Brain Death Cases Research Articles

Is Donor Age an Important Factor in Cadaveric Organ Donation?

Introduction We previously observed that organ donation rate is low among young donors. In this studywe aimed to investigate whether this observation is valid or not and what are the reasons of refusing organ donation in young donors’relatives. Methods Organ donation records in Bursa region between 2011‐2015 years were evaluated and relationship of organ donations with donor age was investigated. A questionnaire, composed of ten questions was prepared for family members of brain death patients who refused donation. The survey was conducted by phone calls and answers were recorded. Results Between the years of 2011‐2015 (5-year) 750 brain death declarations were reported and 508 of them did not accept donation. The donation rate under 30 years of age was lower than the older aged patient group (23,8% vs 32,9%, p: 0.026). From 96 of 126 brain death cases, aged ≤30, concent for organ donation could not be obtained. The most common reason they reported was related to religious issues (29.6%) and the second most common reason was concerns about corruption of bodily integrity (18.5%). Other reasons commonly expressed by the families were that they were skeptical about transplantation of donated organs to appropriate patients and negative behaviors of health care providers. Although, 40.7% of families reported that they had refused organ donation since their patients was too young, only 18.5% of them told that they would accept organ donation if their patients were older. Among those who rejected organ donation 18.5% expressed that they were regretful about their decision and 25.9% stated that they might accept organ donation though it is asked today. The most striking answer to question why they rejected organ donation was that deceased people did not register their intent to donate their organs when they were healthy or alive. It was declaired by the 62.9% of family members who rejected organ donation that they would have accepted donation if there was testament. Conclusions For family members of patients who deceased at young ages emotional attitudes are very important about the decision of organ donation. The testament of person about organ donation is the most important factor affecting the decision of family members.

Current controversies in brain death determination.

Although the concept of brain death is accepted by the majority of physicians, lawyers, ethicists and society at large, controversies about determination of death by neurological criteria persist, and often reach the public eye. In this article, we examine four prominent controversial brain death cases from 2013-2016. We review current controversies, including protocol variability, recognition of the American Academy of Neurology (AAN) criteria for brain death as an accepted medical standard, and management of objections to discontinuation of organ support after determination of brain death. Brain death remains conceptually and legally valid, and it is vital that these issues are solved. We argue that medical societies and governmental regulatory bodies must support the AAN criteria in order to decrease protocol variability, and must fully endorse the validity of these criteria as accepted medical standards.

Brain death diagnosis in adult for potential cadaveric organ donation in Bangladesh

Aim: The objectives of this study was (i) To increase knowledge of the epidemiological and clinical features of patients diagnosed with brain death for potential cadaveric organ donation (ii) To determine the compliance of guidelines brain death based on neurological criteria (iii) To analyse process of clinical decision making regarding continuation of life support after brain death diagnosis.Materials and Method: A prospective observational study was carried out in a 12 bed adult ICU of a tertiary care hospital with neurosurgery services in Bangladesh over a period of 2 years from January 2015 to December2016. All patients admitted during this period were scrutinized for identification of brain death and impending brain death. They were analyzed for causes of brain death, diagnosis of brain death, and the use of ancillary testing. Potential for organ donation was also kept in mind.Results: During the study period, total 1387 patients were admitted into the study ICU and there were 329 deaths. And out of them 69 were diagnosed as brain death. The main causes of brain death were intracerebral haemorrhage (32/69, 46%), followed by ischemic stroke (11/69, 16%), subarachnoid haemorrhage (11/69, 12%), traumatic brain injury (8/69, 12%) and brain tumor and CNS infection. The diagnosis of brain death was made in 33 (47%) cases in the first 48 hours and 23 (33%) cases in 48-96 hours of ICU admission. With the exception of two cases, all study patients had GCS score ? 8 (97%). Brain death was diagnosed according to American Academy of Neurology (AAN) 2010 guidelines. Only two cases Electroencephalography was done for family request. All life-sustaining measures were withdrawn in 67 (97%) cases with consent of family.Conclusion: There is no scarcity of brain death cases in our country according to our study. We need to promote and popularize the cadaveric organ transplant along with living donor transplantation.Bangladesh Crit Care J March 2017; 5(1): 48-52

