Brain death with prolonged somatic survival

Taking the pulse of brain death: A meta-analysis of the natural history of brain death with somatic support

BACKGROUND AND PURPOSE

The conceptualization of brain death (BD) was pivotal in the shaping of judicial and medical practices. Nonetheless, media reports of alleged recovery from BD reinforced the criticism that this construct is a self-fulfilling prophecy (by treatment withdrawal or organ donation). We meta-analyzed the natural history of BD when somatic support (SS) is maintained.

METHODS

Publications on BD were eligible if the following were reported: aggregated data on its natural history with SS; and patient-level data that allowed censoring at the time of treatment withdrawal or organ donation. Endpoints were as follows: rate of somatic expiration after BD with SS; BD misdiagnosis, including "functionally brain-dead" patients (FBD; i.e. after the pronouncement of brain-death, ≥1 findings were incongruent with guidelines for its diagnosis, albeit the lethal prognosis was not altered); and length and predictors of somatic survival.

RESULTS

Forty-seven articles were selected (1610 patients, years: 1969-2021). In BD patients with SS, median age was 32.9 years (range = newborn-85 years). Somatic expiration followed BD in 99.9% (95% confidence interval = 89.8-100). Mean somatic survival was 8.0 days (range = 1.6 h-19.5 years). Only age at BD diagnosis was an independent predictor of somatic survival length (coefficient = -11.8, SE = 4, p < 0.01). Nine BD misdiagnoses were detected; eight were FBD, and one newborn fully recovered. No patient ever recovered from chronic BD (≥1 week somatic survival).

CONCLUSIONS

BD diagnosis is reliable. Diagnostic criteria should be fine-tuned to avoid the small incidence of misdiagnosis, which nonetheless does not alter the prognosis of FBD patients. Age at BD diagnosis is inversely proportional to somatic survival.

Whole body gestational donation

Whole body gestational donation offers an alternative means of gestation for prospective parents who wish to have children but cannot, or prefer not to, gestate. It seems plausible that some people would be prepared to consider donating their whole bodies for gestational purposes just as some people donate parts of their bodies for organ donation. We already know that pregnancies can be successfully carried to term in brain-dead women. There is no obvious medical reason why initiating such pregnancies would not be possible. In this paper, I explore the ethics of whole-body gestational donation. I consider a number of potential counter-arguments, including the fact that such donations are not life-saving and that they may reify the female reproductive body. I suggest if we are happy to accept organ donation in general, the issues raised by whole-body gestational donation are differences of degree rather than substantive new concerns. In addition, I identify some intriguing possibilities, including the use of male bodies-perhaps thereby circumventing some potential feminist objections.

Neuropathologic findings in a young woman 4 years following declaration of brain death: case analysis and literature review

Brain death (death by neurologic criteria) is declared in 2% of all in-hospital deaths in the United States. Published neuropathology studies of individuals maintained on cardiorespiratory support are generally decades old, and notably include only 3 cases with long intervals between brain and "somatic" death (68 days, 101 days, 20 years). Here, we share our observations in a young woman supported for nearly 4½ years following declaration of brain death after oropharyngeal surgery. While limited by tissue availability and condition, we found evidence of at least partial perfusion of the superficial cerebral and cerebellar cortices by external carotid and vertebral arteries (via meningeal and posterior pharyngeal branches), characterized by focal cellular reaction and organization. Dural venous sinuses had thrombosis and recanalization, as well as iron deposition. In nonperfused brain areas, tissue "mummification," akin to that seen in certain postmortem conditions, including macerated stillbirths and saponification (adipocere formation), was identified, and are reviewed herein. Unfortunately, correlation with years-earlier clinical and radiographic observations was not possible. Nevertheless, we feel that our careful neuropathologic inspection of this case expands the understanding of the spectrum of human brain tissue alterations possible in a very rarely seen set of conditions.

Whole-brain death and integration: realigning the ontological concept with clinical diagnostic tests

For decades, physicians, philosophers, theologians, lawyers, and the public considered brain death a settled issue. However, a series of recent cases in which individuals were declared brain dead yet physiologically maintained for prolonged periods of time has challenged the status quo. This signals a need for deeper reflection and reexamination of the underlying philosophical, scientific, and clinical issues at stake in defining death. In this paper, I consider four levels of philosophical inquiry regarding death: the ontological basis, actual states of affairs, epistemological standards, and clinical criteria for brain death. I outline several candidates for the states of affairs that may constitute death, arguing that we should strive for a single, unified ontological definition of death as a loss of integrated functioning as a unified organism, while acknowledging that two states of affairs (cardiopulmonary death and whole-brain death) may satisfy this concept. I argue that the clinical criteria for determining whole-brain death should be bolstered to meet the epistemic demand of sufficient certainty in defining death by adding indicators of cerebro-somatic dis-integration to the traditional triad of loss of consciousness, loss of brainstem function, and absence of confounding explanations.

