Brain-dead Patients Research Articles

Risk Analysis of the Organ Donation-Transplantation Process in Brazil

BackgroundOrgan transplantation has been for years one of the best treatment options for several medical conditions, and, all over the world, thousands of people need an organ transplant. However, the process through which an organ goes from a brain-dead patient to a new recipient is a complex and delicate one. Research questionsThis study aims at identifying and assessing the main risks, their impact, and their relevance on the organ donation-transplantation (ODT) process in Brazil. DesignTo identify and to assess the risks of the process, we interviewed coordinators at the 10 State Transplantation Centers in Brazil, which is responsible for over 90% of donations that occurred in Brazil in 2019. We applied the Failure Mode and Effect Analysis method to calculate the risks in terms of severity, occurrence, and detection. The scores obtained from each risk were used to elaborate a ranking comparing the impact of 1 risk in relation to the others. Main findingsThe interviewees identified 30 risks throughout the ODT process in Brazil. Most of them are related to insufficient human and material resources, lack of staff training and commitment, and poor infrastructure or logistical aspects. ConclusionsThis study complements findings from previous studies and add new risks, based on the Brazilian state coordinators’ point of view. It highlights the most critical weaknesses of the process and serves as a basis for future studies to delve deeper into each of those risks.

Online Noninvasive Assessment of Human Brain Death by Near-Infrared Spectroscopy with Protocol of O2 Inspiration.

Brain death is the irreversible loss of all the functions of the brain and brainstem. Compared to traditional diagnostic methods of brain death, near-infrared spectroscopy (NIRS) is a noninvasive, objective, cost-effective, and safe way of assessment of brain death. Eighteen brain dead patients and 20 healthy subjects were studied by NIRS, with a multiple-phase protocol at varied fractions of inspired O2 (FIO2). We found that the changes in the concentration ratios of oxyhemoglobin to deoxyhemoglobin (Δ[HbO2]/Δ[Hb]) in the cerebral cortex of brain dead patients were significantly higher than those of healthy subjects, and its low-to-high FIO2 phase was most sensitive, with a recommended threshold in the range 1.40-1.50. Our study indicated that NIRS is a promising technology for assessing brain death. The success of this application potentially offers a supplementary technique for the assessment of brain death in real time in order to be able to promptly offer quality-assured donor organs.

Improving psychological security and empowerment: New model for nurses toward the care of potential organ donors.

BACKGROUND:Caring for brain dead patients is the heaviest of duties for nurses, and despite tremendous stress, there are no theories/models to support nurses in this situation. This study designed a supportive model for nurses to provide care for potential organ donors.MATERIALS AND METHODS:This qualitative study was conducted in two stages. In the first stage, semi-structured interviews with 31 nurses and other stakeholders, observation and field notes continued until data saturation, (on 2018), were analyzed using continuous and comparative analysis through Corbin–Strauss method. In the second stage, theory synthesis of Walker and Avant's strategies for theory construction (2011) was used to design a supportive model/theory. The theory synthesis includes three stages: (i) selection of focal concept (the concept of “moral obligation to provide holistic care until the last minute” was selected); (ii) review of studies to identify the factors related to focal concept relevant studies (42 articles were reviewed, statements and concepts related to focal concept were then extracted and classified, and their relations were specified); and (iii) organization of concepts and statements within a relevant general and effective manifestation of the phenomenon under study which led to developing of a model.RESULTS:In this supportive model/theory, “improving psychological security and empowerment” was conceptualized within the conceptual framework. This supportive model entails three main components, including (i) informational and educational support, (ii) systematically support, and (iii) management support.CONCLUSIONS:According to the results, nurses with moral obligation to provide holistic care were faced with several challenges. Therefore, it is recommended that the healthcare system take supportive proceedings for nurses in various fields of the care for brain dead patients to resolve educational, moral, and legal challenges. This supportive model is essential for maintaining the nurses’ health, increasing the quality of nursing care and the health of potential transplant organs.

