BRAIN DEATH BRAIN DEATH (MATI OTAK) (MATI OTAK)

Pusat Transplan NasionalPusat Transplan Nasional

Different groups have different definitions of the word “death”.“death”.

Takrif mati berbeza-beza bergantung dari sudut mana ianya di lihat

Socio-cultural Recognition of Death:Socio-cultural Recognition of Death:

Not moving ( including not breathing) Not responding Pallor Cold Decay

Most Certain Medical Signs of Death:

- hypothermia (sejuk)-dependent lividity ( kebiruan di bawah badan)- rigor mortis ( kaku anggota )

Biologist:

Death is a process of progressive decay of various tissues and organs depending

on their susceptibility to oxygen deprivation.

Death is the cessation of life

Dari segi undang-undang, mati ialah tamat hayat

Conventional Concept of LifeConventional Concept of Life

RespirationRespiration Heart BeatHeart Beat

LIFELIFE

Conventional Concept of DeathConventional Concept of Death

No RespirationNo Respiration No Heart BeatNo Heart Beat

DEATHDEATH

But is every case of no respiration and no heart beat Death?

No Respiration No Heart Beat

No Oxygen to Brain

Brain DeathBrain Death

DEATHDEATH

• Secara umum undang-undang menerima takrif mati dan cara penentuan mati yang di gunakan oleh ahli perubatan berdasarkan ilmu dan amalan semasa perubatan

Stedman’s Medical Dictionary:Stedman’s Medical Dictionary:

Death is when there is permanent loss of heart beat and permanent loss of

spontaneous respiration or when there is cerebral death.cerebral death.

The concept of death is the same for all groups:

The permanent cessation of the coordinated

function of the organism as a whole.

In Many Cultures and Religions:

Respiration is the more important sign of lifeRespiration is the more important sign of life

JUDICIAL HANGINGJUDICIAL HANGING

1. Rupture of ponto-medullary junction.2. Fracture dislocation of the odontoid process

Instantaneous and permanent loss of consciousness and apnoea.

Heart beat continues for ~20 minutes.

Time of death= time of irreversible unconsciousness and apnoea.

After World War 2After World War 2

Intensive care and treating the severely injured and Intensive care and treating the severely injured and severely ill became possibleseverely ill became possible

Use of ventilators became widespread and many Use of ventilators became widespread and many patients were on ventilators for days and weeks patients were on ventilators for days and weeks

when they possibly could have been dead.when they possibly could have been dead.

The DilemmaWhen patient is on respirator

or mechanical heart

WHEN IS DEATH?WHEN IS DEATH? HOW TO DIAGNOSE DEATH HOW TO DIAGNOSE DEATH

Debates and discussions involving many

different groups of interested people;

doctors, priests, lawyers, philosophers,

scientists, sociologists etc.

Kematian yang tidak berpunca dari kerosakan atau kecederaan otak

Pernafasan

Perlahan

Pesakit kebiruan

Nafas Berhenti

MATI

Jantung

Lemah

Tekanan darah menurun

Tiada Tekanan Darah

Jantung Berhenti

Kematian Dalam Serangan Sakit Jantung

Gangguan Bekalan Darah Kepada Otot Jantung

Gangguan Rentak Denyut Jantung( Ventricullar fibrillation or Asystole )

Jantung Tidak Dapat Pam Darah

Darah tidak sampai ke otak

Nafas BerhentiKoma

MATI

Kematian Dalam Kes Kes Kerosakan atau Kecederaan Otak

Otak Rosak Teruk

Tekanan Dalam Kepala Meningkat (Raised ICP)

Tekanan Dalam Kepala Mengatasi Tekanan Darah

Tiada Peredaran Darah ke OtakOtak tidak mendapat Oksigen

Nafas Berhenti

MATI

Sebab-sebab Mati OtakSebab-sebab Mati Otak• Kecederaan kepala yang terukKecederaan kepala yang teruk

- pendarahan / otak bengkak• Strok Strok

- pendarahan spontan (Darah Tinggi /

AVM/Aneurysm )