Controversy in the Determination of Death: Cultural Perspectives

The definitions of death have changed throughout recorded history to include not just cardiac death but death by neurological criteria as well. Given the many cultures present in the world, it comes as no surprise that declaring death takes many forms. In the Western world, brain death has gained common acceptance (though not universal), while other cultures and religions have struggled with this issue, especially as it surrounds the controversy of donated organs. There is legal precedent to support death by neurological criteria, as well as support for hospital systems and physicians to terminate somatic support of the brain-dead patient; however, these laws differ greatly from country to country. When dealing with a controversial topic, differing laws, and grief-laden families, it becomes especially crucial that health care staffs are educated regarding varying cultural beliefs surrounding death. In the majority of cases, with kindness and compassion, common ground between science and social perspectives can be found, leading to resolution of care for this group of patients.

Spinal cord

We first present a brief historic review of developments in the understanding of spinal cord clinical neuroanatomy and neurophysiology over the past 200 years. We then discuss the technical aspects that apply to the examination of the human spinal cord giving details on the interrelations between the spinal cord and the overlying structures, including the meninges and vertebrae. The subsequent discussion focuses on diseases of the spinal cord. Diseases that affect the spinal cord are vascular disease, diseases of spinal column, trauma, developmental abnormalities, central nervous system degenerative disease, inflammatory disease, metabolic and nutritional myelopathies, and tumors. We summarize our knowledge regarding general reactions of spinal cord tissue to disease, in particular Wallerian degeneration of descending/ascending tracts and axonal reaction. Two categories of disease will be covered in depth: vascular disease of the spinal cord, including a review of normal vascular anatomy, and diseases of the vertebral column that can affect the cord secondarily.

Brain death

Since the Harvard report of 1968, the concept of brain death has become widely recognized throughout the world. Most developed countries have accepted brain death as constituting death of the individual, and allow such patients to be used as ‘heart-beating’ organ donors. Although the US and most other countries accept a ‘whole-brain’ definition of brain death, the concept of brainstem death has been adopted in the UK. This article describes the UK diagnostic criteria in detail, and compares these with the criteria used in other countries. Management of the brain dead organ donor is described, and controversies relating to the concept of brain death are also discussed.

Analytic Reviews : The Diagnosis of Brain Death in the Adult Patient

The biological tenet upon which brain death is founded is absolute. The brain's inability to undergo cellular divi sion ensures that once individual neurons die they can not be replaced. Extrapolating this to the total brain, once the entire brain is dead no recovery can occur, and the patient's family can be guaranteed of that fact. The clinician, therefore, is faced primarily with a diagnostic challenge in determining that brain death is indeed pres ent. The components, procedures, and limitations of that diagnostic process in the adult patient are the sub jects of this discussion.

Dilemmas in Intensive Care Medicine: An Ethical and Legal Analysis

The high-technology medicine available in today's intensive care setting not only provides near miraculous benefits for some patients, but it also creates new and troublesome ethical and legal dilemmas for patients and practitioners. Standards for access to and discharge from the intensive care unit, "do not resuscitate" orders, determination of death, organ retrieval, advanced directives, decision-making capacity, and substantive and procedural guidelines for termination of treatment in incompetent patients are among the problems. Those issues, along with the emerging question of withholding nutrition and fluids, are discussed in this article.

“Brain Death,” “Dead,” and Parental Denial

This section provides reactions to current and emerging issues in bioethics.

Loss of faith in brain death: Catholic controversy over the determination of death by neurological criteria

The diagnosis of death by neurological criteria (colloquially known as ‘brain death’) is accepted in some form in law and medical practice throughout the world, and has been endorsed in principle by the Catholic Church. However, the rationale for this acceptance has been challenged by the accumulation of evidence of integrated vital activity in bodies diagnosed dead by neurological criteria. This paper sets out 10 different Catholic responses to the current crisis of confidence and assesses them in relation to a Catholic understanding of philosophical anthropology. Having considered each of these responses, none is found to provide good grounds for the moral certainty about death needed for current transplant practice to be ethically acceptable. Unless adequate grounds for the use of neurological criteria can be restored, current transplantation practice will have become what Pope John Paul II called a ‘furtive, but no less serious and real, form of euthanasia’.

