Department of Forensic Medicine, University of Dundee Lecture Notes

Brain Stem Death and Organ Transplantation

The meaning of death Diagnosis of brain stem death Organ transplantation

The meaning of death For centuries there has been a dread of being declared dead while still alive. However, it is only since 19 9 that there have been conceptual and practical problems with the diagnosis of death following the description of !brain death!. The ability to ventilate brain dead bodies in intensive therapy units preceded the developments of transplant surgery. The concept of brain death is not simply a convenience invented to satisfy the demands of transplant surgeons. There is no legal definition of death. The diagnosis of death is traditionally made using the Triad of "ichat which states that death is !the failure of the body as an integrated system associated with the irreversible loss of circulation, respiration and innervation!. This is also #nown as somatic death or clinical death. Death is now accepted as meaning brain stem death or brain death. The brain stem is a small area of the brain which controls respiration. $f this area is dead the person will never be able to breathe spontaneously or regain consciousness. %olecular death may be defined as !the death of individual organs and tissues of the body consequent upon the cessation of circulation!. Different tissues die at different rates depending on their o&ygen re'uirements. Thus, within four minutes of the blood supply to the brain ceasing, the central nervous system is irreversibly damaged. (ome authorities recognise a third concept of apparent death. This is also #nown as a suspended animation. $t may occur under certain specialised conditions for e&ample drowning or hypothermia. (evere brain damage which does not involve the brain stem may result in a persistent vegetative state. These patients breathe spontaneously, open and close their eyes, swallow and ma#e facial grimaces. However, they show no behavioural evidence of awareness. $t is in these cases that the moral dilemma of !allowing some)one to die! arises. The above dilemma does not apply to those who are brain stem dead. These patients are dead irrefutably and une'uivocally. (witching off a ventilator under these circumstances would not #ill the patient but would discontinue ventilating a corpse. $n 19*+ the ,onference of the %edical -oyal ,olleges and Faculties of the .nited /ingdom issued guide lines on the sub0ect of brain stem death. These guide lines are regularly updated and used by doctors in intensive care units throughout the ../. in the diagnosis of brain stem death.

"ac# to top Diagnosis of rain stem death !"clusions a. where the patient may be under the effects of drugs e.g theraputic drugs or overdoses. b. where the core temperature of the body is below 1 2, e.g. e&posure. c. where the patient is suffering from severe metabolic or endocrine disturbances which may lead to severe but reversible coma e.g. diabetes. #reconditions of diagnosis 1. The patient must be deeply comatose. 3. The patient must be maintained on a ventilator. 1. The cause of the coma must be #nown. #ersonnel a. The brain stem death tests must be performed by two medical practitioners. b. The doctors involved should be e&perts in this field. .nder no circumstances are brain stem death tests performed by transplant surgeons. c. 4t least one of the doctors should be of consultant status. 5unior doctors are not permitted to perform these tests. d. 6ach doctor should perform the tests twice. Tests "efore the tests are performed the core temperature of the body is ta#en to ensure that it is above 1 2,. The diagnosis of brain stem death is established by testing the function of the cranial nerves which pass through the brain stem. $f there is no response to these tests the brain stem is considered to be irreversibly dead. 1. The pupils are fi&ed in diameter and do not respond to changes in the intensity of light. 3. There is no corneal refle&. 1. The vestibulo)ocular refle&es are absent, i.e. no eye movement occurs after the installation of cold water into the outer ears. 7. 8o motor responses within the cranial nerve distribution can be elicited by painful or other sensory stimuli, i.e. the patient does not grimace in response to a painful stimulus applied to the face or to the limbs. . There is no gag refle& to bronchial stimulation by a suction catheter passed down the trachea.

