Neuro: Brain Death and Organ Donation

Today was a crazy day of extreme ups and extreme downs. As it seems all days on Neuro are.  In some ways it is well-balanced that way.

I feel like I must address brain death and organ donation since there are a TON of myths out there about it. For example, if you are an organ donor.... nobody knows it until you are already declared brain dead. So that myth about the doctors not trying to revive you as hard if you have organ donor status, is ridiculous. Trust me, nobody has time to riffle through your pants pockets to decide how hard they are going to work that day... they are busy trying to keep your heart beating.

The organ donation banks are totally separate from the hospital or the doctors. And legally, the doctors aren't allowed to bring it up or discuss it with the family in any way.  So the doctors aren't after your organs, we promise.

Also people think 'brain death' is like it is on the movies. A doc walks in looks at a bunch of tests on the chart and says 'he's dead, let's go tell the family' therefore some docs don't give the patient an opportunity to wake up out of a coma. This is not the case. Brain death is made in a period of 48 hours with extensive testing and multiple doctors have to all agree on the same conclusion without talking to each other. Its very complicated and the chances of waking up after meeting the criteria for brain death is absolutely zero Miracles can happen, but not after brain death.  Noone has ever woken up after being declared brain dead.  You are getting 'brain dead' mixed up with 'coma' totally different.

The neurologist is usually one of the doctors called to assess brain death, since he is after all an expert on the brain. The idea is we are trying to determine "if they are still in there" as the neurologist says. The criteria for brain death is very long and convoluted and I can promise you'd be bored if i went over it, not to mention i'd be bored typing it. But the basic idea is to test the instinctual part of the brain to see if there is any response at all. These are called cerebellar reflexes that are so basic we don't even think about it: pulling away from pain, blinking, moving your eyes when exposed to cold, pupil dilation, etc.  We also you use fancy technology  like EEGs (Electroencephalograms) to figure out if your electrical activity in your brain is active, sleeping, or not present (there are other options but i don't want to get into that now). There are other ways we can evaluate you including a multidude of testing that has to be done to rule out causes that could be keeping you from responding, like drugs, electrolyte imbalances, toxins, temperature, etc etc.

As I said above, people who are 'brain dead' are fairly simple to ascertain. And they are the easy cases. It's the people who don't quite fit all the criteria and who do have some basic reflexes or some brain activity on EEGs that are complicated.  Prognosis is hard to say with those patients.

We had two recently.

The first was an older lady, 88, who we think tried to commit suicide by driving her truck at 70mph off an overpass. She broke at least 3 major bones in every limb of her body and was not conscious. She was intubated, and tho her heart was beating on its own, without medication her heart would not beat fast enough to perfuse her brain or body. She was completely dependent on medical intervention. She did have some electrical activity on EEG and she exhibited some spontaneous movement of her legs that were questionable reflexes vs. seizures vs. voluntary of some nature. So do we recommend that she be unpluged? What are her chances for recovery? These are things the family wants to know. And honestly, we have no definitive answers.  Eventually, after much discussion we told the family what we know and left the hard decisions up to them. Do they want to unplug or put her in a nursing home like this and see if she ever wakes up? The chances of people waking up from this sort of thing is essentially none, but her chances of living in a coma or vegetable state is fairly good.  So how do you decide what life is worth? In these cases, usually the experts discuss 'quality of life' rather than actual living. Sure her body would get blood and make urine and twitch and blink. But would she ever be able to move, talk, understand, think with purpose? Probably not. So we told them the simple things, the things we could for sure tell them. Her kidneys were dying. her heart needed a constant infusion of medicine and her brain while not dead, will never be in control of her faculties like it was before..... And after a long while, I got paged to the bedside and they decided to unplug her.

On an opposite but equally confusing case, We had a 58 year old man who came in unresponsive. He had no reflexes and no pain withdrawl and no movement. He had a heart attack and was under hypothermia protocol. This is a protocol we utilize when someone has not woken up after being recussitated (CPR) after a heart arrest.  The idea is if the body is kept in a lower temperature the oxygen demand of the organs goes down (they need less blood) this gives your brain more time to heal. However, most people have SOME reflexes when on hypothermia protocol. This man did not. We ordered an EEG when they warmed him up (can't declare brain death if they are at a low temp) expecting to declare him brain dead.  But we got a call at noon the next day that he was warmed up. We walk in the room and the guy is TALKING. It was as close to a miracle as I've seen yet.

 I think its important to note that being unresponsive from a heart attack is very different from trauma is very different from any other brain injuries. The brain is still at least 45% of a mystery, even to the neurologists.And its just as frustrating for us medical professionals as it is for the patients.

Also to end this discussion, the hospital gave me a really expensive parking ticket... say what!