Delayed homicides due to infant head injury initially reported as natural (cerebral palsy) deaths

A spectrum of neuropathology occurs in infants who sustain traumatic brain injury. Because of a prolonged survival interval, there is a risk that these deaths may not be recognized as a sequel of trauma. We reviewed the records in New York City of 5 delayed fatalities due to nonaccidental infant head injury that had survival intervals from 2.5 to 17 years. The head injuries occurred at 2 to 3 months of age, and death occurred at 2.5 to 17 years of age. Initially, they were reported as natural deaths by treating physicians, families, and/or police. All 5 infants had unexplained or poorly explained remote traumatic head injury that included subdural hematomas. At autopsy, the neuropathologic exam demonstrated remote subdural hemorrhages and lesions related to chronic hypoxic-ischemic injury including atrophy, arterial infarcts, border-zone infarcts, and cystic encephalomalacia. Each child survived the initial injury but later succumbed to the delayed effects of secondary hypoxic-ischemic encephalopathy. These 5 deaths highlight the need to investigate independently the medical history of any child (or adult) who dies with a clinical diagnosis of "cerebral palsy." The term cerebral palsy often is used as a catchall for any patient who has had neurologic impairment since infancy or childhood. If there is a direct link between the initial injury and the death, even if the injury occurred many years before death, then the injury is the proximate cause of death and dictates the manner of death. All 5 deaths were certified as homicides.

Extended somatic support for pregnant women after brain death

OBJECTIVE

To review case reports of pregnant women who have been supported after brain death until successful delivery of their infants. From these reports and other literature about brain death, normal physiologic changes of pregnancy, and specific needs for fetal development, recommendations were made to assist in supporting pregnant women after brain death until delivery of a mature fetus who is likely to survive.

DATA SOURCES

Personal files and experiences, MEDLINE review of case reports and publications about physiologic changes present during normal pregnancy and after brain death, and the critical needs for fetal development were included.

DATA EXTRACTION

Eleven reports of ten patients comprise the accumulated clinical experience. Hypotension, requiring fluid administration and inotropic/vasopressor therapy, occurred in all the mothers, and in six cases, was the reason for urgent delivery. The longest period of support was 107 days, from 15 to 32 wks of gestation. Two mothers also became organ donors. Recurrent infections, thermolability, and other complications common to prolonged ICU care were encountered. All infants survived. One had congenital abnormalities caused by phenytoin use by the mother. When followed, all others developed within normal growth and mental variables. These cases plus literature citations noted above were used to develop recommendations for maternal/fetal care.

CONCLUSION

Preservation of uterine/placental blood flow is the most important priority during somatic support. Imprecise autoregulation of the uterine vasculature during maternal hypoxemia or hypotension makes this goal a significant challenge. Special considerations for nutrition; medication use; cardiovascular, respiratory, or endocrine therapy; fetal monitoring; hormone replacement; and ethical concerns are discussed.

Palliative care with pregnant women

When a pregnant woman has been declared dead because of brain death or cerebral death and a permanent vegetative state, the life and wellbeing of her fetus become a matter of crucial consideration. The possible options are an immediate caesarean section, continuation of efforts to maintain the organ functions of the woman to allow her fetus to mature, or discontinuation of the woman's somatic organ support. The decisions depend on the viability of the fetus, the probable health status of the fetus, any wish expressed by the mother and the commitment of her next of kin. Maintaining the pregnancy in order for the fetus to become more mature requires counselling of the woman's partner or family members. Immediate recourse of caesarean section should be withheld if the fetus is too immature or has a probable poor health status. Terminally ill pregnant women may require treatments which are potentially harmful to their fetus. Medical abortion early in pregnancy or premature delivery later in pregnancy are the usually recommended options. When the fetus is viable although extremely premature, delivery should not be imposed on a woman concerned with the risk of leaving a possibly handicapped child after her death.

Successful cardiopulmonary resuscitation outcome reviews

An implicit question in every pre-hospital cardiopulmonary resuscitation (CPR) scenario is 'what will be the quality of life if a save is achieved?' This issue has implications for doctrine, policy, training and post-CPR counselling of both resuscitator and victim. Post-salvage neurological syndromes in surviving victims include amnesia, personality change, cognitive loss, depression, Parkinsonian syndromes, decorticate and decerebrate states and permanent brain damage with vegetative existence. Children who are salvaged by CPR rarely have pre-existing co-morbidities; but 75% of adults have pre-existing cardiac disease, cancer or diabetes. Such, of course, continue after a successful resuscitation. In the case of children who are resuscitated from acute hypoxic insults, the quality of life is generally good and, in the specific instance of survivors from near-drowning, some 95% will lead lives relatively unmodified. Although successful CPR resuscitation rates remain low in adults, the quality of life of those who leave hospital remains generally high. CPR involves two feature subjects, the resuscitator and the victim. Just as for the victim, so too the resuscitator's life is modified by CPR and its aftermath, whether immediate salvage has been achieved or not. This review addresses these issues, as a successful CPR (dramatic as it is) is not a conclusion but the beginning of a new phase of life for both resuscitator and victim.

