Understanding Brain Death and Organ Donation
Recently Dr Deepak Agrawal, professor of neurosurgery at the All India Institute of Medical Sciences (AIIMS), New Delhi has explained all about Brain Death through youtube videos. Here is the complete information “What Brain Death is actually Explained by Dr Deepak Agrawal AIIMS”.
What is brain death and how do we define it?
Brain death is the cessation of all brain activity due to a lack of oxygen to the brain cells.
If you remember from my previous video, brain cells are the only cells in the body that cannot regenerate, so if there is a lack of oxygen due to any cause, the cells will die within three minutes. Any hypoxic (lack of oxygen) event can lead to brain death. Common reasons are- attempted hanging, head injuries, spinal injuries or any other condition which leads to a decrease in the oxygen going to the brain.
Can people come to life after brain death?
Now we know what brain death is. However, you must have heard many stories that appear regularly in newspapers or on TV saying that there was a patient who was declared dead in the hospital, but he woke up subsequently in the mortuary or at the cremation ground! These are not untrue stories. Most likely these patients had some metabolic or other reasons which caused the heart to stop or become so faint that it was not detected and when that metabolic condition resolved, the patient became conscious again and started moving around. So do not confuse it with brain death. Brain death if it occurs is irreversible and the patient will/can never come back.
How do we diagnose a patient with brain death?
Now we come to the diagnosis. The best thing in India to happen was this law which was passed, and which was also known as the human organs act (1994), and in this act, the definition of brain death, how to diagnose brain death and what can be done legally in patients with brain death was properly defined. We need only and only clinical tests to diagnose brain death in India:
Assessment of the neurological condition- if the patient is conscious or unconscious and how deep the unconscious level is. This is using a scoring system known as GCS and it has to be at the absolute minimum of that score (3/15) to even qualify for consideration for brain dead testing.
The second thing we test is the pupils of the eyes and we see whether they are fixed and dilated.
3 Spontaneous Respiration
The third thing we see is spontaneous respiration because most of these patients are on ventilators and it is important to see if besides the ventilator breath, is the patient taking his own breath or not
4 Certain Reflexes
The fourth thing is we see for certain reflexes like the cough reflex, corneal reflex and gag reflex- if these are still present because these are the last things to go in a patient who is dying.
5 Apnea Test
Finally, we test for breathing in a different way which is known as the apnea test so that if we stop or disconnect the ventilator, is it possible that after five minutes or ten minutes the patient again starts spontaneously breathing or not. These tests are done by a neurologist or a neurosurgeon and have to be done six hours apart. If at both times they show the same result, the patient can be declared as brain dead.
Now a very important thing to know is that despite being declared brain dead, the patient’s heart will still be beating normally and this is the enigma! If the patient heart’s still beating but the brain has died and a neurosurgeon or a neurologist has said that the patient is brain dead, it is almost equivalent to saying that the patient is dead. However, because of the limitation in the Indian law, we obviously cannot just declare the patient dead and send him to the crematorium with a beating heart. That is why we wait till the heart also stops beating before the final declaration of death.
A lot of people have asked that if the heart is still beating why are you declaring the patient dead, and it is very difficult to explain to them that heart beating is now not considered as important as the brain works. The brain is the most critical organ and if it stops working then other organs take some time before they also stop working, especially in today’s age and date when we have life support equipment like ventilators like cardiopulmonary bypass equipment, wherein we can keep the patient heart beating breathing continuing without patient himself doing anything.
Why it is important to know the difference between brain death and cardiac death
Why is it important to diagnose or to certify a patient with brain death: The most important reason is that then this patient can be eligible for organ donation. As we know the most common causes of brain death are patients with head or spinal injury or from hanging. Most of these patients are young males, and some females between 18 and 30 years, and these are the patients best suited for giving their organs to someone else.
India has the worst organ donation rate in the whole of the world and that is because there are so many concepts around giving organs including religious concepts, stigmas, as well as people who just do not believe that when the heart is beating but the brain is dead so a patient is dead. We try to educate them, but the final education has to come from within.
Despite the legal sanction to diagnose brain death and to actually confirm that this patient is dead from the brain side, there is a lot of resistance. If the relatives agree to organ donation-that is an entirely different story altogether and if we feel that the patient is ready to give his organs and we have a recipient ready- then only is the time that the law allows a doctor to pronounce the patient dead. The patient might still have his heart is beating but this time we can make a death certificate and pronounce him dead giving an arbitrary time when he is being shifted to the operation theater to have his organs taken out.
Then the organ donation team which consists of surgeons like the kidney surgeon, the lung surgeon and the surgeons who remove other organs come together and take out the organs of the patient after that the body is again stitched up and sent to the mortuary and the organs obviously given to the recipients which are available that time.
So I hope you understand a little bit more about brain death, its diagnosis, its implications and how it helps us to have the organs donated to people who are waiting and you know in India there are so many patients with kidney disease, with lung disease, with cardiac problems who are waiting for organs from other patients to help them live longer, so we all have to think as a society.
Although I know that brain death is not a good thing, there are certain things that are not in our hands. The only thing in our hands is to prevent head injuries by wearing helmets and safe driving so that you do not land up with an accident in a hospital in a state like brain death.