- darah beku (Thrombo-embolic ) • Otak tiada oksigenOtak tiada oksigen

- selepas kardio-respiratori terhenti• Barah OtakBarah Otak ( Primary Brain)

Mati OtakMati Otak• Satu cara bagaimana kematian berlakuSatu cara bagaimana kematian berlaku• Kurang daripada 1-2% kematian terjadi beginiKurang daripada 1-2% kematian terjadi begini• Kematian seluruh otak termasuk batang otak yang Kematian seluruh otak termasuk batang otak yang

mengawal penafasan dan fungsi jantungmengawal penafasan dan fungsi jantung• Otak mati kerana tidak mendapat oksigen oleh Otak mati kerana tidak mendapat oksigen oleh

kerana pengaliran darah yang terjejas akibat kerana pengaliran darah yang terjejas akibat tekanan dalam kepala yang terlalu tinggitekanan dalam kepala yang terlalu tinggi

• Tidak bernafas tetapi oleh kerana pesakit di waktu Tidak bernafas tetapi oleh kerana pesakit di waktu itu sedang menerima penafasan dengan machine, itu sedang menerima penafasan dengan machine, jantung masih lagi berfungsi buat seketika dengan jantung masih lagi berfungsi buat seketika dengan sokongan, tetapi akhirnya akan berhenti jugasokongan, tetapi akhirnya akan berhenti juga

Brain Death – Historical PerspectivesBrain Death – Historical Perspectives

1956 – Lodstedt & Von Reis 1st described

ventilated patients with absent brainstem

reflexes, absent cerebral blood flow and

cerebral necrosis

1959 – “ le coma de passe ”“ le coma de passe ” ( Beyond Coma )

Goulon Mollarret

defined death by neurologic criteria

Brain Death – Historical PerspectivesBrain Death – Historical Perspectives

1976 – UK “ Diagnosis of Brain Death “

1995 – Concept of brain stem death in UK

1993 – 1st Malaysian consensus on Brain Death

2003 – 2nd Malaysian consensus on Brain Death

Dx of brain death now accepted throughout the world

Brain deathBrain death

• Accounts for 1% of all hospital deaths

• 13-15 % of deaths in Neurosurgical ICU

Why the need for Brain Death ConceptWhy the need for Brain Death Concept

• Ethical reasons

• Human reason

• Intellectual reason

• Utilitarian reason

BRAIN DEATHBRAIN DEATH

A term that means that a person is recognised as dead based on neurological examination

DEFINITIONDEFINITION

• IrreversibleIrreversible loss of function of the whole loss of function of the whole brain, including the brainstem.brain, including the brainstem.

Features of Brain Death

COMA or UNRESPONSIVENESS

ABSENT BRAINSTEM REFLEXES

APNOEA ( No breathing )

Need to differentiate from :

• COMACOMA: Unarousable unresponsiveness.

• PERSISTENT VEGETATIVE STATEPERSISTENT VEGETATIVE STATE: Absent cognitive function, but has retained brainstem or ‘vegetative’ components.

• LOCKED-IN SYNDROMELOCKED-IN SYNDROME: Alert and aware, but quadriplegic, with only intact vertical eye movements.

BRAIN DEATH MISCONCEPTIONSBRAIN DEATH MISCONCEPTIONS

• NOT vegetative state

• NOT severe brain damage

• NOT “mercy killing”/ euthanasia.

Brain Death CertificationBrain Death Certification

2 specialists trained in brain death diagnosis - usually anaesthetist, neurologist, neurosurgeon, not involved in transplantation

2 tests

Period of observation between tests

Brain death confirmed when second set of tests completed

Brain Death Diagnosis

VERY STRINGENT

1. Preconditions.2. Exclusions.3. A set of Criteria.4. Examinations to meet the criteria.5. Repeat the examination.6. Confirmatory test desirable.