Resuscitation Medicine in Undergraduate Curriculum

A fresh medical graduate posted as an intern in wards has the biggest fear of any patient needing cardiopulmonary resuscitation during his duty hours. He had listened to lectures on cardiopulmonary resuscitation (CPR) in his final year medicine posting, witnessed his seniors performing chest compressions, and also participated by doing some errand jobs (making phone calls, calling nurse, loading drugs) but he is always worried to face a similar situation all by himself as a first responder. The simulation course in CPR which is available under the newer guidelines of the National Medical Council (NMC) undergraduate curriculum is a group activity and it is very much possible that few students get left out in understanding the nuances of good CPR practice. Resuscitation medicine (RM) is a rapidly evolving area that crosses the boundaries of emergency medicine, intensive care medicine, anaesthesia, and acute medicine.1 It is the process of correcting physiological disturbances (such as lack of breathing or heartbeat) in an acutely ill patient. Resuscitation entails more than just guidelines, training centres, and public training. The clinical practice of resuscitation, whether in-hospital or out-of-hospital, has taken on a seriousness that concerns the quality of practice, speed of implementation, and an increasing realization that every one of our patients deserves only the best skill we can offer. It has evolved from the practice of barbaric methods of yelling, slapping, hanging of the victim in face-down condition, etc to the discovery of external chest compressions by William Harvey in 1628.2 The most important contribution to the field of resuscitation medicine was given by an electrical engineer William Kouwenhoven (1886–1975) by rediscovering the science of external cardiac compression by accident during his research on internal and external defibrillation. No doubt that he is remembered as the founder of modern CPR.2 Many pharmacological and device technologies were developed thereafter and integrated into resuscitation protocols, such as the use of epinephrine, calcium, lidocaine, sodium bicarbonate, defibrillation waveforms, and improved electrocardiographic monitoring. More recently, therapeutic hypothermia (TH) in which the body is cooled to between 33 and 36 °C in an effort to decrease the metabolic injury due to ischemia, emergency use of extracorporeal membrane oxygenation (ECMO) in which a pulseless person is rapidly placed on a fully artificial heart and lung machine and controlled reperfusion in which the patient receives pulsatile blood flow rather than a continuous flow to better mimic normal physiology have emerged.3 These therapeutic interventions require the earliest possible recognition of cardiac arrest with the initiation of basic protocols during the initial 3-4 minutes and decision planning for indications and contraindications of advanced techniques. The science of RM is highly subjected to the time taken to address the situation which further makes it compulsory that the education and training should be blended in the curriculum during growing years as a medical student. he first-year students while studying anatomy, physiology and biochemistry should learn about the electrical and circulatory phase of cardiac arrest, the various adverse biochemical reactions associated with arrest, and the anatomy related to efficient chest compressions and basic airway support. The progress of the student’s curriculum into pharmacology, microbiology, pathology, ophthalmology and ENT should simultaneously expose him to the pharmacology of drugs used in resuscitation, pathophysiology and molecular aspects of cardiac arrest, assessment of eye signs for brain dead patients, and the advanced airway management. During the final semesters, education should include the current protocols of CPR and defibrillation. In this way, we can achieve a trained medical graduate well versed with basic tenets of knowledge in resuscitation. The period of internship should expose him to learn advanced protocols of quality management, real-life limitations occasioned by

Prognostic value of serum pentraxin 3 for intracerebral hemorrhage mortality.

Pentraxin 3 is considered an important inflammatory marker is known to increase in patients with ischemic stroke, but the relationship between pentraxin 3 and intracerebral hemorrhage mortality is unclear. The purpose of this study is to investigate the level of pentraxin 3 in serum and its impact on prognosis in 307 patients with intracerebral hemorrhage. During the 5-year follow-up, the mortality rate of patients with intracerebral hemorrhage was 22.5%. The serum pentraxin 3 level of the brain-dead patients was higher than that of the control group (P < 0.05). Logistic regression analysis indicated a high correlation between the pentraxin 3 level and the mortality rate 95% (hazard ratio: 3.671; confidence interval: 1.558-4.297). The receiver operating characteristic curve showed that pentraxin 3 (Area Under Curve = 0.801) had a higher diagnostic value than C-reactive protein (Area Under Curve = 0.701). The pentraxin 3 level increased significantly after intracerebral hemorrhage and has an important predictive value for a prognosis for intracerebral hemorrhage mortality.

