Archives For organ donation

No Consensus on Brain Death

brain deathA forthcoming article in the journal Neurology provides insight into the complexities of achieving international consensus on brain death.

The article by a team of neurologists and medical researchers from clinics and universities around the US catalogues conceptions of brain death in medical institutions around the world.

The authors found that institutional protocols were absent or poorly understood in a significant number of low-income countries. They also found that “substantial differences in perceptions and practices of brain death exist worldwide” and that “whether a harmonized, uniform standard for brain death worldwide can be achieved remains questionable.”

The study – the first to examine opinions in a broad range of countries – involved an electronic survey which was distributed globally to physicians with expertise in neurocritical care, neurology, or related disciplines who would encounter patients at risk of brain death. Physicians from 91 countries responded.

The results were quite revealing

Doctors around the world leave different periods of time following initial neurologic deterioration before they declare brain death. The most common waiting period is between 6 and 10 hours, but reported results ranged from less than 5 hours to more than 25 hours.

“There were several discrepancies regarding the conduct of apnea testing”, the authors report. Views about the import of ancillary testing (EEGs, Dopler ultrasounds etc.) differed significantly between countries.

In their discussion of the results of the study, the authors flagged a need for greater collaboration between medical institutions from different countries:

“To promulgate a unified stance on brain death, valuable for practitioners everywhere, consensus among leading experts in the field is urgently required…[our] findings underscore the importance of international partnerships between institutions to improve medical education and alleviate critical human resource needs in lower-income settings.”

In a comment on the article, Dr. James Bernat observed that there is significant disagreement on brain death even within the US.

“[There is] a surprising degree of practice variation among hospitals in the United States. In contrast to the international circumstance, in which practice disparities arise more because of legal, cultural, or religious differences, those in the United States result more from the biases and ingrained practices of individual physicians.”

 

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My comment 

“Of course, there is no consensus, because “brain death” is NOT true death. I bet they would have no issue determining when someone is truly dead…irreversible cessation of circulatory and respiratory functions. That definition worked fine for us for thousands of years.”

That definition worked fine for us for thousands of years.

The Study

Objective: To assess the practices and perceptions of brain death determination worldwide and analyze the extent and nature of variations among countries.

Methods: An electronic survey was distributed globally to physicians with expertise in neurocritical care, neurology, or related disciplines who would encounter patients at risk of brain death.

Results: Most countries (n = 91, response rate 76%) reported a legal provision (n = 63, 70%) and an institutional protocol (n = 70, 77%) for brain death. Institutional protocols were less common in lower-income countries (2/9 of low [22%], 9/18 lower-middle [50%], 22/26 upper-middle [85%], and 37/38 high-income countries [97%], p < 0.001). Countries with an organized transplant network were more likely to have a brain death provision compared with countries without one (53/64 [83%] vs 6/25 [24%], p < 0.001).

Among institutions with a formalized brain death protocol, marked variability occurred in requisite examination findings (n = 37, 53% of respondents deviated from the American Academy of Neurology criteria), apnea testing, necessity and type of ancillary testing (most commonly required test: EEG [n = 37, 53%]), time to declaration, number and qualifications of physicians present, and criteria in children (distinct pediatric criteria: n = 38, 56%).

Conclusions: Substantial differences in perceptions and practices of brain death exist worldwide. The identification of discrepancies, improvement of gaps in medical education, and formalization of protocols in lower-income countries provide first pragmatic steps to reconciling these variations. Whether a harmonized, uniform standard for brain death worldwide can be achieved remains questionable.

  • Received September 29, 2014.
  • Accepted in final form January 7, 2015.

What if that was your family member and 53% of doctors deviated from the AANC criteria?

Opps

Let’s get rid of the legal fiction of brain death.

Last Thursday night on Grey’s Anatomy, Patrick Dempsey’s character, Derek Shepherd,  was pronounced brain dead. Now Greys Anatomy for all 10 seasons has been pro-organ donation any chance they got. What was interesting is his wife, Meredith Grey had to make the decision to take him off life support. Her comments were interesting in light of the last 10 years.

Paraphrased:  “Ok so now is the time you tell me you waited the number of requisite hours and now you can tell me, he is dead. So you need a bed, and you want me to sign the papers. Now that he is dead, but not really dead. Now I have to decide whether to put him in a long care facility or pull the plug and KILL him.

Did you hear that?  Dead but not really dead, pull the plug and kill him? 

