Two stories have made the news recently about the policies regarding the status of allegedly brain dead patients.
George Pickering III was declared brain dead whilst in a coma in a Texas hospital. He was valuable as an organ donor and his mother gave medics permission to harvest his organs, but his father took matters into his own hands to prevent him from being taken off of life support. Pickering made a full recovery.
That story was followed by a wider view of hospitals’ policies for determining brain death. NPR aired the story Researchers Find Lapses in Hospitals’ Policies For Determining Brian Death on All Things Considered on December 28. “A provocative study finds that hospital policies for determining brain death are surprisingly inconsistent and that many have failed to fully implement guidelines designed to minimize errors.”
We noticed that the photos of Pickering, on life support, didn’t have EEG electrodes during his ICU stay. Continuous EEG (cEEG), can help ensure proper diagnosis of brain health, and determine appropriate cease treatment cases.
Cadwell’s Arc® EEG system is a powerful tool for the ICU. It can help save lives, and also help families know that it’s safe to let go.
Cadwell Editorial: Brain Death Protocol and Brainstem Death
- Schoobaar, Clinical Business Director
Policies for determining brain death is different in many parts of the world. In most parts of Europe, when determining brain death (as part of the organ donor protocol), an EEG is required. There are however important conditions that are to be met.
First of all, the core body temperature is to be about normal (37°C / 98.6°F). The next condition is that there is no hypotension, and the last condition is that there is to be no intoxication by barbiturates and neurodepressive agents such as Propofol and thiopental.
There conditions were set because any of them on their own could cause the EEG activity to disappear and thus lead to the incorrect conclusion of electrocerebral inactivity. The diagnosis brain death is based on this electrocerebral inactivity.
The literature has never reported a patient recovering from this clinical situation provided that the mentioned criteria were met. The problem with this is that sometimes the necessary treatment of patients require them to be hypothermic, hypotensive or medicated at almost toxic levels. This makes it difficult to adhere to all the conditions. Also, the EEG can only record activity from the cerebral cortex and not of the subcortical structures. Therefore, theoretically, you cannot determine total brain death if you cannot measure subcortical brain activity. Because of this, some countries tend to develop alternative/additional ways to determine brain death.
One of the alternatives is to determine brainstem death. The premise is that a functionally intact brainstem is a conditio sine qua non for an intact consciousness. Therefore, proper examination of the brainstem functionality (determining depth of coma and examination of brainstem reflexes is an important way to determine the capability of the patient to regain consciousness and clinically recover from a deep coma. One must be aware that sedatives and metabolic dysregulation can interfere with the outcome of the brainstem reflex testing.
The trend is that EEG and the examination of brainstem reflexes and coma depth assessment is necessary in order to determine total brain death. In most countries in Europe EEG recording is part of the organ donation protocol and the additional brainstem death is being discussed. Some countries perform additional exams like BAEP’s to assess functionality of the brainstem and SEP’s to assess functionality of the cortico-thalamic structures. Some clinics use transcranial Doppler to determine patterns of cerebral blood flow (absence of constant diastolic flow is proof of absent cerebral perfusion) indicative for brain death.
In the USA, the donor protocol is initiated after determining brainstem death. If brainstem death is diagnosed, corroboration by EEG is not required. According to the literature, provided that all criteria are met, clinical recovery is not possible. Retrospective studies have shown that patients that have “miraculously” recovered from a brain death diagnosis have not been examined properly in terms of the criteria discussed above.