In this issue of Neurology Now we address a difficult subject: brain death. It's difficult because death is hard to talk about, but also because some people are afraid that their loved ones will be declared dead prematurely'or worse, that they will be declared dead in order to obtain their organs for transplantation.
Nothing could be further from the truth, but the fear is understandable, because the concept of brain death usually isn't explained very well by doctors or the media.
Until the mid-20th century, the moment of death was easily identified as the moment the heart stopped beating. Advances in medical technology now allow people to be sustained on machines that keep their heart beating and lungs pumping. While these advances have saved many lives, sometimes this treatment keeps the patient's heart beating artificially after vital brain function has stopped and can never be recovered. Doctors and bioethicists refer to this as brain death. Once brain death has occurred, the person known and loved by friends and family is gone.
Tragic stories of people with serious brain injuries, such Terri Schiavo, have added to the confusion and anxiety over brain death. Schiavo spent 15 years in an institution after collapsing at home and spending a long period without oxygen. After a court case that sparked national controversy, Schiavo's feeding tube was ultimately disconnected. Sadly, she passed away in 2005.
However, Schiavo was not brain dead; she was in what is called a persistent vegetative state. The two states can be very clearly differentiated by doctors. Unfortunately, the national conversation that followed the case did little to clarify what brain death is—and is not.
People's concerns and confusion have been made worse by the fact that hospitals across the United States have sometimes used different methods for determining brain death. In response, the American Academy of Neurology is issuing a new guideline for determining when someone is brain dead, which we discuss in “Making Sense of Brain Death,” page 28. The guideline (and our article) explains exactly what brain death is. The guideline also provides neurologists with a checklist that they can take to the bedside to make sure that the determination is made with the utmost precision.
Declaring someone brain dead is not subjective or arbitrary, because brain death is a clinical, measurable condition. The President's Commission for the Study of Ethical Issues in Medicine accepted the definition of brain death in 1981, when Ronald Reagan was president. Families are not asked to “pull the plug” on someone who is alive.
When we began planning “Making Sense of Brain Death,” we weren't sure whether to discuss organ donation in the article or not, for fear of reinforcing a misperception that doctors are declaring people brain dead in order to obtain organs for transplantation. But we decided to take the risk because of the immense need for organs—and because understanding what brain death is helps people make a more informed decision about organ donation. Of the 2.2 million people who die in America each year, relatively few die under circumstances that make them medically eligible to be either organ donors or tissue donors, but more than 100,000 people are currently waiting for a transplant in the United States.
I have never hesitated to check off the “organ donor” box when applying for my Texas driver's license. As a neurologist, I have the utmost confidence that brain death can be determined precisely and objectively. I have also seen how precious a gift organ donation is, enabling the people who need organ transplantation to live long and productive lives.
Are there other end-of-life issues that you would like us to discuss in the pages of Neurology Now? If so, email me at firstname.lastname@example.org.
Take good care,
Robin L. Brey, M.D.