Thursday, August 14, 2008

Just how dead does an organ donor have to be?

From the New England Journal of Medicine (hardly a bastion of right-to-lifers) The Dead Donor Rule and Organ Transplantation

The concept of brain death has served us well and has been the ethical and legal justification for thousands of lifesaving donations and transplantations. Even so, there have been persistent questions about whether patients with massive brain injury, apnea, and loss of brain-stem reflexes are really dead. After all, when the injury is entirely intracranial, these patients look very much alive: they are warm and pink; they digest and metabolize food, excrete waste, undergo sexual maturation, and can even reproduce. To a casual observer, they look just like patients who are receiving long-term artificial ventilation and are asleep.

Translated from jargon to English:

Calling people "brain dead" so we can take their organs and give them to other people -- who, after all, need them to survive -- has worked really well for organ recipients. However, some people insist that "brain dead" isn't dead. After all, these "brain dead" people are warm and pink; they digest and metabolize food, excrete waste, undergo sexual maturation, and can even reproduce. They certainly don't look dead. They look asleep.

Well, yeah, because they're not dead.

The author goes on to concede that "brain dead" patients aren't really dead. Not that he has any problem with gutting them for their organs. After all, somebody else needs them. What he proposes isn't that we stop killing incapacitated people to get organs that livelier people need. He simply proposes that we start being honest about what we're doing.

It's a start. I've been agitating for it already.

Prospective donors need to know exactly how "dead" they will be when their organs are taken -- which is not dead. Some people will have a problem with this; others won't. But ought it not to be their choice whether or not they get cut open while they're still warm, pink, and showing all the signs of life except consciousness?

Prospective recipients need to know exactly how "dead" the donor will be when his or her organs are taken-- which is not dead. Some people will have no problem with this. Others -- myself included -- will, and will voluntarily abstain from getting on any waiting lists for organs. It remains to be seen how much this will reduce the wait for organs.

Here, for your edification, are some photos of a "brain dead" woman, taken from this PDF flier:

Maybe I'm naive, but she just doesn't look very dead to me. And I'd bet that if you were to walk into her room and drive a knife into her heart, you'd be charged with murder. Why should it be okay to take her to the OR, strap her to a table, and start taking her organs out?

free pollsHow does this information impact your feelings about organ donation?
I would still be willing both to donate and to receive vital organs.
I would be willing to donate, but not to receive, vital organs.
I would be willing to receive, but not to donate, vital organs.
I would not be willing to donate or receive vital organs.

Please tell us why you voted as you did.

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Christina Dunigan said...

As I'm sure everybody predicted, I voted "I would not be willing to donate or receive vital organs."

I could not be a recipient, because to do so would be to participate in the killing of an innocent party who was no threat to anyone. I can't do that.

I also can not be a donor because although it is a fine and admirable thing to lay down one's life for another, I couldn't participate in a system that treats any group of people as though their lives are of no value. To devalue my own life in such circumstances would also devalue the lives of others who are incapacitated, and I have no right to devalue their lives.

Anonymous said...

Had not previously given organ donation any thought. Was going to vote option 2, then changed to option 4 after reading your comment, wondering why i hadn't thought of that myself.


Anonymous said...

I saw this story some time ago, about a man who was declared brain dead and recovered. Although he doesn't remember the accident that nearly took his life, he remembers hearing the doctors pronounce him brain-dead! And I also found this story (read the comments afterwards too) about people waking up from supposedly irreversible comas and/or brain-death; and this story about a woman who had a heart attack and supposedly no brain function for 18 hours.

All of these people would have been harvested for organs.

Christina Dunigan said...

Kathy, I started having my doubts about "brain death" when I was getting the "TIPS" newsletter from the Training Institute at Syracuse University. It was a clearinghouse for news clippings sent in from all over the world, and every bi-monthly issue, it seemed, had another story of somebody waking up while doctors were trying to get the family to sign organ donation permission.

I decided then I'd not be willing to receive an organ, since I'd have no way of knowing if the "donor" had really died first or if taking the organs had killed him.

Now, of course, I DO know that I'd the donor is killed to get the organs.