Concordant VS. Discordant Xeno Cardiac Transplantation; The past, the present and future Trends

There is a huge waiting list for recipient of heart for people in need of, yet the pool of donors are limited to less than 10% of all brain death cases coming out of road accidents. NHSA reports 2700 Transplants were harvested out of 55000 road accident brain deaths in 2014. A country (China) expects a record number of transplant this year mainly harvested from executed prisoners (world number one in execution followed by IRAN), despite a new ban applied this year (The south China Morning Post). So one of the most exciting donor pool which also is very close genetically to Human being is Baboon, in which we will try to reignite interest in research and development for farming and harvesting their organs for use in people in need of Cardiac Transplant.

Public education and misinformation on brain death in mainstream media.

We sought to evaluate the caliber of education mainstream media provides the public about brain death. We reviewed articles published prior to July 31, 2015, on the most shared/heavily trafficked mainstream media websites of 2014 using the names of patients from two highly publicized brain death cases, "Jahi McMath" and "Marlise Muñoz." We reviewed 208 unique articles. The subject was referred to as being "alive" or on "life support" in 72% (149) of the articles, 97% (144) of which also described the subject as being brain dead. A definition of brain death was provided in 4% (9) of the articles. Only 7% (14) of the articles noted that organ support should be discontinued after brain death declaration unless a family has agreed to organ donation. Reference was made to well-known cases of patients in persistent vegetative states in 16% (34) of articles and 47% (16) of these implied both patients were in the same clinical state. Mainstream media provides poor education to the public on brain death. Because public understanding of brain death impacts organ and tissue donation, it is important for physicians, organ procurement organizations, and transplant coordinators to improve public education on this topic.

Integrated But Not Whole? Applying an Ontological Account of Human Organismal Unity to the Brain Death Debate.

As is clear in the 2008 report of the President's Council on Bioethics, the brain death debate is plagued by ambiguity in the use of such key terms as 'integration' and 'wholeness'. Addressing this problem, I offer a plausible ontological account of organismal unity drawing on the work of Hoffman and Rosenkrantz, and then apply that account to the case of brain death, concluding that a brain dead body lacks the unity proper to a human organism, and has therefore undergone a substantial change. I also show how my view can explain hard cases better than one in which biological integration (as understood by Alan Shewmon and the President's Council) is taken to imply ontological wholeness or unity.

Unexpected Brain Death in a 20-year-old Man with Chiari Type I Malformation after Trauma: Case Report and Review of Literature

The Chiari I malformation is a congenital anomaly of unknown origin consisting of caudal displacement of the cerebellar tonsils protruding through the foramen magnum, whereas the brainstem and fourth ventricle remain in the cranial vault. We present a case of a sudden brain death of a 20-year-old adult man with trauma who subsequently was found to have a previously undiagnosed Chiari I malformation.

Intracranial pressure and cerebral perfusion pressure in patients developing brain death

PurposeWe investigated whether a critical rise of intracranial pressure (ICP) leading to a loss of cerebral perfusion pressure (CPP) could serve as a surrogate marker of brain death (BD). Materials and methodsWe retrospectively analyzed ICP and CPP of patients in whom BD was diagnosed (n = 32, 16-79 years). Intracranial pressure and CPP were recorded using parenchymal (n = 27) and ventricular probes (n = 5). Data were analyzed from admission until BD was diagnosed. ResultsIntracranial pressure was severely elevated (mean ± SD, 95.5 ± 9.8 mm Hg) in all patients when BD was diagnosed. In 28 patients, CPP was negative at the time of diagnosis (−8.2 ± 6.5 mm Hg). In 4 patients (12.5%), CPP was reduced but not negative. In these patients, minimal CPP was 4 to 18 mm Hg. In 1 patient, loss of CPP occurred 4 hours before apnea completed the BD syndrome. ConclusionsBrain death was universally preceded by a severe reduction of CPP, supporting loss of cerebral perfusion as a critical step in BD development. Our data show that a negative CPP is neither sufficient nor a prerequisite to diagnose BD. In BD cases with positive CPP, we speculate that arterial blood pressure dropped below a critical closing pressure, thereby causing cessation of cerebral blood flow.

