The ambiguity of diagnosing brain death


Hospitals have always served as a lifeline to survival. Whether from pneumonia, heart attack, stroke, or trauma, they have been a community safeguard between life and death.

Today, a cost of care has been added to the patient treatment discussion forcing medical decision-making to look closely at expense. Financial considerations have come to the forefront as preservation of resources will be important to national health care. This can be a threat to hospitalized patients teetering on the edge of life where the gray-zone of technology does not provide all answers, especially regarding brain death. There are adverse and often tragic results of uncertainty in this diagnosis.

A two-year-old is swiftly removed from life support by a hospital before the family can appeal a court order. A son has power of attorney to make decisions for his recently stroked mother and requests a feeding tube, but is denied by the hospital. A family sees their father declared “brain dead” by two doctors, both employed by the hospital, and the ventilator is disconnected.

Can we assure a hospital is making decisions solely on behalf of the patient they serve, as opposed to maximizing profits that personally benefit administrators in salaries, bonuses, and retirement packages?

How do we protect the medical and legal rights of a hospitalized gravely ill patient from potential abuse?

Declaring someone dead in the past was not complicated. No breathing or pulse equals dead. With technology, though, patients can survive on life support: ventilator for breathing; artificial pacemaker to sustain pulse; medication to maintain blood pressure; and feeding tube for nutrition.

This might preserve the body, but here is the fundamental question: Is the brain viable and will the patient be able to return to a normal life? No one has this answer. But because the legal criteria and implementation for brain death are loose and inconsistent, some hospitals and their lawyers have exploited this ambiguity forcing termination of care.

To be declared brain dead, certain medical criteria must be met. Some are achieved at bedside by doctor physical exam, and others defined by testing evolved through scientific technology (EEG/brain wave studies, blood flow exams, or the apnea test). Because of extreme variation of physician education and testing interpretation, application of criteria is not consistent and therefore could be subject to manipulation.

To protect patients from potential abuse, doctors and the public must be better educated on brain death criteria. Loopholes must be shored up, and criteria standardized. With ever-changing science, new testing (like fMRI — a video of brain function) should be harnessed. And finally, utilizing the hospital ethics committee, or having available legal advice through patient advocating ombudsmen can serve as a guide.

We must be aware of the threat profit and greed play in health care. Through education and vigilance, protecting the vulnerable against those who exploit a deficient and susceptible system might safeguard against adverse and tragic results.

Gene Uzawa Dorio is an internal medicine physician who blogs at SCV Physician Report.

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