Brain Death Determination in Israel: The First Two Years Experience Following Changes to the Brain Death Law—Opportunities and Challenges

Abstract

To increase support for the concept of brain death, changes accommodating requirements of the religious authorities were made to the Brain Death Act in Israel. These included (1) considering patient wishes regarding brain death determination (BDD); (2) mandatory performance of apnea and ancillary testing; (3) establishment of an accreditation committee and (4) requirement for physician training courses. We describe the first 2 years experience following implementation (2010-2011). During 2010, the number of BDD decreased from 21.9/million population (during the years 2007-2009) to 16.0 (p < 0.001). Reasons included family resistance to brain death testing (27 cases), inability to perform apnea testing (7) and logistic problems related to ancillary testing (26 cases). The number of physicians available to declare brain death also decreased (210 vs. 102). During 2011, BDDs increased to 20.5/million following the introduction of radionuclide angiography as an ancillary test; other reasons for nondetermination persisted (family resistance 26 cases, inability to perform apnea testing 10 cases). Instead of increasing opportunities, many obstacles were encountered following the changes to the Brain Death Act. Although some of these challenges have been met, longer term follow-up is required to assess their complete impact.

Preliminary Marked Increase in the National Organ Donation Rate in Israel Following Implementation of a New Organ Transplantation Law

“…In 2010, the first year following implementation of the new Brain‐Respiratory Death Law, a significant decrease in the number of brain death determinations was evident (from a mean of 160 per year in the years 2007–2009 to 122 in 2010, p < 0.001) . This decrease was related to unforeseen consequences of the new law such as family refusal to disconnect the deceased from the mechanical ventilator, inability to perform the standard apnea test in some cases and inability to perform the mandatory ancillary imaging testing due to lack of appropriate resources in all hospitals.…”

“…During 2011 most of these obstacles were successfully overcome and the number of brain death determinations (n = 160) returned to that seen in previous years following the introduction of an alternate apnea testing, in which the patient remains connected to the mechanical ventilator with a gas mixture comprising 97% oxygen and 3% carbon dioxide and which decreases apnea time and thus avoids the consequences of prolonged disconnection , and additional ancillary brain imaging tests such as radionuclide angiography using hexamethylpropylene amine‐oxime single photon emission computed tomography (SPECT). The law is now fully implemented country wide and has been largely accepted by large elements among the religious population including the Chief Rabbinate .…”

Organ Donation in Israel—Achievements and Challenges

“…3 Brain death is documented by mandatory performances of an apnea test and an ancillary imaging test demonstrating the absence of blood circulation within the brain. 3 Brain death is documented by mandatory performances of an apnea test and an ancillary imaging test demonstrating the absence of blood circulation within the brain.…”

Religious objections to brain death

“…In Israel, for example, one of the most common objections to accepting the concept of brain death (and equating it with death) and subsequently to organ donation is the belief that it is "prohibited by religion." In fact, this has been shown to be the commonest reason for refusal of accepting brain death and organ donation in Israel [3].…”