Nursing practice for the brain-dead patient’s family until the decision making on brain death organ donation

Nursing practice for the brain-dead patient’s family until the decision making on brain death organ donation

Liver transplantation from brain-dead donors on mechanical circulatory support: a systematic review of the literature.

Mechanical circulatory support (MCS) refers to a range of rescue devices to assist circulation for the treatment of heart failure, including venoarterial extracorporeal membrane oxygenation (VA-ECMO) and ventricular assist devices (VADs). This review aims at evaluating the transplant outcome of the livers procured from brain-dead donors on MCS, who are currently considered as having extended criteria. We identified 22 records (17 on VA-ECMO and 5 on VADs), most of which (68.2%) were case reports. We performed a meta-analysis only when the outcome was reported homogeneously among studies; otherwise, we illustrated the results with narrative synthesis. A total of 156 liver transplants (LTs) have been reported, where VA-ECMO was initiated in the donor with resuscitative intent or as a bridge to donation. Early graft survival approached 100% in most studies. The pooled rate of primary nonfunction was 1% (95% CI: 0-3%). Only three successful LTs from VAD donors have been reported. Particular attention should be paid to cardiological history, biochemical tests, and imaging, as well as MCS parameters, to determine graft eligibility for transplantation. Although further analysis is needed in this field, the results of this review advocate a more systematic consideration of brain-dead patients on MCS as potential liver donors.

Bacterial Pneumonia in Brain-Dead Patients: Clinical Features and Impact on Lung Suitability for Donation.

To appraise the epidemiological features of bacterial pneumonia and its impact on lung suitability for donation in brain-dead patients managed with protective ventilatory settings. Retrospective observational study. Six ICUs from two university-affiliated hospitals. Brain-dead adult patients managed in the participating ICUs over a 4-year period. None. Among the 231 included patients, 145 (62.8%) were classified as ideal or extended-criteria potential lung donors at ICU admission and the remaining 86 patients having baseline contraindication for donation. Culture-proven aspiration pneumonia and early-onset ventilator-associated pneumonia occurred in 54 patients (23.4%) and 15 patients (6.5%), respectively (overall pneumonia incidence, 29.9%). Staphylococcus aureus and Enterobacterales were the most common pathogens. Using mixed-effects Cox proportional hazard models, age (adjusted hazard ratio, 0.98; 95% CI [0.96-0.99]), anoxic brain injury (3.55 [1.2-10.5]), aspiration (2.29 [1.22-4.29]), and not receiving antimicrobial agents at day 1 (3.56 [1.94-6.53]) were identified as independent predictors of pneumonia occurrence in the whole study population. Analyses restricted to potential lung donors yielded similar results. Pneumonia was associated with a postadmission decrease in the PaO2/FIO2 ratio and lower values at brain death, in the whole study population (estimated marginal mean, 294 [264-323] vs 365 [346-385] mm Hg in uninfected patients; p = 0.0005) as in potential lung donors (299 [248-350] vs 379 [350-408] mm Hg; p = 0.04; linear mixed models). Lungs were eventually retrieved in 31 patients (34.4%) among the 90 potential lung donors with at least one other organ harvested (pneumonia prevalence in lung donors (9.7%) vs nondonors (49.2%); p = 0.0002). Pneumonia occurs in one-third of brain-dead patients and appears as the main reason for lung nonharvesting in those presenting as potential lung donors. The initiation of antimicrobial prophylaxis upon the first day of the ICU stay in comatose patients with severe brain injury could enlarge the pool of actual lung donors.

Application of platelet-rich plasma (PRP) improves self-renewal of human spermatogonial stem cells in two-dimensional and three-dimensional culture systems