Brain Death in a Near-Term Infant: A Case Report

Brain death is defined as the complete and irreversible loss of cerebral and brainstem function while the heart continues to beat. Unlike cardiac death, brain death is associated with medical, legal, and ethical issues. Common causes of neonatal brain death are perinatal asphyxia, birth trauma, cerebral infection, malformations, severe intracranial hemorrhage, and metabolic diseases. Although a diagnosis of brain death is usually based on clinical criteria, it is not well defined in neonates, especially in preterm babies. Furthermore, there are no guidelines on life expectancy, prolonging life care, or discontinuation of life support in brain dead newborns in Korea. We report a case of brain death due to hypoxic ischemic encephalopathy in a near-term newborn, present the need to establish guidelines for brain death in newborns based on national standards, and discuss further directions about end of life treatment after brain death.

Transorbital Ultrasonographic Measurement of Optic Nerve Sheath Diameter in Brain Death.

Ultrasonographic measurement of optic nerve sheath diameter (ONSD) can successfully be used to estimate intracranial pressure (ICP) elevation. Its utility in corroboration of brain death (BD) was herein studied. ONSD was measured in 29 subjects with BD; in 19 comatose patients (with raised ICP in 11), 20 patients with various neurological diseases, and 40 healthy control subjects. The distance between the inner and outer edges of the echolucent lines around hyperechoic area surrounding the optic nerve (ON) was identified as ONSD external (ONSDe) and ONSD internal (ONSDi). Compared to patients with neurological diseases (5.75 ± .79 mm) or healthy controls (5.98 ± .63 mm), ONSDe was significantly higher in comatose patients (7.61 ± .97 and 6.71 ± 1.07 mm in those with and without raised ICP) and BD subjects (8.34 ± .66 mm). ONSDi showed similar trends across the groups: 6.09 ± .71 mm in BD; 5.89 ± .37 mm in comatose control with elevated ICP; 5.16 ± .49 mm in comatose control with normal ICP; 4.36 ± .68 mm in neurological control; 4.69 ± .67 mm in healthy control. The accuracy of ONSDe measurements in differentiating patients with ICP elevation (n = 40) was .965 as determined by area under the curve (AUC) of receiver-operator characteristics curves. Similarly, accuracy in discrimination of BD was .952. However, ONSDe showed limited yield to identify BD cases among comatose patients with Glasgow coma scale score of 3, where accuracy was .803 (95% CI: .709-.816) and decreased further to .722 (95% CI: .610-.816) when analyses were restricted to comatose patients with ICP elevation. AUC values for ONSDi was similar or lower. ONSD is significantly greater in subjects with BD. However, quantification of ONSD cannot discriminate BD subjects from comatose ones with raised ICP with 100% certainty.

Critical Care Providersʼ Knowledge and Attitudes About Donation After Circulatory Death.

