THIRUVANANTHAPURAM: Medical practitioners at hospitals can decide on discontinuing ventilator support for brain-dead patients upon certification of the person’s condition by a panel of four doctorsconstituted by the government, according to guidelines issued by the state Health Department on Sunday.
This is for the first time in the country that a state is coming out with guidelines for brain stem death certification, which looks beyond organ donation. Once the panel constituted by Kerala Network for Organ Sharing — the government’s nodal agency for organ donation—certifies brain stem death, doctors at the hospital where the patient is admitted can decide on discontinuing all treatment, including cardiorespiratory support, without the consent of the patient’s family.
“As of now, brain stem death certification is associated with the Transplantation of Human Organs Act. The withdrawal of life support machines is done only on those patients whose families give consent for organ donation. This often puts the doctors in a dilemma as they remain confused about what to do with a patient who is brain dead and his/her relatives refuse organ donation,” said a Health Department official.
Citing the World Health Organisation’s observation that a brain dead person is dead although his or her cardiopulmonary functioning may be artificially maintained for some time, the officer said allowing the brain-dead to continue on ventilator may lead to potential harms, including mistreatment of the ‘dead’, deprivation of dignity, provision of false hope with resultant distrust, prolongation of the grieving process and others.
Health principal secretary Rajan Khobragade said there was a need to streamline the procedures for declaration of brain stem death. “Also, proper capacity building among medical practitioners and awareness among the general public on brain steam death and its certification is required. The guidelines intend to accomplish these objectives,” he said. Kerala Network for Organ Sharing state nodal officer Dr Noble Gracious told TNIE that the guidelines will put an end to the practice of undue prolongation of the dying process among brain-dead patients.
In docs’ hands
● Brain stem death will be certified by a panel to be constituted by Kerala Network for Organ Sharing
● Upon certification, doctors at the hospital, where the patient is admitted, can decide on discontinuing all treatment, without the consent of patient’s family
Tests to confirm brain death before termination
“These guidelines intend to achieve three objectives: through termination of life-saving support of a brain-dead, the ICU resources could be availed by other patients and unnecessary expenses for the brain-dead person’s relatives could be plugged. Besides, it may encourage organ donation,” said Noble.
As per the guidelines, before subjecting a person to brain death evaluation, the clinical evidence of an acute central nervous catastrophe should have to be established. After that, the medical practitioner should alert the near relatives/caregiver regarding the status of the patient in whom brain stem death testing is being considered.
The assessment of brain stem reflexes should have to be done using a series of tests.
The tests will be carried out by a panel of four doctors, including a doctor empanelled by the government.
The Apnoea test (most important clinical test performed usually at the end of brain death diagnosis procedure) will have to be performed if all other tests confirm the absence of other brain stem reflexes.
The guidelines propose neurophysical or imaging study to prove the absence of electrical activity or blood flow to provide the brain stem death confirmation report to the family member/caregiver. It will be after these formalities that all treatment support will be discontinued.