Spermatogonial stem cells (SSCs) are very sensitive to chemotherapy and radiotherapy, so male infertility is a great challenge for prepubertal cancer survivors. Cryoconservation of testicular cells before cancer treatment can preserve SSCs from treatment side effects. Different two-dimensional (2D) and three-dimensional (3D) culture systems of SSCs have been used in many species as a useful technique to in vitro spermatogenesis. We evaluated the proliferation of SSCs in 2D and 3D culture systems of platelet-rich plasma (PRP). testicular cells of four brain-dead patients cultivated in 2D pre-culture system, characterization of SSCs performed by RT-PCR, flow cytometry, immunocytochemistry and their functionality assessed by xenotransplantation to azoospermia mice. PRP prepared and dosimetry carried out to determine the optimized dose of PRP. After preparation of PRP scaffold, cytotoxic and histological evaluation performed and SSCs cultivated into three groups: control, 2D culture by optimized dose of PRP and PRP scaffold. The diameter and number of colonies measured and relative expression of GFRa1 and c-KIT evaluated by real-time PCR.Results indicated the expression of PLZF, VASA, OCT4, GFRa1 and vimentin in colonies after 2D pre-culture, xenotransplantation demonstrated proliferated SSCs have proper functionality to homing in mouse testes. The relative expression of c-KIT showed a significant increase as compared to the control group (*: p < 0.05) in PRP- 2D group, expression of GFRa1 and c-KIT in PRP scaffold group revealed a significant increase as compared to other groups (***: p < 0.001). The number and diameter of colonies in the PRP-2D group showed a considerable increase (p < 0.01) as compared to the control group. In PRP- scaffold group, a significant increase (p < 0.01) was seen only in the number of colonies related to the control group.Our results suggested that PRP scaffold can reconstruct a suitable structure to the in vitro proliferation of SSCs.

The obstacles to organ donation following brain death in Iran: a qualitative study

BackgroundOrgan donation following brain death has become an important way of supplying organs for transplantation in many countries. This practice is less common in Iran for different reasons. Therefore, this study aims to explore the obstacles to organ donation following brain death in Iran.MethodsThis qualitative research was conducted following the conventional content analysis method. The study population consisted of individuals with a history of brain death among their blood relatives who refused to donate the organs. Snowball sampling was employed to select the participants. In-depth semi-structured interviews were conducted for data gathering. Theoretical saturation was achieved through 20 interviews. Data analysis was done following the steps proposed by Graneheim and Lundman. Lincoln and Guba’s criteria were used to ensure data rigor and transferability of the study.ResultsData analyses revealed 185 codes, 23 categories, and seven themes including, poor knowledge about brain death and organ transplantation from a dead body, cultural beliefs, religious beliefs, deficiencies of requesting process, fear and concerns, inability to make a decision, and social learning.ConclusionThere were several factors in families’ reluctance to donate organs of a brain-dead patient. Through improving knowledge and changing cultural beliefs in society, it is possible to take large steps towards promoting organ donation from brain-dead patients.

VALUE OF CTGF IN ASSESSMENT OF LIVER GRAFT WITH NON-ALCOHOLIC FATTY LIVER DISEASE AFTER BRAIN DEATH

Background and Purpose: As the prevalence of nonalcoholic fatty liver disease (NAFLD) is increasing globally, an accurate evaluation of liver steatosis in potential donors is required for liver transplantation. Connective tissue growth factor (CTGF) plays an important role in the acute hepatic inflammation, chronic liver injury and liver fibrosis. In this study, intrahepatic and systemic CTGF expressions were measured from brain-dead donors (BDDs) with NAFLD, and evaluated as biomarker of NAFLD-induced graft injury. Methods: Liver and blood samples were obtained from brain-dead organ donors and patients with angiomas for RNA-sequencing and validation by RT-PCR, WB and IHC. The NAFLD rat model was established by feeding rats with the high fat diet, and thereafter brain death was developed by increasing intracranial pressure in healthy or NAFLD rats. The samples from NAFLD rats, brain-dead rats and the controls were used for further detection and analysis. Systemic CTGF levels from human and rats were measured by ELISA and analyzed the relation with the quantitative histopathological score in livers from NAFLD donors. Results: Through transcriptome analysis, CTGF was down-regulated in the healthy liver from BDDs with the fold change of 0.34 (P<0.05), which was further verified in the healthy livers from humans and rats by RT-PCR, WB and IHC (P<0.05). In parallel, CTGF protein was highly overexpressed in the fatty liver compared with the healthy liver after brain death by IHC (P<0.05). The correlation analysis indicated a linear correlation between serum levels and intrahepatic expression of CTGF in both humans and rats (P<0.05). CTGF concentration correlated with the severity of NAFLD-induced liver injury. Conclusion: After brain death, CTGF was down-regulated in the healthy liver and still over-expressed in the fatty liver from donor with NAFLD. Serum CTGF level from BDDs might be a predictor of steatosis severity for graft evaluation.