Donation after circulatory death (DCD) has increased the number of transplantable organs in the USA. However, some critical care providers continue to have concerns about DCD. We surveyed 98 critical care providers (67% response rate) at one medical center using a DCD Knowledge Questionnaire (14 true-false items) and a DCD Attitudes Scale (37 statements, 5-point Likert scale, higher scores=more favorable DCD attitudes) to examine the relationship between knowledge, attitudes, and provider characteristics. Providers (52 physicians, 38 nurses, 8 allied health) were 40.1±12 yrs old, 67% female, and 80% white. DCD knowledge scores ranged from 5 to 12 (mean=9.4±1.6). More knowledge was associated with older age (r=0.27, p=0.01), more ICU experience (r=0.31, p=0.002), and more DCD experience (r=0.21, p=0.04). Most providers did not know (% incorrect) that patient or family consent is necessary for pre-mortem cannulation (62%), a patient must be on a ventilator to be considered for DCD (59%), 5 min of continuous pulselessness or asystole must occur before organ recovery can begin (57%), and death must occur within 2 hrs of ventilator withdrawal for donation to proceed (52%). The DCD Attitudes Scale had high internal consistency (Cronbach's α=0.90). Total DCD attitudes scores ranged from 77 to 159 (mean=129.9±16.4). More favorable attitudes were associated with white race (t=2.4, p=0.02) and more DCD experience (r=0.32, p=0.002). While DCD attitudes were generally positive overall (e.g., 89% felt that DCD allows something positive to come from the patient's death), compared to donation after brain death cases, some providers felt that DCD cases are more difficult and less predictable (67%) and place more stress on staff (52%), less comfortable talking to families about DCD (47%), and less comfortable with DCD overall (33%) and with DCD death criteria (39%). Higher knowledge of the institution's DCD policy was associated with more favorable DCD attitudes (r=0.48, p<0.001). Despite a long-standing practice of DCD (>40 years) in this OPO service area, our survey identified knowledge gaps among critical care providers that must be addressed to enhance the acceptance of DCD as a standard of end-of-life care. As a result, the OPO has appointed two associate medical directors with intensivist expertise in DCD to improve the knowledge of critical care providers that can impact attitudes and affirmative decisions enabling DCD.

Bacterial Culture Surveillance in a Brazilian Organs and Tissues Procurement Program.

In order to recognize active infection in the organ donor after brain death, it was established in the Brazilian Organs and Tissues Procurement Program the collection of blood and urine culture during their evaluation as a potential donor. The purpose of this study was to identify the pathogens that cause infection and that can be transmitted for the organ recipient. This retrospective study evaluated 232 cases of brain death in 2012, which 71 were potential donors and 161 were not. The average length of stay of potential donors was 6 days. Positive urine culture was found in 10% of reports, 20% of potential donors. The pathogens detected in urine culture were Serratia marcescens, Staphylococcus saprophyticus, Staphylococcus species, Enterococcus faecalis, Escherichia coli, Candida tropicalis, Pseudomonas aeruginosa, Enterobacter cloacae. Regarding blood cultures, 8% were positive, 24% of potential donors. The pathogens detected in blood culture were Staphylococcus species, Staphylococcus epidermidis, Staphylococcus haemolyticus, Serratia marcescens, Streptococcus agalactiae, Corynebacterium, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterobacter aerogenes, Staphylococcus aureus, Streptococcus mitis. The results previously obtained to the multiple-organ harvesting were communicated to the transplant teams. It is noticed that none recipient has developed infection related to positive cultures. In this way it is possible to define the pathogens that can be transmitted from donor to recipient, delineate strategies to prevent infection post transplantation, as well as understand the risks of transmission of infection in organ recipients from deceased donors.

Brain death: what health professionals should know.

