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130110P - BRAIN DEATH: CRITERIA, SIGNS, AND TESTS (Word Slides)

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Presented at the Faculty of Medicine Bayero University, Kano, Nigeria on 10th January 2013 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Department of Bioethics King Fahad Medical City Riyadh EM: omarkasule@yahoo.com. WEB: www.omarkasule-tib.blogspot.com


CASE #1:
·         A 60-year old comatose accident victim suffering from severe multi-organ traumatic injury and with a signed organ donation card was evaluated in the ERof a remote rural hospital. There was no other plausible cause of reversible coma or of brain death.
·         Clinically: no pupillary reflexes, fixedly-dilated pupils, no corneal reflex, no eye movements, no blink reflex, no vestibule-ocular reflex, no cranial reflexes, and no gag reflex. Findings were equivocal regarding the apnea test, cephalic reflexes, and motor response to pain.
·         Investigations: jugular vein partial oxygen pressure could not be determined. The EEG was isoelectric. Bedside trans-cranial Doppler showed no cerebral circulation.
·         Family members with the exception of the mother were certain of death and asked the physician not to institute any life support and to call the organ harvesting team. The doctor was not sure what to do he however convinced the family to start life support to keep the organs viable until the transplant team arrived by helicopter.
·         While walking along the corridor, a nurse overheard members of the family talking about a 15-year old cousin of the victim lying in a hospital in the capital waiting for a kidney transplant.

CASE #2:
·         A 40-year old billionaire stage 4 cancer victim with multi organ failure in ICU and on artificial life support
·         Determined clinically dead on the basis of clinical signs repeated after 6 hours (pupillary reflexes –ve, fixedly-dilated pupils, corneal reflex –ve, eye movements –ve, blink reflex –ve, cold water test –ve, cranial reflexes –ve, apnea test –ve, cephalic reflexes –ve, motor response to pain –ve, gag reflex –ve).
·         All confirmatory tests were also negative (jugular oxygen partial pressure -ve, EEG=0, CT angiography).
·         Family members begged the physicians not to withdraw life support and not declare death until his beloved last daughter arrives from London. She might die from shock if she does not see him alive before death. They were willing to pay for the extra days of ICU stay.

CASE #3
·         A 90-year old deeply comatose man with multiple organ failure was admitted to the last available ICU bed and was put on artificial life supportminutes when the family refused a DNR order.
·         A few minutes later ambulances started bringing in over 100 casualties from an air crash site. The head of the ICU carried out a rapid assessment of the comatose man showed equivocal clinical signs of brain death;some indicating death and others not. None of the confirmatory tests was positive.



NATURE OF DEATH
·         Death is a process and not an event
·         Death is failure of the heart and lungs to deliver oxygen and nutrients to cells
·         The brain is the most sensitive organ to oxygen and nutrient deprivation and is therefore the first to die
·         Death of the brain leads to death of the vital centers that control the respiratory and the cardiovascular systems
·         Brain is Command-communication-coordination (CCC) center; its death signals loss of body integrity and coordination
·         Cyclic chicken-and-egg situation with few exceptions

INDICATORS OF DEATH
·         Historically3 indicators of death: neurological, respiratory, and cardiac
·         Neurological failure (consciousness and coma) always came first.
·         Recognition of brain death as an early indicator is not new
·         New indicators are able to detect the point of irreversible vital organ failure earlier
·         As new knowledge and technology are developed death can be detected earlier
·         Clinical tests relate more to brain stem death
·         Confirmatory tests relate more to whole brain death
·         Is the dichotomy brain stem death vs whole brain death relevant?

ETHICS AND LAW
·         Ethics is about morality right vs wrong
·         Law is about legality legal (can be done) vs illegal (punishable)
·         In Islamic Law morality = legality because shari’at is positive law + morality
·         In secular law some moral things may be illegal and some immoral things may be legal
·         Strictly speaking we should not have a term for ethics because it is included in the shari’at

3.0 MOTIVATION OF BRAIN DEATH CRITERIA
·         al umuur bi maqasidiha
·         al ‘ibrat fi al maqasidwa al ma’aani la al alfaadhwa al mabaani
·         Three motivations for brain death criteria:
o   harvest transplantation organs earlier
o   save intensive care resources by earlier cessation of life support
o   obtaining tissues for research before deterioration.