Tonja said...

Brain dead is exactly what that means. Once the respirator is closed off, you will never breath again. In these photos, I cannot see that this patient is on a respirator, which YOU WOULD NEED if you are BRAIN DEAD.

Without a brain, alive that is, you DO NOT breath on your own.

I 22-year-old son OD'd on methadone and xanax and WITH the help of a respirator, continued to have trouble breathing. His respirations improved, the machine/pulmonary specialist turned the respirator to 3.

My son Timmy reached brain death after a tracheotomy was performed on him 9 days later. He had to have the breathing tube removed from his mouth/throat and have the breathing/feeding tube go through the tracheotomy in his neck. At that time, he was on Blood-Thinners because he had blood clots lodged in his body, his R arm to be specific. Anywhere else, who knows.

INvasive surgery such as a tracheotomy would have caused such bleeding.

Seven days after his trach, after Labor Day of 2008, we were told he was BRAIN DEAD.

I knew this already. During one of my many visits to my son, and after he was so unresponsive after his trach, I took the flashlight off of his nightstand at the ICU ward (a BIG CLUE there) and shone it in his right eye. His pupil, very fixed and very dilated. This usually indicates one distinct, horrific sign: BRAIN DEATH

(Unless you are using methamphetimines or cocaine, not my son's case here!)

My son exhibited NO signs of life after his trach. NONE. If it were not for the ventilator forcing him to respirate/breathe, which in turn OXYGENATES the body and keeps the HEART BEATING, he would have been what we considered DEAD.

Timmy's brain was receiving NO PERFUSION, which means my son's brain was receiving NO blood circulation at all.

This photo shows a "Brain Dead" woman moving her arms?? This only proves one thing: SHE WAS NOT BRAIN DEAD!

Either the person who submitted this photo is a liar, or the webmaster is.

Tonja said...

I take that back, I can see what appears to be a respirator tube extending from her neck, going through a tracheotomy of course.

But she is not brain dead if she is moving her arms. Whoever declared that she is needs to be sued, forever.

Something is not being told to us here on this forum.

Brain dead people do not move, period, end of story.

Christina Dunigan said...

Tonja, I'm very sorry for the loss of your son.

After your comment, I did another web search. I found these:

Frequency of spinal reflex movements in brain-dead patients: "Spontaneous and reflex movements may occur in brain-dead patients. These movements originate from spinal cord neurons and do not preclude a brain-death diagnosis. In this study, we sought to determine the frequency and characteristics of motor movements in patients who fulfilled diagnostic criteria for brain death. .... Clinical brain death was diagnosed according to our national law. .... Spinal reflex movements were observed in 18 out of 134 (13.4%) brain-dead patients during the study period. Lazarus sign, the most dramatic and complex movement seen in brain-dead patients, was observed a few times in two patients during an apnea test, an oculocephalic test, after a painful stimulus, and after removal of a ventilator. The other reflex movements observed in our brain-dead patients were finger and toe jerks, extension at arms and shoulders, and flexion of arms and feet. The occurrence of spinal reflexes in brain-dead patients may certainly delay decision making, such as starting a transplantation procedure, because of difficulties in convincing the family or even a physician taking part in the diagnosis of brain death."

I also found this:

Fast Fact and Concept #115: Declaring Brain Death
: "Typically, all of the following must be met to ensure the diagnosis: *No spontaneous movement and no movement in response to painful stimuli (movement due to spinal reflexes are acceptable)"

These two indicate that the standards for "brain death" vary in different jurisdictions. In some jurisdictions, spontaneous movement may be seen and the patient still be "brain dead", but in other jurisdictions only "spinal reflex movements" may be seen. Which is still movement.