[Technical recommendations for the electroencephalogram (EEG) recording in suspected brain death]

Brazilian Clinical Neurophysiology Society guidelines and pertaining comments concerning electroencephalogram (EEG) recording in suspected brain death are presented. EEG is not intended as a substitute, rather as a complement to neurologic evaluation.

The physiological changes associated with brain death--current concepts and implications for treatment of the brain dead organ donor

The profound physiological disturbances associated with severe intracerebral pathology have long been recognized. These changes have also been described in the brain dead potential organ donor but have only been studied since the early 1980s. Physiological disturbances in the brain dead organ donor result in a diffuse vascular regulatory injury and a diffuse metabolic cellular injury. The net result of these changes is an inexorable deterioration of all organs and eventual "cardiovascular death" of the patient. This paper reviews these physiological changes and the effect they may have on solid transplantable tissues, and discusses the management of brain dead organ donor with regard to these changes. Current concepts of brain death and how they may affect the interpretation of the observed physiological changes are also reviewed.

Moral, Ethical, and Legal Issues in the Intensive Care Unit

The United States Supreme Court's recent ruling in Cruzan and Congress' passage of the Patient Self-Determination Act of 1990 are part of the expanding legal and ethical concerns affecting medicine. These changes force us to examine not only issues in termination of treatment and advanced directives, but questions of medical futility and the quandary of how to pay for beneficial but costly new technologies. These problems indicate the need for more vigorous intensive care unit admission and discharge criteria and for policies on appropriate care of patients. We review these developments and propose approaches to such issues as do not resuscitate orders, requests for “futile” treatments, brain death, organ retrieval, advanced directives, and decision making for competent and incompetent patients.

The pregnant brain dead and the fetus: must we always try to wrest life from death?

This article deals with the ever more timely and often vexing topic of maintaining a brain-dead mother as an incubator for her developing offspring. It explores the issue by: (1) reviewing the history of the problem and the "state of the art" today, (2) examining the moral problem of using brain-dead persons as incubators for potential or actual others, (3) searching for moral differences between maternal death early or late in pregnancy, and (4) presenting a possible resolution in such tragic cases. It concludes that (1) a moral necessity to deliver viable infants from brain-dead mothers exists; (2) the farther from viability brain death occurs, the more maintaining the mother as an incubator resembles experimental therapy with its imperative for careful, informed consent; (3) experimental therapy not being morally necessary, its proceeding under these tragic circumstances should invoke community support for the next of kin in dealing with the immediate and long-term costs; (4) all ethical problems proceed in a context to which the moral actors must be sensitive and one that alters the conclusions made.

Late neuropathological consequences of strangulation

A case of a young man who was a victim of strangulation is presented. He arrived at the hospital in refractory status epilepticus, controlled only with intravenous pentobarbital. The initial CT scan showed mild cortical edema. Two days later, a CT scan showed diffuse cortical swelling and bilateral basal ganglia infarcts. Upon discontinuation of pentobarbital therapy, his neurological examination revealed spontaneous ventilation and a gag reflex. A CT scan 4 weeks after the insult demonstrated hypodensities in both cerebral hemispheres and hydrocephalus. EEG was isoelectric throughout his hospitalization. He survived nearly 5 months and succumbed to pneumonia. Neuropathological examination demonstrated severe encephalomalacia, multiple cystic infarcts and generalized compensatory ventriculomegaly. Microscopic examination was particularly remarkable for a pronounced gemistocytic astrocyte proliferation in the white matter. This case illustrates the long-term neuropathological consequences of severe, global hypoxia/ischemia and the paucity of intact brain required to maintain a persistent vegetative state.

Management of maternal vegetative state during pregnancy

A pregnant patient with irreversible anoxic brain damage was maintained by life-support measures from 14 weeks' gestation until delivery of a healthy male infant at 34 weeks. Because two patients (the mother and the fetus), as well as the surviving family members, will be affected by decisions about life support, each case should be assessed individually.

Later changes in brain death. Signs of partial recirculation

The varying cell picture of the brain in brain death is impressive. Some authors have interpreted this cell picture as a result of intravital autolysis and others as necrosis, at which the maturation time obviously plays an important part. The following time-dependent cerebral changes were established on the basis of an evaluation of 190 brain death cases: (1) neuronal necroses that arise at different rates within the cerebral cortex and the lower brain stem; (2) a hemorrhagic-meningoencephalitic reaction that occurs exclusively at least 4 days after brain death or hemorrhages alone after intervals of at least 48 h; and (3) a washed-out tissue picture. The alterations in the spinal border zone of the total infarction, like in the brain itself, increase rapidly after 48 h. The regular onset of inflammatory alterations after long brain death intervals can only be explained by partial recirculation due to a decline of the high intracranial pressure. The hemorrhages and increasing necroses in some cases with longer intervals therefore are likewise evidence of a not entirely complete cerebral ischemia in spite of an angiographically demonstrable circulatory arrest.