Brain Death

There are a lot of uncertainties in medicine, but death ought not be one of them. It seems like among all the things doctors know, we should know when someone is dead. And though these remarks seem facetious, they're not entirely off base. In fact, in 1981, a law was passed in order to define when someone is dead, the Uniform Determination of Death Act (UDDA). The American Medical Association, American Bar Association, and a commission on ethics all weighed in to figure out when someone dies. There are two ways to meet the criteria; the first is straightforward: irreversible cessation of circulatory and respiratory functions. But the second criteria has proved complicated: irreversible cessation of all the functions of the entire brain including the brain stem.

In medical school, we learn how to perform the brain death exam, and we learn that a patient who is brain dead is dead. A year and half ago, these accepted medical standards were challenged with the case of Jahi McMath. She was a thirteen year old girl who had complications from surgery, suffered a cardiac arrest, and was declared brain dead by multiple pediatric neurologists. The tragedy of this perioperative pediatric death has not been the focus of media attention, but rather the family's challenge that the patient was not, in fact, dead. The family filed legal action to keep the patient on life support. The court ruled that based on independent neurologic exams, EEG, and perfusion studies (the latter two are not necessary, but are adjuncts), the patient was indeed dead. At this time, the family argued that application of the Uniform Determination of Death Act was a violation of constitutional and privacy rights. There may be some precedent for this; in New Jersey, state law allows religious objection to declaration of death by neurologic criteria. As a result, the patient was kept on life support, though the exact religious objection to the UDDA is not clear to me. Then, there is an odd circuitous circumstance where the body is released to the coroner who issues a death certificate but then released to the mother. The mother then moves the body to New Jersey, where a tracheostomy and a feeding tube are placed.

This all seems crazy to me, especially since the cost of a lot of this is shouldered by society in general. However, it's even more crazy when we encounter this situation. This last month, an elderly patient presents with a devastating stroke. She is declared brain dead by two separate examinations. However, the family refuses to believe she is, in fact, dead. They object to the withdrawal of life support and ask us to seek other hospitals who may be able to accept this brain dead patient. Ethically, we feel that we can (and perhaps should, given limited resources) withdrawal life support. However, given the temporal and geographic proximity of the McMath case, felt that our hands were tied. Ultimately, the patient progressed with anuric renal failure and cardiopulmonary death so the situation was resolved. However, it taught me a lot about how medical perception and public perception of brain death may be quite incongruous.