Brain death

ICEL Brisbane Australia 2014

I had the great pleasure of participating in this conference. It was particularly satisfying as Brisbane, Australia, is my home town.

The conference was the International Conference on End of Life: Law, Ethics, Policy and Practice 2014 (ICEL 2014). The conference was hosted by the Queensland University of Technology Australian Centre for Health Law Research in Brisbane, Queensland, Australia on the 13-15 August 2014.

Highlights for me were:

  1. The wonderful welcome and organisation of Prof. Ben White and Prof. Lindy Willmott
  2. One of the friendliest conferences I have ever attended.
  3. Hearing Peter Singer speak and getting him to sign the ethics book I own of his!
  4. Finding myself more open to concepts of euthanasia and assisted dying, then I have previously.
  5. Being exposed to different consenting models for organ donation (more about that is a future post)

I delivered two lectures at the conference.

The major keynote lecture I delivered was entitled
Diagnosing Death in the 21st Century.
Doctors diagnose death. It is a simple enough truism but one that appears to have been forgotten in recent debate. There appears to be a growing misunderstanding about what doctors are doing when they declare death. Doctors do not use magic or divine inspiration to confirm death. Instead doctors apply their training and skills in the use of the diagnostic process to the patient before them. This is done in the exact same manner in which doctors would apply the diagnostic process to every other disease process in medicine.

Modern death criteria commenced in 1846, when Eugene Bouchut won the Academy of Science prize in Paris for suggesting a safe and prompt way to prevent premature burial. Bouchut advocated the use of an 1819 device, the stethoscope, where after five minutes of absent heart beat, death could be diagnosed. This French discovery was only slowly adopted worldwide, finally finding its way into the UK Code of Practice for Confirming and Diagnosing Death in 2008. Prior to this, though UK doctors used the stethoscope to diagnose death, there was no published or taught standard, for diagnosing death after cardio-respiratory arrest.

Ultra-modern criteria were developed, again by the French, in 1959 to diagnose death in a rare subset of patients, comatosed and apnoeic patients on intensive care units. This followed the invention of mechanical ventilation and the discovery it was possible for organ function to persist even after the brain had ceased to function.

Advances in resuscitation technologies continue to ask legitimate questions about how death should be defined. There is growing medical consensus that all human death is anatomically located to the brain. There are three sets of criteria doctors use to diagnose death in the 21
st Century, somatic, circulatory and neurological, and they are all criteria for the permanent loss of the capacity for consciousness and the capacity to breathe.

In this lecture I showed YouTube clips of animal experiments predominantly from the 1950-1970s and these may be distressing to some viewers and listeners.
I would wish to state I do not endorse such experiments and I would like to acknowledge the suffering these animals must have gone through and express my gratitude to their contribution and sacrifice.

The Podcast is available:

Podcast (recorded in my hotel room the night before)

The vidcast of the lecture is available in the Vidcast page of this website and the PDF (large 62.4 MB file).

The second lecture I delivered was
How the UK overcame the Ethical, Legal and Professional challenges in Donation after Circulatory Death

The UK has experienced an exponential growth in Maastricht Category III and IV Donation after Circulatory Death (DCD). Since the year 2000 DCD has increased 1321% (from 38 donors to 540), compared to a 6.3% rise in Donation after Brain Death (DBD) (from 734 donors to 780). DCD accounts for more than 40% of all UK deceased organ donation, which with the Netherlands, are the highest rates in Europe. This increase still hides the cultural change in deceased donation that has occurred in the UK. Since 2010 more families have consented to DCD each year then DBD, making it the number one commenced deceased donation pathway in the UK.

To achieve such growth the UK had to explicitly address the ethical, legal and professional challenges inherent to DCD. Significant concerns were raised, and continue to be raised in other countries, surrounding how DCD satisfies the Dead Donor Rule and the ‘Consenting Donor Rule’, the absolute need to ensure actions to facilitate donation remain in the interests of the dying patient and are in alignment with their wishes and the wishes of their surrogate decision makers.

Recommendation 3 of the 2008 UK Organ Donor Taskforce recognised that, ‘Urgent attention is required to resolve outstanding legal, ethical and professional issues… Additionally, an independent UK-wide Donation Ethics Group should be established.”

Since 2008 there have been seven UK publications, seeking to address issues in deceased donation. Most importantly to DCD were criteria for the diagnosis of death after cardio-respiratory arrest, legal guidance recognising that obligations in DCD are the same as for any other living and incapacitated patient, a duty on doctors to explore donation at the end of life from the General Medical Council and a comprehensive exploration of ethical issues in DCD by the independent UK Donation Ethics Committee.

Again the
podcast and vidcast (both recorded in my hotel room the night before) and PDF are available.