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Brain Stem Death - An Overview: JSRG Saran and Jagadish R Padubidri
Brain Stem Death - An Overview: JSRG Saran and Jagadish R Padubidri
Brain Stem Death - An Overview: JSRG Saran and Jagadish R Padubidri
Medico-Legal
Journal 0(0) 1–3
Abstract
The concept of brain death has been a very intriguing topic and has taken many forms over the years. Brain stem death is
a complex state of inactivity defined by the loss of reflexes of the pathways that pass through the brain stem, the ‘shaft’
of the brain which links the spinal cord to the cerebral cortex and the cerebellum where there is apnoea, loss of eye
movement and pain sensation. There are many criteria, based on which a person can be said to be brain dead. The best
recognised of these are the Harvard, Minnesota and Philadelphia criteria. India follows the UK notion of brain stem
death, and the Transplantation of Human Organs Act was passed in 1994 by the Indian parliament, which legalised
brain- stem death, and in 1995 ordered the brain death certification procedure, which is certified by a ‘Board of Medical
Experts’. Also, there are some legal and ethical implications that have to be considered in cases of disagreement in
diagnosis among the panel of doctors, time of death in cases when patients’ relatives disagree or request more time for
organ donation or to disconnect the life support system. In routine clinical practice, the issues pertaining to brain stem
death should be dealt with by experienced physicians, counselling the family members or relatives and educating them
about organ donation.
Keywords
Brain stem death, Harvard criteria, evolution of brain stem death, ethical and legal implications
Introduction
cord below; hence, it is a very important structure in
The declaration of a person to be brain dead has always relaying information and inputs from the periphery to
been a topic of debate and has been an unresolved the brain. It is formed by the midbrain superiorly, pons
problem for a long time, even now. There always Varolii and medulla oblongata inferiorly which
arises a common question, ‘Is a brain dead person clas- continue with the spinal cord. Its main functions are
sified as living or dead?’ Also the different criteria used regulating the rate of respiration through the respira-
to diagnose a person as brain dead has evolved over tory centre, to control of eye movements, reflexes and
many years, some follow brain stem death and others, level of consciousness, perception of pain and the regu-
brain death concepts. Now there are a panel of doctors lation of the cardiovascular system. Therefore, if the
who should individually assess, collectively come to an brain stem is dead, then all the functions are lost.
agreement and declare a person brain dead. Of course, Thus, brain stem death can be defined as a complex
there are many legal and ethical implications that have state of inactivity, portrayed by the loss of reflexes of
to be considered, both among the doctors or the the pathways that pass through the brain stem, which
patient’s family. Therefore, the public should be made eventually results in apnoea, loss of eye movements and
aware of issues relating to brain stem death, and hence
educated and encouraged to proceed towards organ 1
Kasturba Medical College (affiliated to Manipal Academy of Higher
donation. Education, Manipal, Karnataka, India), Mangalore, India
2
Department of Forensic Medicine, Kasturba Medical College (affiliated
to Manipal Academy of Higher Education, Manipal, Karnataka, India),
Brain stem death and its causes Mangalore, India
Before we talk about brain stem death, we should know Corresponding author:
about the brain stem and its functions. The brain stem Jagadish R Padubidri, Kasturba Medical College Mangalore, Manipal
is a stalk-like structure, which acts as a bridge between Academy of Higher Education, Manipal, India.
the cerebral cortex and cerebellum above and the spinal Email: ppjrao@gmail.com
2 Medico-Legal Journal 0(0)
Table 3. Philadelphia criteria. Table 4. Tests done to document loss of brain stem function.
Absence of responsiveness to internal and external environment 1. Pupillary or light reflex (both sides)
No spontaneous breathing for more than 3 min 2. Doll’s head eye movement or vestibulo-ocular reflex
Absence muscular movements with generalised flaccidity 3. Corneal or blinking reflex (both sides)
Absence of reflexes and responses 4. Gag or pharyngeal reflex
Declining arterial pressure without the use of drugs or by other 5. Cough (tracheal)
measures 6. Eye movements on caloric testing bilaterally
Isoelectric electroencephalogram recorded spontaneously and 7. Absence of motor response in all cranial nerve distributions
during tactile and auditory stimulation 8. Apnoea test
Saran and Padubidri 3
neuromuscular receptors. Primary hypothermia, hypo- experienced group of doctors for diagnosing the cases.
volemic shock and metabolic and endocrine disorders Also, the family and relatives of the patient should con-
should also be sought for and excluded. stantly be counselled on multiple occasions about brain
stem death and about organ donation, as it can help
save a living patient who is suffering from an organ
Legal and ethical implications dysfunction which has to be transplanted in order for
Sometimes, due to difference in opinion, there can be his or her survival.
disagreements as to diagnosing the patient with brain
stem death among the panel of doctors, when further Declaration of conflicting interests
confirmatory tests are carried out.5 Also, there is a con- The author(s) declared no potential conflicts of interest with
fusion sometimes as to the declaration of the time of respect to the research, authorship, and/or publication of this
death of the patient, i.e. when the brain dies or when article.
the life support system is removed and the heart stops.
Due to this, the patient’s representatives may try to Funding
prolong the usage of life supporting system on a The author(s) received no financial support for the research,
brain dead patient and may be completely against authorship, and/or publication of this article.
organ donation. This query is answered by the United
Kingdom criteria, the one that is followed in India, References
which states that the medical officer who is part of 1. Wijdicks EF. Brain death. Philadelphia: Lippincott
the panel of doctors will speak to the patient’s repre- Williams and Wilkins, 2001, p.175.
sentatives and will announce the demise. Therefore, the 2. Wig N, Gupta P and Kailash S. Awareness of brain
time of death is documented as the moment when the death and organ transplantation among select Indian
final evaluation to satisfy the criteria for brain stem popula- tion. J Assoc Physicians India 2003; 51: 455–
death is complete.5 Also, if the deceased is pregnant 458.
at the time of diagnosis of brain stem death, it is also 3. Shroff S, Navin S, Abraham G, et al. ‘Ramachandra
a very complex situation, as it has to be handled sensi- protocol’ for organ donation. Antiseptic 1997; 94: 73–74.
4. Government of India. Ministry of Law, Justice and
tively and with care as to make sure no harm is done to
Company Affairs (Legislative Department) New Delhi.
the foetus with complete monitoring until its delivery. The Transplantation of Human Organs Act, 1994.
Different religions have many diverse beliefs and do Central Act 42 of 1994.
not accept brain stem death as the ultimate end. 5. Sethi NK and Sethi PK. Brainstem death: implications in
According to a few minority Muslim people, death is India. J Assoc Phys India 2003; 51: 910–911.
acknowl- edged only by cardio-pulmonary criteria.6 6. Miller AC, Ziad-Miller A and Elamin EM. Brain death
and Islam: the interface of religion, culture, history, law
and modern medicine. Chest J 2014; 146: 1092–1101.
Conclusion
The approach to handling the issues of brain stem
death in clinical practice should be handled by an