Furthermore, it is also presumed that owing to the public's mistrust in
the healthcare system, the relatives fear that the patient has been declared
brain dead for the purpose of organ donation. It, therefore, becomes essential
to de-link brain death from organ donation and frame a uniform policy in the
country, which requires the inclusion of "brain death" in the definition of
death in The Registration of Births and Deaths Act, 1969.
In Indian law, brain death is defined for the purposes of
organ donation and
transplantation through the
Transplantation of Human Organs Act in
1994, followed by an amendment in 2011. (
4✔)
Brain Death Certification
When the family of a person declared brain dead consents to donate any
of the deceased's organs, the steps laid out in the THOA for brain death
declaration are followed. Four doctors are required for certification of brain
death, and this certification is to be done twice, six hours apart, as per the
THOA. (
5✔) However, there are no clear guidelines on the standard of care when
the family declines to donate.
Doctors treating such patients are often unsure of what needs to be done
and hence do not turn off the ventilator. This practice of ventilating a
deceased goes against ethical medical practice and also blocks a valuable ICU
bed that may be required by needy and such shortages are more acute in
government hospitals.
Apnoea test, the gold standard in
brain death certification, is done to substantiate the initial diagnosis of
brain death characterized by signs such as lack of pupillary response, corneal
reflex, or cough reflex.
A patient is declared brain dead by a panel of four doctors when the
absence of spontaneous breathing is established by performing the apnoea twice.
The practice prevalent in some units involves clinicians performing the second
apnoea only if the family agrees to organ donation, as it is presumed that
brain death certification is only for the purpose of organ donation. This is
also because, in many instances where after the second apnoea is done and the
patient is declared brain dead, the family can decline to donate and request
the doctors to continue the ventilator support till circulatory death occurs.
The doctors find themselves bound to comply with such requests of the
grieving families and also the absence of guidelines with respect to
disconnecting the ventilator prevents them from making an informed decision.
Furthermore, many doctors are of the opinion that consent from the family is
required to withdraw support and take a defensive stand, fearing controversies,
yielding to the requests of families. (
6✔)
Guidelines for Brain Stem Death Declaration
In this context, the GO passed by the Kerala government, which clearly
defines the next step after a brain death declaration is made, is a welcome
move. The GO lays out guidelines for brain stem death declaration to ensure
standard clinical procedures are followed during the declaration.
- Establishing clinical brain
death diagnosis prior to subjecting a person to further confirmatory tests
- Clinicians should inform the
prognosis to the family of the patient who would be subjected to brain
stem death tests, including apnoea
- Assessing brain stem reflexes
using a series of tests, with an interval of six hours, by a panel of four
doctors (one impannelled by the Appropriate Authority)
- Apnoea test to be the last of
tests and to be performed only if other tests confirm the absence of brain
stem reflexes
- Apnoea to be performed twice,
with a minimum of 6-hour interval, for certainty and to avoid errors
- Neurophysiological or imaging
study to be performed when in doubt about the brain stem death diagnosis
to establish the absence of blood flow and electrical activity
- If brain stem death criteria is
met after two sets of examinations, the committee must declare patient
dead, note date and time
- Time of death is to be when
arterial pCO2 reaches target value during the second apnoea
- Family should be given brain
stem death confirmation report signed by all four doctors
- Cardiorespiratory support and all treatment
should be discontinued once brain steam death is declared
The Annexures attached to the order elaborate on the tests to be
followed to establish the absence of brain stem functions.
Conclusion
The GO paves the way for inclusion of brain death as a form of death in
both The Registration of Births and Deaths Act and in the death certificate. It
makes it possible to arrive at a uniform definition of death, which would
include both the circulatory and neurological criteria of death. The GO
achieves this primarily by steering clear of organ donation, thereby giving no
leeway for ambiguities.
References : - Ministry of Law, Justice and Company Affairs, Govt of India. The Transplantation of Human Organs Act, 1994 - (https://mohfw.gov.in/sites/default/files/Act%201994.pdf)
- Brain Death Revisited - (https://www.ncbi.nlm.nih.gov/pubmed/29547144)
- To help the living, India's hospitals need a uniform definition of death - (https://scroll.in/pulse/826963/to-help-the-living-indias-hospitals-need-a-uniform-definition-of-death)
- Ministry of Health and Family Welfare, Govt of India. The Transplantation of Human Organs and Tissues Rules, 2014 - (http://www.mohanfoundation.org/THO-Rules-2014.pdf)
- Evolution of deceased-donor transplantation in India with decline of commercial transplantation: a lesson for developing countries - (https://www.kisupplements.org/article/S2157-1716(15)31117-5/pdf)
- Discontinuation of ventilation after brain stem death - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1116089/)
Source: Medindia