Start at 1:11 to watch the exchange.

Killing for Organs Push in The Atlantic.

Wesley SmithThis is an article by Wesley Smith, author of the book, Culture of Death,The Assault of Medical Ethics in America,  in response to the Atlantic article which is advocating killing the profoundly disabled or imminently dying for their organs.  

I’ve been saying this for the last three years here on this blog and everywhere I can that this is where we are headed.

Excerpts from Wesley’s post: 

I have repeatedly warned about articles published in medical and bioethics journals advocating killing the profoundly disabled or dying for their organs. The assault on the “dead donor rule” has now filtered down to the popular media.

The Atlantic has an article advocating that dying patients be killed for their organs rather than having to actually, you know, die first. From, “As They Lay Dying:”

Transplant-surgery programs in the United States are scrutinized by an alphabet soup of federal and nongovernmental entities. Centers with worse-than-expected transplant outcomes can be placed on probation or shut down.

Centers with worse-than-expected transplant outcomes can be placed on probation or shut down.

From the earliest days of transplantation, surgeons subscribed to an informal ethical norm known as the “dead-donor rule,” holding that organ procurement should NOT cause a donor’s death.

In practice, this meant waiting until patients were by all measures completely dead—no heartbeat, no blood pressure, no respiration—to remove any vital organs. (Sometimes 2 minutes, comment by me) 

 

A more useful ethical standard could involve the idea of “imminent death.” Once a person with a terminal disease reaches a point when only extraordinary measures will delay death; when use (or continued use) of these measures is incompatible with what he considers a reasonable quality of life; and when he therefore decides to stop aggressive care, knowing that this will, in relatively short order, mean the end of his life, we might say that death is “imminent.”

If medical guidelines could be revised to let people facing imminent death donate vital organs under general anesthesia, we could provide patients and families a middle ground—a way of avoiding futile medical care, while also honoring life by preventing the deaths of other critically ill people. Moreover, healthy people could incorporate this imminent-death standard into advance directives for their end-of-life care. They could determine the conditions under which they would want care withdrawn, and whether they were willing to have it withdrawn in an operating room, under anesthesia, with subsequent removal of their organs. There’s a name for that: Homicide. Doctors should never be killers, even for a “beneficial” purpose. 

If medical guidelines could be revised to let people facing imminent death donate vital organs under general anesthesia, we could provide patients and families a middle ground—a way of avoiding futile medical care, while also honoring life by preventing the deaths of other critically ill people.

Moreover, healthy people could incorporate this imminent-death standard into advance directives for their end-of-life care. They could determine the conditions under which they would want care withdrawn, and whether they were willing to have it withdrawn in an operating room, under anesthesia, with subsequent removal of their organs.

There’s a name for that: Homicide. Doctors should never be killers, even for a “beneficial” purpose. 

As my friend, Carolyn said on her Facebook page, and I agree. 

“Oh, this really makes me sick! Wake up everyone, the government is about to pass another law to enable the greedy the ability to dissect a living person for their organs. How many of you really want to die being dissected alive to satisfy the greed of a medical community and government gone mad? You think this could not happen to you, but it could.

The reason why so many fall in this cesspool of being a potential organ donor is because they are denied treatment.

Once this happens the doctor legally can demand the patient be denied anymore treatments. You can beg, I begged, You can cry, if you scream and act out, you will be arrested. Your loved is in harm’s way in a hospital in the World. You are at the mercy of a trained denial of medicine. Now they want to legally deny care to the almost, which is really what they have been doing all along.”

Read Caroly’s story about her daughter Melissa here.

I wrote on this and the dead-donor rule back in October, 2013 and the voices continue to get louder. 

The “Dead Donor Rule”

The “dead-donor rule” refers to two accepted ‘ethical norms’ that govern the practice of organ harvesting before transplantation:

1) vital organs should be taken only from dead patients,

2) living patients should not be killed for or by organ procurement.

There is a movement now by several well-known transplant surgeons to get rid of the “dead donor rule,” and call it what it is a legal fiction. Tell people the truth about what is happening…that you are not dead…yes, critically injured…but you are NOT dead.

Transplant surgeons believe that with such consent, there is no harm or wrong done in retrieving vital organs before death, provided that anesthesia is administered. But, many doctor’s and OPO’s (Organ Procurement Organizations) are not so sure and are fearful that more people will NOT consent if the truth is exposed. 

Beware of these words from doctors, “devastating neurological injury, no hope, and now “imminent death.”


