Brain Death

1. Brain Death Courtney Bartel,Vishruth Reddy

2. What is Brain Death? • Brain Death is defined as irreversible unconsciousness with complete loss of brain function, although the heartbeat may continue; the cessation of detectable electric activity in the cerebral cortex. • Not to be confused with a persistent, vegetative state.

3. Demonstrating Brain Death • Demonstration of brain death is the accepted criterion for establishing the fact and time of death. Factors in diagnosing brain death include: • Irreversible cessation of brain function as demonstrated by fixed and dilated pupils, lack of eye movement, absence of respiratory reflexes (apnea), and unresponsiveness to painful stimuli. • In addition, there should be evidence that the patient has experienced a disease or injury that could cause brain death. • A final determination of brain death must involve demonstration of the total lack of electrical activity in the brain by two electroencephalographs (EEGs) taken twelve to twenty-four hours apart. • Finally, the physician must rule out the possibilities of hypothermia or drug toxicities, the symptoms of which may mimic brain death. (Some central nervous system functions such as spinal reflexes that can result in movement of the limbs or trunk may persist in brain death.)

4. Defining Death • For many centuries death has been thought to occur when the vital functions cease—breathing and circulation (as evidenced by the beating of the heart). This view has been challenged, however, as medical advances have made it possible to sustain respiration and cardiac functioning through mechanical means. • Thus, more recently, the concept of brain death has gained acceptance. In this view, the irreversible loss of brain activity is the sign that death has occurred. • French neurologists were the first to describe brain death in 1958. Patients with coma depasse were unresponsive to external stimuli and unable to maintain homeostasis. • In 1968 the "Harvard criteria" for determining brain death were published in the Journal of the American Medical Association, under the title of "A Definition of Irreversible Coma.“ • A majority of the states in the United States had accepted brain death as an essential sign of death by the late 1980s.

5. Defining Brain Death • Brain death is not medically or legally equivalent to severe vegetative state. In a severe vegetative state, the cerebral cortex, the center of cognitive functions including consciousness and intelligence, may be dead while the brain stem, which controls basic life support functions such as respiration, is still functioning. • Death is equivalent to brain stem death. The brain stem, which is less sensitive to anoxia (loss of adequate oxygen) than the cerebrum, dies from cessation of circulation for periods exceeding three to four minutes or from intracranial catastrophe, such as a violent accident. • Even the concept of brain death has been challenged in recent years, because a person can lose all capacity for higher mental functioning while lower-brain functions, such as spontaneous respiration, continue. • For this reason, some authorities now argue that death should be considered the loss of the capacity for consciousness or social interaction. The sign of death, according to this view, is the absence of activity in the higher centers of the brain, principally the neocortex.

6. Defining Brain Death • Difficulties with ethics and decision making may arise if it is not made clear to the family that brain stem death is equivalent to death. • According to research conducted by Jacqueline Sullivan and colleagues in 1999 at Thomas Jefferson University Hospital, roughly one-third to one-half of physicians and nurses surveyed do not adequately explain to relatives that brain dead patients are, in fact, dead. • Unless medical personnel provide family members with information that all cognitive and life support functions have irreversibly stopped, the family may harbor false hopes for the loved one's recovery. • The heartbeat may continue or the patient may be on a respirator (often inaccurately called "life support") to maintain vital organs because brain dead individuals who were otherwise healthy

7. Ethical Questions • Who shall decide the criteria for death—physicians, legislatures, or each person for him- or herself? • Is advancement of the moment of death by cutting off artificial support morally and legally permissible? • Do people have the right to demand that extraordinary measures be stopped so that they may die in peace? • Can the next of kin or a legal guardian act for the comatose dying person under such circumstances? • All these questions have acquired new urgency with the advent of human tissue transplantation. The need for organs must be weighed against the rights of the dying donor.

8. End Of Life Issues • Money Spent of End-of-life Care • Organ Donation • Right to Die • Living Wills

9. Terri Schiavo Case • NOT BRAIN DEATH • Terri was in a Persistent Vegetative State (PVS) for 15 yrs • PVS is wakefulness without awareness • Collapsed in 1990-respiratory and cardiac arrest caused brain damage • Her husband, Michael, fought for 7 years to have her feeding tube removed. Her parents were opposed to the removal.

10. Terri had no living will. Years of court battle created a high profile case. Congress actually passed a bill to get federal jurisdiction over the case. President Bush flew into DC to sign the bill at 1am. Ultimately proved to be ineffective Terri’s feeding tube was ultimately removed in March 2005 and she died 2 days later. Autopsy reports showed she would have never recovered (Left, Normal Brain Right, Terri’s Brain)

11. Ethical Questions • Who shall decide the criteria for death—physicians, legislatures, or each person for him- or herself? • Is advancement of the moment of death by cutting off artificial support morally and legally permissible? • Do people have the right to demand that extraordinary measures be stopped so that they may die in peace? • Can the next of kin or a legal guardian act for the comatose dying person under such circumstances? • All these questions have acquired new urgency with the advent of human tissue transplantation. The need for organs must be weighed against the rights of the dying donor.

12. End Of Life Issues • Money Spent of End-of-life Care • Organ Donation • Right to Die • Living Wills

13. Works Consulted • Microsoft® Encarta® Encyclopedia 2002. • http://www.deathreference.com/Bl-Ce/Brain-Death.html