Brain Death

Brain death is a state when the function of the brain as a whole, including that of the brain stem, is irreversibly lost.

This method of ascertaining death is only limited to patients in the Intensive Care Units (ICUs) who are deeply unconscious and whose cardiopulmonary functions are supported by machines. It accounts for less than 1% of all deaths


DIAGNOSIS OF BRAIN DEATH

1. Preconditions (all to be fulfilled):
• Patient in deep coma, apnoeic and on ventilation, for at least 24 hours.
• Cause of coma fully established and sufficient to explain the status of the patient.
• There is irremediable brain damage.

2. Exclusions
• Coma due to metabolic or endocrine disturbance, drug intoxication and primary hypothermia (defined as a core temperature of 32 C (90 F0 or lower).
• Certain neurological disorders, namely Guillian-Barre syndrome and locked-in syndrome.
• Coma of undetermined cause.
• Preterm neonates.

3. Diagnostic criteria (all to be fulfilled)1
• Deep coma, unresponsive and unreceptive, Glasgow coma score (GCS) 3/15.
• Apnoea, confirmed by apnoea test.

• Absent brain stem reflexes confirmed by the following tests:
- Pupillary light reflex
- Oculo-cephalic reflex
- Motor response in cranial nerve distribution
- Corneal reflex
- Vestibulo-ocular reflex (Caloric Test)
- Oro-pharyngeal reflex
- Tracheo-bronchial reflex



The Committee made the following recommendations:

1. That the concept and entity of brain death be recognised and accepted; and that brain death means death.
2. The diagnosis of brain death is a clinical diagnosis and no confirmatory test is necessary. The exception to this is only for children because of the greater ability of the child’s brain to withstand damage.
3. Two specialists who are registered medical practitioners, and who are experienced in diagnosing brain death, are qualified to certify.
4. Doctors involved in organ transplantation are not allowed tocertify brain death.
5. Hospitals where brain death is being certified, shall have a committee that functions as a coordinating body and is responsible for general policies, training and accrediting staff, counseling and overseeing the facilities available.
6. The brain death guideline shall be reviewed every 5-10 years to accommodate new knowledge and contemporary practice.


QUALIFICATIONS OF DOCTORS CERTIFYING BRAIN DEATH
1. Each hospital must have a subcommittee to appoint and review doctors authorised to certify brain death in that hospital.
2. Two specialists, with at least three (3) years of postgraduate clinical experience and trained in brain death assessment and in diagnosing brain death, are qualified to certify brain death. They should preferably be anesthesiologists, physicians, neurologists and neurosurgeons.

QUALIFICATIONS OF HOSPITALS
Brain death certification must be done in areas of the hospital with full facilities for intensive cardiopulmonary care of comatose patients.


Assessment and certification
• The assessment of brain death is to be carried out by two specialists. A repeat assessment and certification must be carried out at least 6 hours after the first, not necessarily by the same pair of specialists.
• The brain death certification is for 2 tests to be done 6 hours apart. The repeat test should still be performed regardless of whether the patient will or will not continue to be an organ donor.
• The “Brain Death Certification” form is filled up by the first set of doctors (A and B) and completed by the second set of doctors (B and C); or Doctors A and B if the same doctors are performing the repeat test. The time of death will then be declared by the doctors performing the repeat test.
• The time of death is at the time of the second testing. If for any reason, the second test is unable to be carried out 6 hours later,e.g. patient is unstable, then the time of death will be when the test is next repeated. Should the patient’s heart stops before the repeat test, that will be taken as the time of death.


OTHER CONSIDERATIONS
1. During the period of observation, the patient shall remain deeply comatose with no respiratory effort, no abnormal posture or movements in cranial nerve distribution.
2. Patients who do not meet all the above criteria shall not be considered for brain death certification.
3. For children, additional guidelines are required:
• The interval between two examinations is lengthened depending on the age of the child.
• An ancillary test (EEG) is recommended for those less than one year old.
• No recommendations are made for newborns or preterm infants.
4. Pitfalls in diagnosis may occur, especially if certain aspects of the clinical tests cannot be reliably performed (or evaluated). Ancillary laboratory tests (not usually mandatory) may be useful in these situations and in certain instances where children are involved.


Extracted from:GUIDELINE OF THE MALAYSIAN MEDICAL COUNCIL, MMC Guideline 008/2006 "BRAIN DEATH"