Read more of Wesley’s post here. 

Head Transplants

Brain injured

Perhaps you saw this on the news. I think I caught a glimpse of it somewhere but when it came up on my Twitter feed from Journal of Medical Ethics, I went and did a little digging. 

Fortunately New Scientist Magazine had carried an article on it. Sergio Canavero, Surgeon at the Turin Advanced Neuromodulation Group in Italy, first proposed the idea in 2013 and he now says it is completely possible by 2017. 

Canavero plans to announce the project at the annual conference of the American Academy of Neurological and Orthopaedic Surgeons (AANOS) in Annapolis, Maryland, in June 2015. 

I don’t even know what to say to this latest “Scientific research???  

Furthermore, Dr. Canavero is calling his new surgical strategy the HEAVEN procedure, which preserves brain function through hypothermia during the transplantation procedure, which is performed at cervical level C5/6. 

Basically doing a head transplant requires cooling the recipient’s head and the donor body to extend the time their cells can survive without oxygen. The tissue around the neck is dissected and the major blood vessels are linked using tiny tubes, before the spinal cords of each person are cut. 

Details will be presented at the conference in June however you IF you ARE interested in this you can read some of the details here.

Ethics

Transplanting living human heads onto new bodies raises extraordinary ethical questions. But so did a non-beating heart donor a few years ago. Canavero intends to use brain-dead organ donors to test the fusing of the spinal cord with Polyethylene glycol. 

Polyethylene glycol (PEG) is a polyether compound with many applications from industrial manufacturing to medicine.

Dr. Scripkoa neurologist and bioethicist with an interest in headache, traumatic brain injuries and concussions at Salinas Valley Hospital in California said that “many of the ethical implications related to the surgery depend on how you define human life. “I believe that what is specifically human is held within the higher cortex. If you modify that, then you are not the same human and you should question whether it is ethical. In this case, you’re not altering the cortex.” However, she adds that many cultures would not approve of the surgery because of their belief in a human soul that is not confined to the brain.”

So it all boils down to yes maybe it CAN be done, But SHOULD it be done? 

  • When does human life begin? 
  • Who should determine’s when someone is dead? 

You know my belief, life begins at conception and ends when true death occurs? It is not our choice but God’s. He is the author and finisher of life. The beginning and the end. True death occurs WHEN the soul leaves the body. 

Your eyes saw my unformed body; ALL the days ordained for me were written in your book before one of them came to be. Psalm 139:16

Vital organs need to be fresh and undamaged for transplantation. Vital organs (from the Latin vita, meaning life) include the heart, liver, lungs, kidneys and pancreas. In order to be suitable for transplant, they need to be removed from the donor before respiration and circulation cease.

We know that brain death is not true death. We know that without blood and oxygen the brain it starts to die within a few minutes. So I think we can conclude that in a head transplant the brain would need to alive with blood and oxygen flowing into both the donor and the recipient. As Dr. Canavero said doing a head transplant would require cooling the bodies of both donor and recipient to slow down cell death. 

My question is WHY is this cooling NOT being done in hospitals to prohibit the brain swelling after a traumatic brain injury? 

I posted on guidelines for treating trauma here and asked why hospitals aren’t doing it as a standard protocol? 

As I quoted from the Nova interview between Dr. Jamshid Ghajar: 

It’s a lot easier just to put the patient on the ventilator and then turn up the rate and then give them some drugs and come back next week and see how they’re doing. They’re lying there in a coma. They’re not screaming out for help. They’re not saying, “I’m in pain.” And so it would be quite easy to say, “Well, they have half a foot in the grave, why do anything else?” 

“That’s the real issue. I think if these patients were awake and saying, “Listen do something for me,” we’d be doing a lot more for them. But because they’re in a coma and they cannot speak for themselves, we’re treating them the way they are now.”

I find in unconscionable that we are on the verge of head transplants as a scientific reality and doctors can’t immediately use hypothermia to cool down the body and the brain of an injured person upon first entering the hospital. 

Dr. Jamshid Ghajar continued, “here are a lot of young people, children, especially, who are dying unnecessarily. These kids could live and have a very good quality of life, and they’re dying.

Flickr Photo Credit 

Organ Donor Found Not Quite Dead

SurgeryThe phrase “not completely brain dead”, like “not completely pregnant”, has a Monty Python-esque ring to it. But it is the way the Daily Mail described an alarming organ transplant incident in the German city of Bremen.