Brain death is not a new phenomenon—it has been clearly established in clinical medicine and law for decades. Nonetheless, controversial cases involving brain death erupt into the news with distressing regularity. One recent example is the case of Jahi McMath, a California adolescent who met the criteria for brain death due to complications after a routine tonsillectomy. Jahi's family was devastated, understandably, but their desolation took the form of denying that their child was dead. The McMath family succeeded in having the body of their deceased daughter transferred to the morgue, and then to another facility, which allegedly will continue to maintain Jahi's organs as long as possible. In another recent and distressing case, Marlise Munoz, a young pregnant wife and mother in Texas suffered a massive blood clot to her lungs late one night. The patient—and her fetus of 14 weeks gestation—suffered a prolonged period without oxygen, resulting in loss of all brain function for the mother. The Texas hospital to which Munoz was admitted told her grieving husband that she met criteria for brain death, but refused to declare her dead, claiming instead that Texas law required them to maintain Munoz's organs in order to preserve the life of her fetus. This case is unusual in that it was the health care facility, not the family, who rejected the diagnosis of brain death. Munoz’s husband took the hospital to court, where a judge sensibly found that no Texas (or other) law can require that dead people receive medical care. The hospital was forced to declare Munoz dead and disconnect her from the ventilator. All parties agreed that the fetus was not and had never been viable. After 2 months of trauma, the Munoz family was able to mourn their loss. These 2 awful cases will fade from the news, as have other controversial brain-death cases before them. The trauma for the affected families will last far longer than the public’s memory. Sadly, other cases will likely take their place in the years to come, since brain death remains deeply confusing to the news media, to families, and even to some health professionals. However, there are steps that health professionals can take to help prevent others from enduring this type of trauma. First, it is important to review and clarify key concepts related to brain death. Inexplicably, many health professionals do not have a clear grasp of brain death’s definition and assessment. No group of health professionals is blameless; doctors, nurses, social workers, and others within the health professions make incorrect statements about brain death. And even among those who are well informed, poor use of language when communicating with families of brain dead patients is disturbingly common. To address these problems, we’ll begin with a brief review of brain death and some of the challenges related to it. Next, we'll think about better ways that health professionals can talk with families and colleagues about brain death. Finally, we examine ways to support best practices through policy and education, so that our communities are shielded from the trauma of these public controversies.

Potential brain death organ donors - challenges and prospects: A single center retrospective review

Organ donation after brain death (BD) is a major source for obtaining transplantable organs for patients with end-stage organ disease (ESOD). This retrospective, descriptive study was carried out on all potential BD patients admitted in different intensive care units (ICUs) of the Hamad medical Corporation (HMC), Doha, Qatar during a period from January 2011 to April 2012. Our aim was to evaluate various demographic criteria and challenges of organ donation among potential BD organ donors and plan a strategy to improve the rate of organ donation in Qatar. Various aspects of BD patients in the ICUs and their possible effects on organ donation were studied. The time intervals analyzed to determine the possible causes of delay of organ retrieval were: time of diagnosing fixed dilated pupils in the ICU, to performing the first BD test, then to the second BD test, to family approach, to organ retrieval and/or circulatory death (CD) without organ retrieval. There were a total of 116 potential BD organ donors of whom 96 (82.75%) were males and 20 (17.25%) were females. Brain hemorrhage and head injury contributed to 37 (31.9%) and 32 (27.6%) BD cases, respectively. Time interval between diagnosing fixed dilated pupil and performing the first test of BD was delayed >24 h in 79% of the cases and between the first and second BD tests was >6 h in 70.8% of the cases. This delay is not compatible with the Hamad Medical Corporation (HMC) policy for BD diagnosis and resulted in a low number of organs retrieved. BD organ donation, a potential source for organs to save patients with ESOD has several pitfalls and every effort should be made to increase the awareness of the public as well as medical personnel to optimize donation efficacy.

A Case of Brain Death in the Medical Intensive Care Unit

SESSION TITLE: Critical Care Case Report Posters I

Perfusion “Brain Death“ Scintigraphy in Traumatic and Hypoxic Cerebral Insults

In the United States, approximately 1.7 million patients are treated annually for traumatic brain injury, and cerebrovascular insults are the third leading cause of death. Although CT plays a central role in the initial assessment of suspected intracranial injury, planar brain scintigraphy provides valuable information regarding cerebral perfusion, function, and brain death. An understanding of the complexity of injuries is helpful in scintigraphic image interpretation. To illustrate potential scintigraphic confounders, we present 8 suspected brain death cases with correlative CT. Even with negative brain death studies, severe brain injury by CT portends grave outcomes.