OPCR DBD, “ORGAN PRESERVING CARDIOPULMONARY RESUSCITATION IN DECEASED BRAIN DEAD DONOR” TO MINIMIZE WASTAGE OF ORGANS

Introduction: Although lot of advances in the management of brain dead patients are undergoing, but in a resource limited country with an incipient deceased donation program there practicality is difficult. In such situations, Organ preserving cardiopulmonary resuscitation (OP-CPR) is an excellent cost-effective way to minimize organ wastage. OP-CPR is defined as the use of CPR in cases of cardiac arrest to preserve organs for transplantation, rather than to revive the patient. The implementation of OP-CPR in various countries are controversial, but in our country we don’t have any legal barriers for this practice. This would be the first study which highlights the characteristics of renal transplant recipient with deceased kidney from OP-CPR. We would try to solve lot of research questions like immediate and long-term outcome with OP-CPR, comparison with marginal donors and standard criteria donors, ethical issues to be addressed, applicability of OP-CPR and hurdles involved. Materials and Methods: This was a prospective institutional and ethical board approved case control single center study. All organ donation and retrieval procedure are done as per rules of Transplantation of Human Organs and Tissues Act (THOTA 2014). Informed consent for OP-CPR was taken. We discarded all DCD, and DBD converted to DCDs. If patient relatives didn’t consent for OPCPR then we followed do not attempt cardiopulmonary resuscitation (DNACPR). We compared the outcome of OP-CPR DBD with marginal donors and standard criteria donors in terms of BPAR, infections, patient and graft survival. Result: A total of 109 OPCPR-DBD transplant cases were done. The patient and graft survival in OPCPR with or without AKI showed no statistical difference. OPCPR outcome with non OPCPR group as well as SCD group were also similar. Rejection rate were similar in all group. Discussion: Previously only few cases of OPCPR has been reported, we describe the maximum no of cases so far. Few countries don’t accept OPCPR while some don’t use defibrillation in OPCPR. We don’t have any restriction in our nation. OP- CPR can help a family from fulling there last wish to be an organ donor but OP- CPR could also prove to be a distressing event, It can feel like stretching the agony before death. How long OP CPR can be continued, what should be the cutoff for DNACPR, long-term outcome of OP CPR recipients are some of the research questions which further needs consideration. Small sample size, and short followup was the limitation of our study. Conclusion: OPCPR proved to be a successful cost effective procedure in expanding the donor poll in our study. With promising results in our center we recommend to follow OPCPR in all institutions which are linked to transplant centers nationwide. Trainings like ALS, BLS should be incorporated to all medical strata, and intensive care should be more strengthened so that more lives can be saved, even after death.

Editors' note: Disruption of the ascending arousal network in acute traumatic disorders of consciousness

In “Disruption of the ascending arousal network in acute traumatic disorders of consciousness,” Snider et al. compared ascending arousal network (AAn) connectivity seen on high-angular-resolution diffusion imaging in patients with traumatic coma to normal controls and found reduced AAn pathway integrity in patients with traumatic coma. Machado commented that consciousness requires some preservation of the AAn pathway and proposed the need to assess the AAn pathway in brain dead patients as a means to assess for awareness. Edlow and Snider responded that it is unknown how much of the AAn pathway must be intact to facilitate consciousness and advised against using AAn connectivity as a means to assess for consciousness. Furthermore, they noted that assessing AAn connectivity may be beneficial for patients with disorders of consciousness, but they do not consider this technique applicable to patients who are brain dead. In “Disruption of the ascending arousal network in acute traumatic disorders of consciousness,” Snider et al. compared ascending arousal network (AAn) connectivity seen on high-angular-resolution diffusion imaging in patients with traumatic coma to normal controls and found reduced AAn pathway integrity in patients with traumatic coma. Machado commented that consciousness requires some preservation of the AAn pathway and proposed the need to assess the AAn pathway in brain dead patients as a means to assess for awareness. Edlow and Snider responded that it is unknown how much of the AAn pathway must be intact to facilitate consciousness and advised against using AAn connectivity as a means to assess for consciousness. Furthermore, they noted that assessing AAn connectivity may be beneficial for patients with disorders of consciousness, but they do not consider this technique applicable to patients who are brain dead.