Doctors in a hospital in Bremen had already made an incision in the abdomen of a man who was presumed to be dead when they discovered that the deceased donor was still alive according to organ transplant protocols.

The operation was immediately terminated – and the brain-damaged patient died. The incident is being investigated by the German Medical Association.

The Süddeutsche Zeitung (the source for the Daily Mail) was told that “it is quite possible that the man’s brain was so damaged that he would not have been able to return to a normal life, but as long as he was not properly diagnosed as brain dead, nobody knows.”

The article above is published by and BioEdge.org under a Creative Commons licence.

Here are excerpts from the original article in the Süddeutsche Zeitung German Paper  If you go read it there, just translate it to English at the top of your browser.

My takeaway’s from the German article which unfortunately happen’s here in the US but goes unreported.

Critics warn some time: The brain death diagnosis is uncertain

The case proves once again what critics have long admitted: The diagnosis of brain death is not secure enough in Germany. Doctors are not sufficiently trained in how they determine the loss of brain function in a patient correctly. So it always comes back to errors.

Especially terrible was the idea that a patient whose brain still shows residual activity may suffer the pain of surgery and organ removal as opposed to a brain dead.

Did he know he was going to have his organs harvested but couldn’t show anything to stop the doctors? Did he feel pain when the doctors sliced into his abdomen? You do know by now from reading my blog that anesthesia is NOT used

Perhaps the man in Germany felt the way Christina Nichole Thornsberry, did when she was paralyzed in a hospital in Spokane,WA where she stated on her blog, 

“Don’t cut me open — don’t hurt me! Let me wake up!.” While doctors hovered over her bed… discussing organ donation, Christina Nichole could hear every word they said – and their conversation terrified her.

Doctors who want to change the conversation about brain death.

Dr. Robert Truog, Harvard Medical School and Boston Children’s Hospital  and Dr. Frank Miller, National Institute of Health

We seek to change the conversation about brain death by highlighting the distinction between brain death as a biological concept versus brain death as a legal status. The fact that brain death does not cohere with any biologically plausible definition of death has been known for decades. Nevertheless, this fact has not threatened the acceptance of brain death as a legal status that permits individuals to be treated as if they are dead. The similarities between “legally dead” and “legally blind” demonstrate how we may legitimately choose bright-line legal definitions that do not cohere with biological reality. Not only does this distinction bring conceptual coherence to the conversation about brain death, but it has practical implications as well. Once brain death is recognized as a social construction not grounded in biological reality, we create the possibility of changing the social construction in ways that may better serve both organ donors and recipients alike.

American Journal of Bioethics, 14(8):9-14,2014

Both doctors have written extensively about brain death and ethics in organ donation. I have quoted them many times here as they became famous for their term brain death as a legal fiction and brain death is as good as dead. 

“Although it is clear that brain death is not the same as death, moreover, brain death does correspond to the loss of an ability to interact with others and the world in meaningful ways. With consent for withdrawing therapy and a separate consent for organ donation, it is reasonable for brain-dead patients to serve as organ donors, and it may even serve to leave behind a valuable legacy of having saved the lives of others.

It makes sense ethically to employ a status legal fiction to ensure that brain-dead donors can be treated as dead for the purposes of vital organ donation and withdrawal of therapy.”I radically disagree with them on their theory of being able to withdraw life support to donate organs.”

Although they have argued for exposing this legal fiction they have also said brain death and true death should be treated the same for harvesting organs.

Human BrainI applaud them in understanding that brain death is NOT true death and wanting to expose the legal, medical fiction of brain death. 

Dr.Alan Shewmon, UCLA, and former advocate for brain death who has changed his mind, compiled 150 documented cases of brain-dead patients whose hearts continued to beat, and whose bodies did not disintegrate, past one week’s time.

In one remarkable case, the patient survived 20 years after brain death before succumbing to cardiac arrest. Dr. Shewmon has successfully documented and published on somatic integration of the human body and all its functions. 

LIFE processes after pronouncing brain death

  • Cellular wastes continue to be eliminated, detoxified, and recycled.
  • Body temperature is maintained, though at a lower than normal temperature and with the help of blankets.
  • Wounds heal.
  • Infections are fought by the body.
  • Infections produce fever.
  • Organs and tissues continue to function.
  • Brain-dead pregnant women can deliver a baby.
  • Brain-dead children mature sexually and grow proportionately.

Full text of Truog and Miller recent paper

Flickr photo credit