A brain dead woman, giving birth in the 23rd week of pregnancy, used as an organ donor: A case report

Maternal brain death during pregnancy is an exceptional case when somatic support might be continued despite diagnosed death. There are only a few cases of maternal brain death during pregnancy reported in the literature and detailed data regarding the frequency of such cases are lacking. The case of a 40-year-old woman, diagnosed brain dead due to a subarachnoid and intracranial hemorrhage in the 21st week of pregnancy is presented. The patient was admitted to the neurosurgery department and then to the intensive care unit, where brain death was diagnosed. The medical team decided to perform a caesarean section, and a living female infant was delivered. After delivery, maternal kidneys were recovered and successfully transplanted. This challenging case indicates that prompt diagnosis of maternal brain death is required to facilitate decision-making regarding somatic support prolongation to save the life of the fetus, as well as to allow procurement of the maternal organs.

A Case of Brain Death Due to Asthma Exacerbation in a Noncompliant Patient with Refractory Asthma

난치성 천식으로 잦은 천식 ì• í™”ë¥¼ 경험해 온 환자가 더욱이 순응도까지 좋지 않아 평소 천식 ì¡°ì ˆì œë¥¼ 잘 사용하지 않는 상황에서 심한 천식 발작 후 심폐 ì •ì§€ 및 뇌사에 이른 안타까운 증례이다. 다시 한 번 환자 교육 및 순응도 ê°œì„ ì„ 위한 의료진의 더욱 ì ê·¹ì ì¸ ê°œìž ì´ 중요하다는 ì ì„ 강조하는 바이다. 중심 단어: 천식; 뇌사; 천식발작

Legal Briefing: Futile or Non-Beneficial Treatment

This issue's "Legal Briefing" column covers recent legal developments involving futile or non-beneficial medical treatment. This topic has been the subject of recent articles in JCE. Indeed, it was the subject of a "Legal Briefing" in fall 2009. Accordingly, this column focuses on legal developments from the past two years. These developments are usefully grouped into the following 11 categories: 1. Texas Advance Directives Act, 2. Ontario Consent and Capacity Board, 3. Surrogate selection, 4. Ex post cases for damages, 5. Ex ante cases for injunctions, 6. Coercion and duress, 7. Assent and transparency, 8. Brain-death cases, 9. Criminal and administrative sanctions, 10. Conscientious objection, 11. Penalties for providing futile treatment.

Nurses' Locations as Organ Transplantation Coordinators in the Turkey National Coordination System

Background Turkey is one of the worst countries in the European region for the number of deceased organ donors (3.6) per million people. The aim of this study was to evaluate the location of nurses who have been attached to the National Coordination System as coordinators to increase this number. Methods We chose 4 regional coordination centers in which the most brain death cases were reported: Istanbul, Izmir, Antalya, and Ankara. Coordinators were classified according to their occupations. We evaluated the numbers of brain deaths and of donors from 2006 to 2009 in hospitals that have coordinators. Results The centers that have only nurse organ transplantation coordinators reported 60.3 (total n = 138) of the brain deaths in 2007, 54.8% (n = 97) in 2008, and 47.5% (n = 152) in 2009 in the Istanbul region; 8.4% (n = 131) in 2007, 25% (n = 164) in 2008, and 20% (n = 169) in 2009 in the Izmir region; 42.6% (n = 61) in 2007, 42.6% (n = 56) in 2008, and 32.4% (n = 111) in 2009 in the Antalya region; and 54% (n = 120) in 2007, 45.2% (n = 104) in 2008, and 41.8% (n = 122) in 2009 in the Ankara region. Conclusion Brain death numbers have increased in all regions after the nurses started to work as coordinators. Still many potential donor center have no transplantation coordinator.