Objective: To evaluate whether current clinical criteria and confirmatory tests for the diagnosis of 'brain death' satisfy the requirements for the irreversible cessation of all functions of the entire brain including the brainstem. Data sources: Medical, philosophical and legal literature on the subject of 'brain death'. Data extraction/synthesis: We present four arguments to support the view that patients who meet the current operational criteria of 'brain death' do not necessarily have the irreversible loss of all brain (or brainstem) functions. First, many clinically 'brain-dead' patients maintain residual vegetative functions that are mediated or coordinated by the brain or the brainstem. Second, it is impossible to test for any cerebral function by clinical bedside exam, because the tracts of passage to and from the cerebrum through the brainstem are destroyed or nonfunctional. Furthermore, since there are limitations of clinical assessment of internal awareness in patients who otherwise lack the motor function to show their awareness, the diagnosis of 'brain death' is based on an unproved hypothesis. Third, many patients maintain several stereotyped movements (the so-called complex spinal cord responses and automatisms) which may originate in the brainstem. Fourth, not one of the current confirmatory tests has the necessary positive predictive value for the reliable pronouncement of human death. Conclusion: According to the above arguments, the assumption that all functions of the entire brain (or those of the brainstem) in 'brain-dead' patients have ceased, is invalidated. Reconsideration of the current concept of 'brain death' is perhaps inevitable.
A 16-year-old male patient was admitted to hospital because of a fainting episode which was accompanied by diarrhoea that was dark red. All investigations were normal except a low haematocrit, a technetium-99m pertechnetate abdominal scan, which showed a large area of moderate activity in the upper left abdomen, and digital subtraction angiography, which showed bleeding in the same area where the abnormal finding on the pertechnetate scan was found. Ectopic gastric mucosa and a deep ulcer in an otherwise normal jejunum were found during the urgent exploratory laparotomy.
Inconsistencies Related to the "Brain Death" ConceptThe entity of "whole brain death" (or "whole brain failure") is impossible to be diagnosed by the clinician who examines the comatose patient for any signs of brain stem function. It is obvious that one cannot test for any cerebral function by clinical bedside examination because the tracts of passage to and from cerebrum through the brain stem are invariably destroyed or nonfunctional in "brain dead" patients [2].According to Professor Adams (member of the Ad hoc Committee of the University of Harvard Medical School), the criteria for "brain death" determination included "a permanent state of complete unreceptivity and complete unresponsively, the latter including all responses, whether brain stem, spinal or cerebral in origin" [3]. As a consequence, all spontaneous movements and
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