsence of eye opening Absence of verbal or motor response to painAbsence of verbal or motor response to pain Loss of brain stem reflexes (such as pupil Loss of brain stem reflexes (such as pupil

response, corneal reflexes, caloric response to response, corneal reflexes, caloric response to vestibular stimulation, cough reflexes and vestibular stimulation, cough reflexes and hypercapnia)hypercapnia)

Brain death criteria cont;Brain death criteria cont;

Total unresponsiveness to these tests, Total unresponsiveness to these tests, combined with good evidence that it is caused combined with good evidence that it is caused by by irreversible structural damage to the brainirreversible structural damage to the brain means that person will never regain means that person will never regain consciousness consciousness

Vegetative State:Vegetative State:

Refers to plant life i.e. without locomotion)Refers to plant life i.e. without locomotion)

It is a brain injury resulting from Trauma or It is a brain injury resulting from Trauma or Diseases, where higher functions of brain are Diseases, where higher functions of brain are lost while the non-cognitive functions, like lost while the non-cognitive functions, like breathing and heart beating are retained. breathing and heart beating are retained.

Vegetative state

“Eyes-opened unconsciousness” There is a disassociation between wakefulness and

awareness. While patients may appear awake, there is a lack of

evidence that the upper brain receives or projects information.

The upper brain and the midbrain are not integrated in function with the brain stem or the rest of the body, although the brain stem continues to manage the vegetative functions.

Vegetative state

“Sustained and reproducible voluntary response” is important in the diagnosis

Prognosis is determined by the Cause of the injury Length of time the patient has been in the

vegetative state Comorbid conditions.

Duration of the vegetative state also affects nomenclature

A duration >1 month is said to be persistent. When the cause of the vegetative state is

nontraumatic —such as an anoxic injury after cardiopulmonary resuscitation a duration >3 months is said to be permanent

BUT When the cause of the vegetative state is traumatic a

patient must remain vegetative for >12 months before the condition is defined as permanent.

Locked-in state

Consciousness is preserved but the patient is paralyzed except for eye movement and blinking.

Locked in SyndromeLocked in Syndrome

Paralyzed from head to toe, the patient, his mind Paralyzed from head to toe, the patient, his mind intact, is imprisoned inside his own body, but unable intact, is imprisoned inside his own body, but unable to move or speak.to move or speak.

“ “In my case blinking my left eyelid is my only In my case blinking my left eyelid is my only means of communication….My heel hurt, my head means of communication….My heel hurt, my head weighs a ton, and something like a giant invisible weighs a ton, and something like a giant invisible diving-bell holds my hole body prisoner”diving-bell holds my hole body prisoner”

Jean-Dominique Bauby describing his experience in The Jean-Dominique Bauby describing his experience in The Diving Bell and the Diving Bell and the ButterflyButterfly, a book dictated entirely by eye movements, a book dictated entirely by eye movements

Minimally conscious state Sleep-wake cycles exist, just as in the vegetative state.

Arousal levels range from obtundation to normal arousal.

There is reproducible but inconsistent evidence of perception, communication ability, and/or purposeful motor activity.

Visual tracking is often intact but typically inconsistent.

Communication ranges from none to unreliable, with inconsistent yes-no responses, verbalizations (typically fewer than six words), and gestures

Can we cease our medical efforts to Can we cease our medical efforts to keep alive some one who is brain keep alive some one who is brain dead?dead?

Islamic perspectiveIslamic perspective

Unanimous approval of whole brain death Unanimous approval of whole brain death criterion and its permissibility within Islamcriterion and its permissibility within Islam

(Acdemy of Islamic jurisprudence, Jordan1986}(Acdemy of Islamic jurisprudence, Jordan1986}

PAKISTANPAKISTAN

Brain death is widely accepted Brain death is widely accepted Legislation?Legislation?

Famous cases for legal Battles

Karen Quinlan Nancy Cruzan Theresa Schiavo

ReadingsReadings

Bioethics for clinicians: 24 Brain death by Bioethics for clinicians: 24 Brain death by Neil M. Lazar et alNeil M. Lazar et al

The final diagnosis of brain death: David C. The final diagnosis of brain death: David C. Kaufman www.sccm.org Kaufman www.sccm.org

Ethical & social dimensions of brain death. Ethical & social dimensions of brain death. F.Moazam. Pakistan journal of neurological F.Moazam. Pakistan journal of neurological sciencessciences

wikipedia.orgwikipedia.org