Discontinuation of ventilation after brain stem death
Editor—We were interested in the educational debate concerning withdrawal of ventilatory support after confirmation of brain stem death.1 Clearly if ventilatory support is withdrawn without the agreement of the family, although such action may be medically and legally correct, the potential for sensationalised unfavourable headings in tabloid newspapers must be considered.
Although the medicolegal and ethical aspects of the issue have been discussed, the scientific aspects have not been. Unlike in the persistent vegetative state, brain stem death is followed by a series of profound changes in the autonomic and hormonal mechanisms regulating the cardiovascular system. Complete cardiovascular and autonomic uncoupling has been shown in humans after brain stem death.2 In validated animal models of brain stem death a catecholamine surge was consistently observed after brain stem death, followed rapidly by decreases in vasopressin, adrenocorticotrophic hormone, thyroxine, and glucagon concentrations.3 Inotropic and vasoactive treatment is therefore frequently required to maintain organ function for potential donation.
It has been established that, despite full cardiovascular support, most deeply comatose patients (97% of 140) will develop asystole in a week.4 Clearly, the time for developing asystole is likely to be shorter in patients with brain stem death, especially if full cardiovascular support is not attempted. We suggest that in such cases it would be reasonable to continue ventilatory and circulatory support without further manipulation. In almost all cases managed in this way rapid cardiac death will ensue.
Although we have no satisfactory answer to the central question raised as to whom the duty of care is greatest—the grieving family or another critically ill patient—we believe that nature should be allowed to take its own course and end the dilemma.
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Jews accept brain stem death
Editor—The issue of brain stem death1-1 became important in Israel in the 1980s, when heart and liver transplantation began. Many people objected to organ donations in “beating heart” situations, fearing conflict with the religious Halachic law.
In 1986 the chief rabbinate of Israel responded to an approach from me (as the then director general of the Ministry of Health) and Professor Abraham Sahar, a neurosurgeon, to accept brain stem death as religiously acceptable for (a) pronouncing death and (b) obtaining permission for harvesting organs from donors. There were two points we asked them to consider.
The first point was the rule that “Breathing is equivalent to soul.” In Hebrew the word neshama is from the same root as neshima; while the first means “soul” the second means “respiration.” One saying is “haneshama hee hanefesh” (“haneshamais the soul.” In this case neshamaalso means “breathing.” The second point relates to the saying that one should not stop the neshamafrom leaving the body (when the time comes). Therefore we maintained that when spontaneous respiration does not exist, a state of death has been reached and at this point we should not, in the Halachic sense, continue artificial respiration, which prevents the soul from leaving the body. In this situation we maintained that it should be permissible to harvest organs of the dead person that may preserve the life and health of another.
The chief rabbinate had about eight months of internal deliberations before they accepted this formula. Since that time in Israel the official Jewish religious authorities have accepted brain stem death for the declaration of death and for approaching families to accept donation of organs for transplantation.
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