+. 8o respiratory movements occur when the patient is disconnected from the ventilator for long enough to ensure that the carbon dio&ide concentration in the blood rises above the threshold for stimulating respiration i.e. after giving the patient 199: o&ygen for minutes the ventilator is disconnected for up to 19 minutes. $f no spontaneous breathing of any sort occurs within that 19 minutes the brain stem is incapable of reacting to the presence of the carbon dio&ide and is thus dead. Once two doctors have performed these tests twice with negative results the patient is pronounced dead and a death certificate can be issued. $t is at this stage that a decision concerning the use of organs for transplantation purposes may be raised and the decision made as to the whether the corpse should be maintained on the ventilator until the organs may be harvested. 4dvances in medicine have enabled the use of several organs for transplant purposes. $t is now possible to harvest from a cadaver the eyes, #idneys, liver, pancreas, small intestine, lungs and heart. From the living donor it is possible to transplant one #idney. The cornea of the eye may still be suitable for transplant up to 37 hours after death. Other organs such as the heart, are very sensitive to low o&ygen levels and deteriorate very 'uic#ly following the cessation of circulation. $t is this which has led to the controversy regarding the ventilation of corpses prior to harvesting of organs. O$%&N T$&NS#L&NT&T'ON Transplantation of human organs is now covered by The Human Tissue 4ct 3997. This 4ct replaces The Human Tissue 4ct 19+1, The 4natomy 4ct 19;7 and The Human Organ Transplants 4ct 19;9. The (uman Tissue &ct )**+ < http=>>www.legislation.gov.u#>acts>acts3997>39979919.htm? 4pplies to 6ngland @ Aales. Brovisions relating to retention of material for D84 testing also apply to (cotland . Formulated in response to public concern regarding organ retention scandals <"ristol -oyal $nfirmary @ 4lder Hay, Civerpool ? (ummary= -egulates removal, storage @ use of human tissue ,reates new offence of DD84 theftE %a#es it lawful to preserve organs of deceased for transplantation 4uthorises museums to move human remains (uman Tissue ,Scotland- &ct )**. <http=>>www.legislation.gov.u#>legislation>scotland>acts399+>399+9997.htm? #art / 0 Transplantation etc1 (ets out the (cottish %inistersF duties as respects transplantation, ma#es provision for the authorisation of the use of parts of the body of a deceased person for purposes of transplantation, research, etc, contains restrictions on transplants involving living donors, and prohibits commercial dealings in human body parts for transplantationG #art ) 0 #ost0mortem e"aminations ma#es provision for the authorisation of hospital post)mortem e&aminations by an adult or mature child while still alive, or, failing such authorisation, by a nominee of the person or by his or her nearest relative, and, for children, authorisation by a person with parental rights and

responsibilitiesG #art 2 0 Tissue sample or organs no longer re3uired for #rocurator Fiscal purposes Brovides for tissue samples no longer re'uired for the fiscalFs purposes to be retained as part of the deceasedFs medical record and used without authorisation for diagnostic and audit purposes, and for such tissue samples and organs no longer re'uired for the fiscalFs purposes to be used, with authorisation, for education, training or research #art + 0 Supplementary provision to #arts / to 2 Defines Fnearest relativeF and ma#es provision about witnessing of authorisations and related matters #art 4 0 &mendment of the &natomy &ct /56+ %a#es changes to provisions which govern the use of cadavers and body parts for the purposes of anatomical e&amination, the principal purpose being= to allow for the practice of surgical reconstruction to be carried out on bodies and body parts and also the practice of removing whole organs and parts of organs by healthcare professionalsG prevent any unlicensed e&hibition of bodies and body parts in public e&hibitions under the guise of education or art, and enable the post of H% $nspector of 4natomy for (cotland to continue following changes in 6ngland and Aales. #art . 7 Miscellaneous %a#es provision to allow the (cottish %inisters to arrange with a public authority anywhere in the ./ to assist them with certain of their functions under the 4ct, and gives the (cottish %inisters power by regulations to amend the 4ct in order to give effect to ,ommunity obligations relating to material consisting of human cells.