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Brain Death: The “Emerging” Debate Alan Sanders, Ph.D. Director, Center for Ethics Saint Joseph’s Health System, Atlanta, GA System Ethicist, Catholic Health East

Outline History and Current Context Case of Jacob The meaning of ‘Death’ Considerations

History 1950’s – Mechanical ventilation –“Barely alive” –Beyond coma 1968 – “A Definition of Irreversible Coma” 1981 – President’s Commission: –Two Standards for Death: irreversible cessation of circulatory and respiratory functions irreversible cessation of all functions of the entire brain, including the brainstem

Current Context Donation after Cardiac Death (DCD) –designed specifically for organ retrieval –considered by some to be overly aggressive Donating organs and withdrawing life sustaining treatment Brain dead patient kept “alive” until baby is brought to term Always in the minds of the public: miracles and medical errors

The Situation You have just sat down with the parents of Jacob, a 17-year old boy who was in a terrible auto accident. You suspect that Jacob may be brain dead. You plan to tell them of this suspicion and the need to test for this possibility. Understandably Jacob’s parents are in shock. Also they are very inquisitive and generally skeptical of health care professionals.

The facts Severe head trauma Patient unresponsive –No pupillary reflex –No reaction to painful stimuli Need to test for presence of any neurological functioning – total brain failure

What is Brain Death? Irreversible end of all brain functions, including the brain stem NOT the same as: –Coma Usually some evidence of interaction with environment –Reflexes, painful stimuli –EEG –Persistent Vegetative State Sustained autonomic function –Heart, lungs, sleeping and waking cycles

Testing: Cardinal Findings Unresponsiveness Brainstem reflexes –Eye movement & reflexes –Facial responses to painful stimuli –Gag & cough reflex Apnea testing

Tests: Additional Confirmatory Tests –Electrical activity Electroencephalography (EEG) Somatosensory and Brain Stem Auditory Evoked Potentials –Blood Flow Cerebral Angiography Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Transcranial Doppler Sonography

Tests Confirm Brain Death Jacob’s parents still filled with questions: –What is the chance of recovery? –How do you know for sure? –Is he really dead? He’s breathing, warm “I’ve heard that patients on a ventilator can still deliver a baby!”

Physiological Functions ‘Dead’ bodies can demonstrate –Wound healing –Hormone balancing and secretion –Elimination of cellular waste Sophisticated medicine –Maintains many biochemical functions –Questioned the integrative role of the brain

The concept of ‘Death’ ‘Death’ cannot be based exclusively on clinical criteria –Where is the line? –Splitting hairs, whiskers, and beards Concept of Person –A sum of the total of body parts/functions?

Pope John Paul II, 2000 In this regard, it is helpful to recall that the death of the person is a single event, consisting in the total disintegration of that unitary and integrated whole that is the personal self. It results from the separation of the life-principle (or soul) from the corporal reality of the person. The death of the person, understood in this primary sense, is an event which no scientific technique or empirical method can identify directly. –Address to 18 th International Congress of the Transplantation Society

Pope John Paul II, 2000 Yet human experience shows that once death occurs certain biological signs inevitably follow, which medicine has learnt to recognize with increasing precision. In this sense, the "criteria" for ascertaining death used by medicine today should not be understood as the technical-scientific determination of the exact moment of a person's death, but as a scientifically secure means of identifying the biological signs that a person has indeed died. –Address to 18 th International Congress of the Transplantation Society

President’s Commission, 2008 Why do we describe the central question of this inquiry as a philosophical question? We do so, in part, because this question cannot be settled by appealing to exclusively to clinical or pathophysiological facts. After all, some biological activity in cells and tissues remains for a time even in a body that all would agree is a corpse. Such activity signifies that disparate parts of the once-living organism remain, but not the organism as a whole. –Controversies in the Determination of Death, Chapter Four, “The Philosophical Debate”

President’s Commission, 2008 Openness to the world, that is, receptivity to stimuli and signals from the surrounding environment. The ability to act upon the world to obtain selectively what it needs. The basic felt need that drives the organism to act as it must, to obtain what it needs and what its openness reveals to be available. –Controversies in the Determination of Death, Chapter Four, “The Philosophical Debate”

Translation for Jacob Jacob has died, even though certain biological systems still function –Jacob does not perceive anything in his environment He cannot hear you, feel your touch –Jacob has no brain activity, no consciousness He is not thinking, dreaming –Jacob breathing and heart beat or controlled completely by a machine He is no longer capable of maintaining those functions on his own

Some Recommendations Language, Language, Language –Consider your use of the term “brain death” May imply more than one type of death “Jacob (the person) has died.” –Avoid talking about “Life” sustaining treatment Mechanical ventilation or artificial respiration –Avoid talking to patient as if he or she is still alive –Offer family your condolences & support Prepare family and loved ones for removal of the body from mechanical ventilation

Other Considerations –Review policies Ensure strict adherence to AAN Guidelines Check that staff are comfortable with protocols –“What is the patient codes during the apnea test?” Prepare for possible conflicts –What is your institution prepared to do if the family vehemently disagrees?

Discussion

References Guidelines for Diagnosing Brain Death –American Academy of Neurology, “Practice Parameters: Determining Brain Death in Adults.” Summary Statement, 1994, available online at ads/118.pdf ads/118.pdf

References Church Teaching on Brain Death –Pope John Paull II “Address of the Holy Father John Paul II to the 18 th International Congress of the Transplantation Society.” August 29 th, Available online at l_ii/speeches/2000/jul- sep/documents/hf_jp- ii_spe_ _transplants_en.html l_ii/speeches/2000/jul- sep/documents/hf_jp- ii_spe_ _transplants_en.html

References President’s Commission on Brain Death –President’s Council on Bioethics, “Controversies in the Determination of Death: A White Paper by the President’s Council on Bioethics.” January, Available online at x.html x.html