Not All Hospitals Comply With Brain Death Criteria
Of the total, about a third of policies (33.1%) required specialist expertise in neurology or neurosurgery, but 150 policies had no mention of who could perform the determination. Many policies still allow for more junior physicians to determine brain death, the authors noted.
Unfortunately most hospitals (97.4%) required apnea testing which is the WORST thing to do for a severely injured trauma brain injured patient.
Uniform Determination of Death Act (UDDA)
The Uniform Determination of Death Act (UDDA), drafted in 1980 by the National Conference of Commissioners on Uniform State Laws to provide “comprehensive bases for determining death in all situations,” determined death by the following criteria:
So the UDDA allowed the determination of death to be made in accordance with accepted medical standards, but left it up to each hospital to determine those standards.
I know you’ve heard me talk about if you were injured in Iowa your treatment may be different than IF you were injured in Michigan. If you were taken to the U of M Hospital your care may be different from if you are taken to Beaumont Hospital in the suburbs of Detroit. My point is that it appears and I could certainly be wrong in my intepretation is that the authors are now advocating for more uniform, written standards and protocols in hospitals.
Comments on the article
Here are some of the comments on the original article that I found revealing. (Highlights mine, links mine, no attempt to correct the spelling in their comments)
As an RN who was involved with brain death organ donation in the 1970s, even then I had questions about the diagnosis such as the claim that such patients would die anyway after 2 weeks even with a ventilator but I was assured that greater minds than mine had it all figured out.
I really became alarmed when I saw that pregnant women diagnosed as brain dead were sometimes able to gestate their babies for months and these babies could survive and be healthy. Obviously, the 2 week claim was wrong but I still see it used today.
Later, I served on an ethics committee where one doctor canvassed the brain death criteria in our area, found that the criteria varied wildly but yet suggested that our hospital change its criteria to match the least restrictive one he found so that we could harvest more organs. I protested but was told that I didn’t understand how much these organs meant to the recipients.
I have also even seen a doctor tell a family that their loved one was brain dead even when the could take some breaths without a ventilator and despite apnea being the crucial criteria for brain death. In that case, the goal was not organ harvesting but rather to persuade the family to take the ventilator off a patient with a poor prognosis and give high doses of morphine as “comfort care”.
I am also appalled that this article repeats the claim that “there have been no documented reports of regaining function after a declaration of brain death” despite the recent Zach Dunlap and the current Jahi Mahi cases. These cases and other such cases should be written up for medical journals, not ignored.
Thus, I am not surprised by the problems this article presents. I hope it will lead to unbiased further research even if it results in a reexamination of brain death and even if it means fewer organs for people like my daughter-in-law who needs a kidney transplant. In the meantime, we are hoping for a living donor.
Unfortunately, federal regulations and financial incentives tend to encourage hospitals to pursue a rushed process of diagnosing brain death and procuring organs, with no incentives to make accurate diagnoses. Thus, Dr. Geer’s effort to “light a fire” is likely to make little headway with disinterested hospitals. A better approach to organ procurement would be to financially reimburse potential living donors for kidney transplants than to appeal to a professionalism that runs counter to federally constructed financial incentives for procuring cadaveric organs.
Why am I not surprised?
This past summer, my nephew suffered a TBI in a motor vehicle accident. I received the phone call saying that he was “brain dead,” and his organs were going to be donated, but my sister had requested that he be kept on the ventilator until all family could come to say goodbye. Through a series of unexpected events, my 8 hour trip turned into a 24 hour trip, and I was the last to arrive at the hospital. When I arrived, I was told that a possible pupillary response had just been observed by a nurse. A few hours later, he was re-assessed by the neurologist and a definite pupillary response was present. When I asked the neurologist about the type and location of the injury, I was told “It doesn’t matter – this is not a survivable injury. The brain is dead.” The trauma specialist told us that it was a diffuse axonal injury to “most of” the left hemisphere, with additional damage from multiple strokes in the right cerebellum. After five days with a Glasgow score of 3, he opened his eyes and looked around. His GCS increased to 5, then 6. He began breathing on his own. After weeks in CCU, additional weeks in a neuro step down unit, and more weeks of inpatient TBI therapy, he was able to go home. It has now been 6 months since his injury. He is walking, talking, laughing, reading, texting. His long term memory, personality, and sense of humor are intact. He’s still working on his short term memory, cognition and vision, with remarkable improvement and strong motivation. He’s waiting impatiently for snow so he can start cross country skiing. He will be re-starting college in a few weeks.
Was it a mistake? Was it a miracle? A little of each? I have no idea. The trauma specialist said it is proof that God exists. I just know that I am profoundly grateful. And I believe there need to be uniformly followed guidelines for declaring brain death, including multiple assessments with a waiting period between assessments.
Dr. Arthur Drazan
What happened to the proven nuclear medicine brain scan?
Dr. William Goldie
I am concerned that there is no comment about standards for use of EEG as ancillary test for determining brain death. Many well trained specialists who consider themselves experts in brain death will order EEG with no understanding of the necessary standards for using EEG in this setting. Few hospitals have EEG technicians who are qualified to perform ECS EEG, and few have neurologists available who are qualified to interpret ECS EEGs. I would hope that brain death policies include the use of quality EEG to assist with the clinical diagnosis of brain death.
Does Dr. Goldie not know that EEG have not been used since the Minnesota Criteria?
When Harvard first published their criteria in 1968, EEG’s were a part of the evaluation, then in 1971 the Minnesota criteria along and they decided patients didn’t need EEG’s because too many families got upset when they saw brain waves. Then the “Pittsburgh protocol” came along and they began to take organs not from “just” the “brain-dead” patient but from patients after cardiac death. Now in Denver they are waiting 75 sec for a babies heart to stop and then proceeding with organ harvesting.
I believe life and death are NOT human decisions but one that only God can make. He gives life and He takes life away.