USE OF CRITERIA IN DETERMINING BRAIN DEATH
·         1968: Harvard criteria: apneic coma with no evidence of brain stem or spinal reflexes and a flat electroencephalogram over a period of 24 hours.
·         No consensus on brain death criteria: variation by country and by institution
·         Brain death criteria change with time with new knowledge and new technology
·         Criteria development coincided with rise of organ transplantation? Causal link


CRITERIA OF BRAIN DEATH: CLINICAL TESTS
·         Eliminate causes of reversible coma
·         Identify a plausible cause of brain death
·         Tests related to the eyes and ears
·         Tests related to motor response
·         Tests related to the cough or gag reflex
·         The apnea test
·         Repeat of the examination within 24 hours

CERTAINTY OF DEATH: CONFIRMATORY TESTS
·         No consensus on confirmatory instrumental tests
·         Tests done to confirm clinical diagnosis
·         Chemical tests of blood oxygenation
·         Tests related to brain electric activity
·         Tests related to brain blood flow

APPROACHES TO AN ETHICAL ISSUE
·         1st epoch: until ~1420H: direct reference to Qur’an and sunnah
·         2nd epoch: 1420-14xx: use of qiyaas
·         3rd era: Use of maqasid and qawa’id al shari’at in ijtihad
·         Maqasid are not new pioneered by Shaikh al Haramain, Abu Hamid al Ghazzali, IbnTaymiyah, and Ibn al Qayyim al Jawziyat, Abu Ishaq al Shatibi al Maliki al Andalusi
·         Derived from the sources by induction they provide an intellectual frame work to reason out difficult situations
·         Qawaid are axioms of the Law that facilitate logical ethical reasoning

THE 5 PURPOSES OF THE LAW, maqasid al shari’at
·         Protection of morality, hifdh al ddiin
·         Protection of life, hifdh al nafs
·         Protection of the progeny/family, hifdh al nasl
·         Protection of the mind, hifdh al ‘aql
·         Protection of resourcesmhifdh al maal

THE 5 PRINCIPLES OF THE LAW, qawaid al shari’at
·         The principle of intention, qa’idat al qasd
·         The principle of certainty, qa’idat al yaqeen
·         The principle of injury, qa’idat al dharar
·         The principle of hardship, qa’idat al mashaqqat
·         The principle of custom, qa’idat al ‘aadat

INTRODUCTION
·         Ethical issues relating to brain death are analyzable according to the purposes of the Law, maqasid al shari’at, and principles of the law, qawa’id al fiqh, to reach conclusions of practical importance.
·         3 Motivation to declare death earlier:
o   harvest viable organs earlier
o   save intensive care resources
o   obtaining tissues for research before deterioration.

PRINCIPLE OF INTENTION, qa’idat al qasd
·         Violation of the principle of intention, qa’idat al qasd, which requires that actions be judged by underlying intentions and that the end does not justify the means.
·         Are these ends noble enough to justify early death declaration by brain death?
o   Save the life of the organ recipient?
o   Save resources wasted by futile medical intervention?
o   Medical research to advance knowledge?

PRINCIPLE OF CERTAINTY, qa’idat al yaqeen
·         The requirement, by the principle of certainty, qa’idat al yaqeen, of evidence-based proof of death are partially fulfilled by brain death criteria, tests, and examinations.
·         There is almost unanimous consensus on clinical tests in determining brain stem death but no such consensus exists for confirmatory instrumental tests.
·         An individual practitioner in charge of the patient may not be convinced by the signs and tests

PRINCIPLE OF CUSTOM, qa’idat al ‘aadat
·         innamayu’utabar al ‘aadatidhaatradat aw ghalabat
·         al ‘ibrat li al ghaalib al shai’u la al naadir
·         Consensus on clinical signs as indicators of brain stem death
·         The principle of custom, qa’idat al ‘aadat, is partially fulfilled because there is no universal consensus on criteria of brain deat
·         Brain death criteria vary by country, by institution, and over time.

OUTSTANDING QUESTIONS…1
·         Do we do brain death testing routinely or are we selective?
·         Is repetition of the testing needed after 6, or 24 hours?
·         How soon shall we act after brain stem death is confirmed clinically?
·         Relevance of cerebral death vs brain stem death difference?

OUTSTANDING QUESTIONS…2
·         Feasible?(a) other causes of reversible coma (b) plausible cause of brain death
·         Protection of life, maqsadhifdh al nafs, vs and mistakes in death determination
·         protecting resources, maqsadhifdh al mal, vs delayed death determination
·         Pressure for organ donation: specific individual vs. general public
·         Near death vs dead

CONCLUSIONS
·         The criteria and determination of brain death do not fully conform to principles of intention, certainty, and custom.
·         Considerations of organ harvesting, ICU costs, and research have been a driving force behind development of brain death criteria.
·         These criteria have been changing with development of knowledge and technology and have not reached the level of universal consensus having variation by country and by institution.
·         There is consensus about the reliability of clinical tests of brain stem death

RECOMMENDATIONS
·         Brain stem death, determined by clinical examination with or without instrumental confirmation, should remain the mainstay of death definition
·         The public interest in organ harvesting and saving ICU resources overrides the doubts that we may have about clinical criteria of brain death
·         Legal rulings, fatwa, on brain death should be reviewed every 3 years to take into consideration new developments in medical knowledge and technology.