Factors that affect consent rate for organ donation after brain death: A 12-year registry

ObjectiveTo account for factors affecting family approach and consent for organ donation after brain death (BD). Material and methodsA prospective cohort study in a large, tertiary, urban hospital, where we reviewed the database of all brain-dead patients between January 2006 and December 2017 cross-matched with local organ procurement organization (OPO) records. ResultsTwo-hundred sixty-six brain-dead patients were included (55% African Americans (AAs)). Two-hundred twenty-two were approached for donation. The reason for not approaching families was medical exclusion due to cancer or multi-organ failure. Patient demographics or religion were not associated with approaching families. Lower creatinine level was the only independent factor associated with higher approach. Consent rate for organ donation was 72.5%. Consent was significantly higher in Caucasians (89% vs 62% for AAs), younger patients (46.7 vs 52.5 years old), in patients with lower creatinine at time of death (1.7 vs 2.4 mg/dL), patients for whom apnea testing was completed (92% vs 80%) and patients with diabetes insipidus (DI) (72% vs 54%). There was no significant relationship between consent and patient gender, admission diagnosis, number of examinations or completion of a confirmatory test. In a logistic regression model, only AA race independently predicted consent for donation (odds, 95% CI, 0.27, 0.12–0.57 p < .001). In a different model, apnea test completion was an additional independent predictor (3.66, 1.28–10.5 p = .015). ConclusionsApproaching families for organ donation consent was associated with medical suitability only and not with demographic or religious characteristics. AAs were 3.7 times less likely to consent for organ donation than non-AAs. Completion of apnea testing was associated with higher consent rates, an observation that needs to be explored in future studies documenting the effect on bedside family presence during this test.

Clinical Ethics in Neurological Emergencies and Critical Care

The author has examined the characteristics of clinical ethics regarding neurological emergencies and critical care. Ethics are involved in areas such as emergency medicine standards, intensive care strategies for brain dead patients who are followed by organ donation as well as those who do not donate their organs, resulting in cardiac deaths, and serious problems about distributing medical resources among the elder in extremely aged society. We must understand not only that we encounter a variety of fluctuating patient emotions in emergency rooms, but also that it is difficult or even impossible for many patients with a disturbance in consciousness to express what is on their minds. Therefore in many cases, we need to consider the patient's dignity be of the ultimate priority and that one of the most important duties for medical personnel is to display autonomy in utilizing the principle of benevolence. Additionally, hospital administrative staff should fully support the autonomy of doctors and other medical personnel.

Three-dimensional co-culture of human spermatogonial stem cells with Sertoli cells in soft agar culture system supplemented by growth factors and Laminin

Application of a three-dimensional (3D) culture system for in vitro proliferation and differentiation of human spermatogonial stem cells (SSCs) is a useful tool for the investigation of the spermatogenesis process and the management of male infertility particularly in prepubertal cancer patients. The main purpose of this study was to investigate the proliferation of human SSCs co-cultured with Sertoli cells in soft agar culture system (SACS) supplemented by Laminin and growth factors. Testicular cells were isolated from testes of brain-dead patients and cultured in two-dimensional (2D) culture system for 3 weeks. After 3 weeks, functional SSCs were evaluated by xenotransplantation and also identification of cells was assessed by immunocytochemistry, flow cytometry, and RT-PCR. Then, SSCs and Sertoli cells were transferred to the upper layer of SACS for 3 weeks. After 3 weeks, the number of colonies and the expression of specific SSCs and Sertoli cell markers, as well as apoptotic genes were evaluated. Our results showed that transplanted SSCs, migrated into the basement membrane of seminiferous tubules of recipient mice. The expression of PLZF, α6-Integrin, and Vimentin proteins in SSCs and Sertoli cells were observed in 2D and 3D culture systems. The expression rate of PLZF, α6-Integrin, Bcl2, and colony number in SACS supplemented by Laminin and growth factors group were significantly higher than non-supplemented groups (P ≤ 0.01), but the expression rate of c-kit and Bax in supplemented group were significantly lower than non-supplemented groups (P ≤ 0.05). This 3D co-culture system decreased apoptosis and increased propagation of human SSCs. Therefore, this designed system can be utilized to increase the proliferation of human SSCs in prepubertal male cancer and azoospermic men to obtain an adequate SSCs number to outotransplant success and in vitro spermatogenesis.

