Demystifying brain death

cerebral-bllod-flow-scan-wikimedia-commons Representational image | Wikimedi Commons

In 2013, the sensational case of Jahi McMath rocked the United States. The African American girl, then 13 years old old, experienced a massive haemorrhage following a complex tonsillectomy, and was declared brain dead.

Although the hospital certified the girl as brain dead, the family rejected it, since her heart continued to beat and her "ankles, arms and hips seemed to move sometimes". However, the doctors insisted that her primary senses had stopped responding. Now, four years later, at 17, she continues to thrive on ventilator support and feeding tubes, growing up smoothly through puberty. Now, a legal battle is in full swing in the US.

Last month, Robert Troug from the Center of Bioethics, Harvard Medical School, wrote a paper—Defining Death—breaking down the essential principles that guide the medical fraternity in the declaration of brain death, and the religious belief of patients who reject such claims. He believes that virtually every function that takes place in an otherwise healthy body, can be seen in a brain dead person who is on ventilator.

Rahul Pandit, Director, Intensive Care, Fortis Hospital, Mulund in Mumbai, clears the air on the criteria behind certifying a patient as 'brain dead,' and also explains India's stand in this regard and explains when and why brain dead patients are really dead.

What is brain death declaration?

The concept of brain death has been there for a long time. In 1968, the world medical assembly in Sydney formulated the first brain death criteria.

In India, it is essentially referred to in the context of organ donation. Essentially, there are two ways in which a person can die. One is cardiac death, in which the important organs such as the heart and the lungs stop functioning. Brain death is an equally accepted legal and medical terminology. The 1994 transplantation of Human Organ Act of India identifies brain death as a legal form of death. The difference with brain death is that, for some time, with the help of supporting machines, we can keep the organs functioning—a few hours to few days—although ultimately those organs too would stop functioning, because the brain is dead. It is an irreversible process. It is those few hours or couple of days before the organs die out, which offer a window of opportunity for organ donation.

When can a person be declared legally brain dead?

The brain is a hundred times softer than most other organs. Its death occurs due to lack of oxygen, stroke, bleeding, etc. It has a tendency to swell up very fast. But the brain has the skull, a protective mechanism which stops it from swelling up. Normal pressure inside the skull is equivalent to pressure inside the right side heart, almost 10-15 mm of mercury. But, when the skull starts to swell up, the pressure inside it can go beyond one's blood pressure, and once it goes above 70, the skull stops receiving blood flow; because there is no blood supply to the brain, it dies.

What are the issues doctors face when it comes to brain death declaration?

The biggest challenge is convincing doctors themselves that brain death exists, and is legal, and has to be understood right. Doctors who don't work in the ICU, or in neurology or neurosurgery, are never exposed to it. Secondly, given that the organs actually seem to work (albeit with the help of machines) even when the brain is dead, it is difficult to explain to the family members about the patient's state.

Shouldn't we do more to popularise the concept

The government, I believe, must do a lot more to promote the concept of organ donations in brain dead patients. For instance, if we can compulsorily enforce a column on the driving license which gets people to declare whether or not they'd like to be organ donors, i think we will have informed a lot of people about the concept in a limited time frame. Also, I think brain death should be included in the MBBS syllabus in the country so as to make sure that budding doctors are aware about the concept.

How many instances of brain death are seen at present?

Maharashtra itself witnesses about 150 organ donations per year and it is bound to increase considerably this year, I assume. Unfortunately, we don't have data on the number of patients who were diagnosed brain dead and the number of those whose organs actually got donated because that kind of data is limited to hospitals. Personally, when I do brain death tests, I take one of the family member inside the room with me, so that when they observe the test they realize that the patients is actually not breathing when taken off the ventilator. That helps them understand that the patient is, in fact, not alive anymore.

What is the legally accepted definition in India?

​In India, we follow the UK system which is the brain stem death. ​In the US, some states follow the brain stem death, while others follow the principle of 'whole brain death'. 

How is the process of declaration legally safeguarded in India?

It's a process which is heavily legally guarded in India. There are specified doctors (neurologists, neurosurgeons, intensivists, anaesthetists and physicians of MD level approved by the government) who can declare a person brain dead. Two different doctors carry out tests of reflexes to certify brain death in a gap of six hours, independently. The end of the second test is the time of death and then one can talk about organ donation to the family and counsel them. These organs, which are supported by machines when the patient is dead, have the ability to function normally once they are transferred into the body of a living patient, within the stipulated time frame after the patient's death. The donor families are the real heroes in the entire gamut of organ donation.

What is the difference between coma and brain death

Coma is, in layman's terms, unconsciousness. It may have reflexes, whereas brain death is irreversible and hence, it is beyond coma. In fact, the French definition of brain death is 'Coma de passe' meaning a state beyond coma.