Miscellenia
Brainstem Death : Implications in India
NK Sethi*, PK Sethi**
Abstract
Brainstem death and brain death although practically same with regards to the concept of organ donation,
remain technically different. Brain death mandates irreversible cessation of all the functions of the
entire brain and brainstem while brainstem death signifies irreversible damage to the brainstem. As per
the Indian law, brainstem death is the legal requirement and not brain death.
R ecently in a big super-specialty hospital in New Delhi, a
patient was declared brain dead as per the currently
accepted standard criteria followed to make such a diagnosis.
The confusion arose when a doctor ordered an EEG as a
confirmatory test. The EEG showed some cortical activity
and when the patient’s relatives showed this EEG to another
doctor in another hospital, he opined that that the patient
could not be declared brain dead as the EEG was showing
cortical activity. The relatives were justifiably confused and
angry and sought an explanation for this paradox. Such cases
are being increasingly encountered in our clinical settings
especially in large superspeciality hospitals where cadaveric
organ donation programs are being aggressively pursued.
The confusion regarding brainstem death versus brain death
lends one to ask ‘how much brain is needed to be dead for it
to be called brain death?’
Death today is both a legal and a medical question. Before
the concept of brainstem death or brain death came into
existence, the determination of death involved simply the
documentation of loss of vital signs. The loss of
cardiopulmonary function as a determination of death is a
concept inherently simpler to understand and accepted by
the relatives as against brainstem death or brain death.
Beginning in the middle of the 20th century, medical science
had advanced to the point that it was possible to sustain
more and more patients who had suffered irreversible head
trauma. Then there were those patients whose
cardiopulmonary status had been restored but who remained
profoundly and persistently unconscious and unresponsive.1
This led to the development of guidelines for making
neurological based determinations of death. The first such
guidelines were advanced by a committee at Harvard Medical
School in 1968. These guidelines differ in some aspects in
different countries around the world. The differences are
*Resident, Department of Critical Care; **Senior Consultant and
Chairman, Department of Neurology; Sir Ganga Ram Hospital,
Rajender Nagar, New Delhi.
Received : 14.1.2002; Revised : 23.4.2003; Accepted : 8.8.2003
910
essentially with respect to the mandatory qualifications of
the physicians; number of physicians needed to declare brain
death, time of observation and the need for confirmatory
laboratory testing.2 Let us try to discuss some of these issues
with respect to India.
In India, the Transplantation of Human Organ Bill was
introduced in the Lok Sabha on 20th August 1992 and became
the Transplantation of Human Organ Act in 1994.3 This
essentially follows the United Kingdom criteria for brainstem
death as against the United States criteria where as per the
Uniform Determination of Death Act irreversible cessation of
the entire brain and brainstem function needs to be
documented that is brain death and not brainstem death. The
United Kingdom criteria for brainstem death permeate in the
previously colonized countries (such as India) while Central
and South American countries generally follow the United
States position on whole brain death. As per the
Transplantation of Human Organ Act of 1994, to make a
diagnosis of brainstem death requires a panel of four doctors
consisting of the doctor in charge of the patient, the doctor
in charge of the hospital where the patient was treated, an
independent specialist of unspecified specialty and a
neurologist or a neurosurgeon. The burden of proof rests
with the specialist of the neurosciences, with the other
members confirming the diagnosis. All the four doctors sign
each test done to document absence of brainstem function
namely pupillary reflex, doll’s head eye movement, corneal
reflex (both sides), gag reflex, cough (tracheal), eye movements
on caloric testing bilaterally, absence of motor response in
any cranial nerve distribution and apnoea test. Reversible
causes of coma should be excluded by all possible means
namely the absence of any intoxication (alcohol), depressant
drugs and neuromuscular blocking agents. Primary
hypothermia, hypovolaemic shock and metabolic and
endocrine disorders should also be sought for and excluded.
Thus in India, it is brainstem death and not brain death which
is the legal requirement. EEG is not mandatory nor are other
confirmatory tests like cerebral angiography, transcranial
Doppler and radionuclide scan. So theoretically it is possible
JAPI • VOL. 51 • SEPTEMBER 2003
that a patient may be certified ‘deceased’, eventhough the
EEG may be documenting some cortical activity because in
India we are documenting brainstem death and not whole
brain death. Confirmatory tests may however be carried out if
the panel of doctors is in doubt or disagreement of the
diagnosis. This raises two interesting questions. First, if the
relatives refuse the donation of organs in a brainstem-dead
certified patient, can the life support systems be disconnected
and switched off. Second, if the relatives request more time
to decide about organ donation during which the
cardiopulmonary function of the deceased patient ceases,
what time does one record as the time of death. Can one die
more than once (first, when one’s brain dies and again later
when one’s heart stops).
Unfortunately the Transplantation of Human Organs Act,
1994 does not clearly give any answers to the above two
questions. However the United Kingdom criteria (on which
the transplantation of human organs act of 1994 is based)
provides an answer to the above difficult question where it
states that ‘the medical officer will usually speak to the
relatives and announce the death. The time of death is
recorded as the time when the final test to fulfill the criteria
for brainstem death was satisfied’. In the Dority Vs Superior
Court of San Bernardino County of USA case4 the court ruled
that “ brain activity is a necessary condition to legal
personhood and perhaps with the exception of the fetus, it is
a sufficient condition for legal personhood. It appears that
once brain death has been determined...no criminal or civil
liability will result from disconnecting the life support
devices.” To the best of our knowledge no such case has
been ruled upon by the Indian judiciary but the above case
can be quoted in defence of disconnection of life support
devices once a patient has been certified as brainstem dead.
CONCLUSION
The distinction between brainstem death versus brain
death is essential for all physicians whatever may be their
speciality. The knowledge of the prevailing law with regards
to brainstem death as against brain death in India as also the
ambiguity in the law with regards to disconnection of life
support devices in a brainstem death certified patient will go
a long way in preventing unnecessary confusion and
apprehension both on the part of the treating physicians and
the relatives.
REFERENCES
1. Capron AM. Brain death-well settled yet still unresolved. N
Engl J Med 2001;344:1244-6.
2. Wijdicks EFM. Brain death worldwide: accepted fact but no
global consensus in diagnostic criteria. Neurology 2002,58:20-
25.
3. The Transplantation of Human Organs Act, 1994 Republic of
India.
4. Dority V. Superior Court of San Bernardino County 1983,193
Cal. Rptr.288-91.

Announcement

8th International Epidemiological Association (IEA) - South East Asia Regional Scientific
Meeting will be held on 5-8 December 2004, India.

For further details please contact : Dr. Babu L Verma, South East Asia Regional Office, Division of
Biostatistics, Department of Social and Preventive Medicine, MLB Medical College and Hospital,
Jhansi 284 128, UP, India.
Phone : +91-517-2320196 (Main Office), +91-517-2320193 (Camp. Office), Mobile : 9415030170,
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Sd/-
BL Verma

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