FHIR based System for Managing Physiological Parameters of Brain Dead Patients

FHIR based System for Managing Physiological Parameters of Brain Dead Patients

Brain death in early pregnancy: A legal and ethical challenge coming to your intensive care unit?

Increasingly, reports are emerging of maternal physiological support after brain death in pregnant women declared brain dead long before the gestational age of foetal viability. While these 'miracle babies' often receive significant media attention - such as the recent case of Catarina Sequeira - it is difficult to estimate the probability of a live birth in such circumstances given a clear publication bias in favour of reporting good outcomes. In a number of highly publicised cases, continuation of maternal physiological support after brain death has been attempted against the express wishes of the patient's family in jurisdictions where a foetal right to life is given weight in law. The legal issues around discontinuation of maternal physiological support after brain death have not yet been assessed by a UK court. The scenario is easily envisioned, however, where conflict emerges as to the appropriateness of such support. While there is no statutory definition of death in the UK, the courts have accepted brain-dead patients as legally dead upon completion of brainstem testing. However, as UK law grants few explicit legal rights to a foetus, it is unclear as to how conflicts are to be resolved. This article is not intended as a systematic review of the medical or legal academic literature, nor as a review of the clinical management of the pregnant brain-dead patient; rather, it aims to summarise the evidence base for maternal physiological support after brain death and the relevant case law. Using a recent case as an example, this article will outline the legal approach to death in the UK, contrast the status in law of a brain-dead mother and her foetus, and advance an argument of the circumstances in which maternal physiological support after brain death may be ethically justifiable. The authors hope this will assist the UK intensivist in the complex decision-making such cases demand.

Brain Death Islamic Perspective

Western world has well defined criteria for declaring the patient brain dead and discontinuation of life support treatment. However in the Muslim world these methods and practices are seen with skepticism as to their acceptance from Islamic and Sharia point op view, which in fact is incorrect and is due to lack of knowledge and absence of Institutional guidelines on this matter. Islamic law permits the withdrawal of futile treatment, including life support, from brain dead patients allowing death to take its natural course. “Do not resuscitate” is permitted in Islamic law in brain dead patients. Euthenesia is however unacceptable in Islam. Although debate continues about the details of brain death criteria within Islamic scholars, brain death is accepted as true death by the majority of Mulim scholars and there is concensus on discontinuation of life support treatment in brain dead patients.

Controversies in Brain Death Declaration: Legal and Ethical Implications in the ICU.

Purpose of reviewThis article provides a brief overview of the history and complexities of brain death determination. We examine a few legal cases that highlight some of the controversies surrounding the validity of brain death tests in light of varying state laws and institutional policy, the appropriateness of making religious accommodations, the dilemma of continuing organ-sustaining support in a pregnant brain-dead patient, and the issue of whether to obtain informed consent from surrogate decision makers before proceeding to testing.Recent findingsIn response to physician concerns about navigating these complex cases, especially with laws that vary from state to state, the American Academy of Neurology has published a position statement in January of 2019 endorsing brain death as the irreversible loss of all functions of the entire brain. It provides positions on the determination of brain death as well as guidance surrounding requests for accommodation.SummaryAlthough death by neurologic criteria has been accepted as death medically for over 40 years, legal variance exists throughout the states, especially regarding religious accommodations and in pregnancy. Questions of whether to obtain informed consent from surrogate decision makers prior to brain death testing remain, and there is no guideline regarding obtaining ancillary testing. We expect to see continued cases that cause medical, legal, and ethical controversies in our ICUs. As such, uniform training in proper methodology in performing the brain death examination and appropriate use of ancillary testing is crucial, and there is a need for legal consistency in the acceptance of the medical standard.