when the brain dies

Thursday, November 22, 2012

No matter how athletic one might be, or not, there is but one prime purpose for the body. Its job is to provide a supportive environment for the brain to function at maximal capacity and perhaps to be a vehicle to take the brain to experience the world around it. When the body dies, when the lungs don’t work and provide oxygen and the heart no longer pumps blood, the brain dies as well. But what happens when the body is alive and well but the brain no longer functions. The plight of Hector Camacho illustrates how difficult it is for doctors to make the diagnosis of brain death and how hard it is for families to accept.

The Camacho family is split about whether to turn off the ventilator, the machine breathing for Mr. Camacho because his brain no longer sends signals for the lungs to work. The same fears strike families every day in the US and they are lean on the doctors at the bedside to explain what is happening. It is a tough explanation. While they can intellectually accept that the brain is not alive but with their eyes they see a warm body with a heartbeat and whose chest rises and falls with each cycle of the ventilator. What if the doctors are wrong and there is a flicker of a person alive deep inside that body? What happens if they shut off the machine and the body still lives? What if?

In response to the Uniform Determination of Death Act of 1993, the American Academy of Neurology developed guidelines to help physicians decide who was brain dead and who wasn’t. Without those guidelines, each hospital in the country had to develop their own standard. Those recommendations were most recently updated in 2010 and set standards for what patient was eligible, what needed to be found on physical examination and what tests needed to be performed before the patient could be declared brain dead. (http://www.aan.com/elibrary/neurologytoday/?event=home.viewArticleGraphic&size=full&id=ovid.com:/bib/ovftdb/00132985-201006170-00001&objectID=TTU1)

There are two parts of the brain that need to fail. The cortex, where body control and thought are located and the brain steam where automatic controls of the body (like breathing) are housed. Not only does the doctor need to establish that the whole brain no longer works, but that certain conditions (for example, high spinal cord injuries, fertilizer poisonings) that mimic brain death are not present.  The decision to declare a person brain dead is not taken lightly.

While the American Academy of Neurology has set its standards for the United States, other countries may have their own guidelines or none at all. All this does not help the Camacho family come together to decide who gets to decide whether the machines need to stop. Without an advance directive, sometimes called a living will, the wishes of the patient may not be known and the weight of the decision is borne by the family. Should families have end-of-life discussions when calm exists, it can be a blessing to the family in times of crisis. Knowing what the patient wants is better than guessing.

In the ideal world, everyone would pass away peacefully in their own bed, surrounded by loved ones. Unfortunately, the real world can get in the way.

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