If in doubt , do not proceed with diagnosis

Brain Death DiagnosisBrain Death Diagnosis

1. Severe and irreparable structural brain damage AND 2. Irreversible coma AND 3. (a) Irreversible loss of brain stem reflexes and respiratory function ( apnoeic ) OR (b) Cessation of intracranial blood flow

Brain Death TestBrain Death TestClinical bedside testing of brainstem function

1.Coma or unresponsivenes

- absence of coordinated eye movement and motor activity including decorticate and decerebrate posturing

- Absent spontaneous motor activity ( except for spinal reflexes ) and seizures

- No motor response to deep pain

2. Absent Brain stem reflexes 3. Apnoea

Brain Death AssessmentSupportive Tests

Four vessel intracranial angiogram

Brain perfusion scan

Transcranial Doppler studies

EEG

Most Unequivocal Proof of Dead

Brain is NO CIRCULATION

Paediatric Brain Death

• EEG mandatory

• Interval between 2 examinations 7 days to 2 months old : at least 48 hrs 2 months to 1 year old : at least 24 hrs 1 year to 2 years old : at least 12 hrs

“Ventilator Brain”

• Widespread necrosis

• Oedematous hemispheres and brainstem

• Microscopic haemorrhage

• Pericellular oedema.

Sequalae of Brain Death

Heart will stop within few hours to few days irrespective of what treatments are given.

Documented 2004 cases all developed asystole

Japanese Group: 718 cases, average time to asystole 4 days (90% in 8 days)

Termination of ventilator

Time of death certified at confirmation of brain death - not at time of cardiac asystole or ventilator disconnection

Ventilator can be disconnected anytime after confirmation of brain death - no need to wait for asystole to occur

THE MUSLIM WORLD

• 1. Islamic Jurist at Jeddah Conference, 1985.

Acceptance:• 2. Amman Conference, 1986 – recognised Brain

Death as Death.• 3. Reaffirmed by 10th Fifq Academy Conference ,

Makkah 1987.

33rdrd International Conference of Islamic Jurists International Conference of Islamic Jurists

Amman Oct 1986 ( 1407)

A person is pronounced legally dead and consequently all dispositions of the Islamic law in case of death apply if oneof the two following conditions has been established :1. There is total cessation of cardiac and respiratory functions , and doctors have ruled that such cessation is irreversible2. There is total cessation of all cerebral functions and experienced There is total cessation of all cerebral functions and experienced

specialised doctors have ruled that such cessation is irreversible specialised doctors have ruled that such cessation is irreversible and the brain has started to disintegrateand the brain has started to disintegrate

In this case , it is permissible to take the person off resuscitationIn this case , it is permissible to take the person off resuscitationapparatus , even if the functions of some organs e.g heart, are stillapparatus , even if the functions of some organs e.g heart, are still

artificially maintainedartificially maintained

Persidangan AntarabangsaPersidangan Antarabangsa Amman Oct 1986 ( 1407)Amman Oct 1986 ( 1407)

Seseorang itu di sahkan mati dan segala urusan berkaitandengan kehendak Islam perlu di laksanakan apabila salah satudari dua perkara berikut berlaku:1. Apabila jantung dan pernafasan berhenti, dan di sahkan

oleh doktor bahawa ianya tidak dapat di pulihan2. Apabila semua fungsi otak telah berhenti dan doktor

yang mahir mengesahkan bahawa ianya tidak dapat di pulihkan dan otak telah mula hancur

Dalam keadaan tersebut, boleh lah di cabut mesin pernafasanwalaupun fungsi organ lain misalnya jantung masih berjalan

• 4. Singapore Islamic Religious Council, 1994.• 5. Indonesian Islamic Groups and Federation of

Islamic Medical Association.

6. Malaysia- the National Fatwa Council

endorsement by Med. Fac UM and MOH ,

1992

BUT no formal statement .

CONCLUSION

• Brain death is a clinical diagnosis.

• Brain death is certified only on patients in ICU, on ventilators.

• Causes of brain death :

- Primary / Secondary brain injury

• Brain death IS DEATH.Brain death IS DEATH.

• Brain death = Organ Transplant.