Lazarus' sign and respiratory-like movement in a patient with brain death: "We presented a patient who showed a complex movements of upper limbs (Lazarus' sign) and respiratory like movement during the apnea test for the determination of brain death. .... She became apnea and no brain stem reflexes elicited. Three days later, electrophysiological examination revealed a flat recording of electroencephalography, absence of auditory evoked potentials and no response of blink reflex. .... This patient fulfilled all other criteria for brain death. Four days after, an apnea test was performed. Spontaneous movements of both upper limbs were observed starting between 7 and 8 minutes after disconnecting the intubation tube from the ventilator. Both arms flexed at the elbow, abducted and elevated from the bed. Then, both hands were brought up to chest. Wrist and fingers were in a neutral position (Lazarus' sign). Simultaneously, shallow and irregular respiration like movements were recognized. These movements ceased immediately after connecting the respirator."

Christina Dunigan said...

Are they really dead?: "In what must surely be the basis for a new orror movie researchers have just released a study relating to the spontaneous movements (such as jerking of fingers and bending of toes) of brain dead people. These movement occur in 39 percent of brain dead patients and can be disturbing to family members and health care professionals and even cause them to question the brain-death diagnosis. All this macabre information is included in a study published in the journal of the American Academy of Neurology." -- the article then goes on to have a doctor explain that the movements are "spinal reflexes".

One of the most startling movements for family members and health care professionals is called the "Lazarus sign." It is a sequence of movements lasting for a few seconds that can occur in some brain dead patients, either spontaneously or right after the ventilator is disconnected. According to Bueri, "It starts with stretching of the arms, followed by crossing or touching of the arms on the chest, and finally falling of the arms alongside the torso. It is also a spinal reflex, but it can be disturbing to family members and others who see this."

Lazarus sign and extensor posturing in a brain-dead patient. Case report.: "A man was declared brain dead after having sustained a gunshot wound to the head. All clinical criteria for the diagnosis of brain death were met. The electroencephalogram was isoelectric, and four-vessel angiography demonstrated the absence of cerebral blood flow. However, stereotypic spontaneous movements were observed which persisted for several hours."

Christina Dunigan said...

Complex spinal reflexes during transcranial Doppler ultrasound examination for the confirmation of brain death : "Complex sets of movements of the extremities can be seen in patients with brain death (BD), and are typically observed during apnea testing or removal of ventilatory support (also called the Lazarus sign). We here describe brain-dead patients who had not shown previous movements, even during apnea testing, but presented complex spinal reflexes during transcranial Doppler (TCD) examination elicited by neck flexion."

Spontaneous and reflex movements in brain death : "Spontaneous and reflex movements may be found in patients with brain death (BD). The authors prospectively evaluated their frequency using a standardized protocol. Among 38 patients who fulfilled criteria for BD, the authors found 15 (39%) with spontaneous or reflex movements. The most common movement was finger jerks. Undulating toe flexion sign, triple flexion response, Lazarus sign, pronation–extension reflex, and facial myokymia also were seen. These movements may be more common than reported and do not preclude the diagnosis of BD."

Core Curriculum: Brain Death Guidelines: "Deep tendon reflexes including stereotypic triple flexor responses in the lower extremities are compatible with brain death. These include spontaneous slow movements of an arm or leg. Bizarre movements of entirely spinal origin may sometimes occur in brain dead patients. Also, coordinated movements can occur with shoulder elevation and adduction, back arching and the appearance of intercostal muscle contraction without detectable tidal volumes. Finally, in a few patients, the "Lazarus sign" may develop when the ventilator is permanently disconnected; the head and torso may flex and for a few seconds rise from the bed with arms outstretched, then falls back and the dead body remains permanently flaccid in the supine position."

Anonymous said...

My aunt was diagnosted as being brain dead after a nuclear medicine study indicated she had no blood flow to her brain only to her brain stem. The ICU explained that after the vent was taken off she would stop breathing completely and would pass away. However, she was able to breathe on her own for more than 4 hours without the help of a vent or any other kind of medical mechine.
So my point is, if you are able to breathe on your own for 4 hours like she did how can doctors tell you they are not alive?

Christina Dunigan said...

that really blows, Rachel.

I really don't get how you can be "dead" when you still show signs of life.

Anonymous said...

Interesting, I already told to my parents (I'm just 23) if something like this happends to me, give my organs to someone else or they can donate my body to the medicine, times like now are not attractive to invest in a dead body which is just flesh.

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