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Thursday, October 28, 2010

new brain death guidelines

The new guidelines for brain death in the journal Neurology this year state that they are attempting to make a very variable process for determining brain death more uniform. I am concerned about two things in the guidelines.

The first problem is accepting only one examination to determine brain death. All human evaluation is subject to error and a brain death exam is no exception. The reliability and consistency of all physical examination and diagnostic tests is not 100% and in some cases is extremely low. When declaring brain death, a judgment based on many, many tests and findings, the possibility of error increases, and requiring two examinations would make the probability of error a little lower, although not zero. Allowing brain death to be declared with only one exam greatly increases the false positive rate. I cannot agree with this strategy, inconvenient and costly as it may be for our medical system to keep someone alive who has only a slim chance of recovery.

Many of my readers may not agree, but I personally abhor the recent trend in Medicine towards allowing people to die, even when they and their families wish such efforts to be made. While I will defend to the death (now increasingly easily labelled!), that we should follow patients' wishes, those who wish to "rage, rage against the dying of the light", as Dylan Thomas urged, should be supported to do so. It is a very important moral and ethical use of our health care funds, as this care for life is an important piece of our humanity.

I have always valued the lesson taught me by one of my patients when I was a medical resident in training. She was a radiologist in her 30s who developed very severe systemic lupus erythematosis. She had hemolytic anemia (a process where her immune system destroyed her own blood cells), gangrene, and many infections of a catheter inserted for temporary dialysis. She needed constant transfusions, and her blood was infected. She had pneumonia and kidney failure. Her blood pressure was low. She kept us day and night for weeks treating her illness. We became tired and fatigued. I felt we were fighting a hopeless battle and that we should let her die. Her husband wanted us to do everything to try to save her. Her attending physician insisted that we keep at it. We did. She recovered completely. 25 years later, she is still alive. Recently on an East Coast trip, I took a detour and visited her at her home a few years ago and thanked her for what she taught me: A patient's life should not be threatened by doctors' fatigue and their feeling that dedicated family members are over the top. These family members may need to be over the top to save the lives of their dear ones. Young doctors do not appreciate the potential for recovery and the meaning of death. How can they when they so often have had so little experience of life?

Our protocols for brain death should err on the conservative side, because the doctors in charge, de facto, of these decisions in our acute care hospitals are so young and so often err the other way. What's your opinion?

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