Wednesday, May 11, 2016

Brain death. Japanese perspective.

Araki T, Yokota H, Fuse A. Brain Death in Pediatric Patients in Japan: Diagnosis and Unresolved Issues. Neurol Med Chir (Tokyo). 2016 Jan 15;56(1):1-8.

Brain death (BD) is a physiological state defined as complete and irreversible loss of brain function. Organ transplantation from a patient with BD is controversial in Japan because there are two classifications of BD: legal BD in which the organs can be donated and general BD in which the organs cannot be donated. The significance of BD in the terminal phase remains in the realm of scientific debate. As indicated by the increasing number of organ transplants from brain-dead donors, certain clinical diagnosis for determining BD in adults is becoming established. However, regardless of whether or not organ transplantation is involved, there are many unresolved issues regarding BD in children. Here, we will discuss the historical background of BD determination in children, pediatric emergencies and BD, and unresolved issues related to pediatric BD.

From the article:

Essentially, abused children are not to be diagnosed for the aim of organ donation but as part of routine medical practice; therefore, a framework for the detection of any kind of abuse cases should not be prepared to enable organ donation from brain-dead donors. It has also been indicated that when responding to cases of past abuse, the prompt response to requests for the disclosure of information from child consultation centers is strongly encouraged.

The prohibition of organ donation from abused children is a rule that is only enforced in Japan. Furthermore, many physicians in Japan are also of the opinion that the requirement to investigate past instances of abuse places a heavy burden on those in medical practice. Currently, if there is even a slight suspicion of abuse, legal BD will not be determined.  Moreover, regardless of whether a child suffered BD or cardiac death, organs will not be donated if there is a suspicion that they were the victim of abuse. However, even children who suffer severe brain damage due to abuse may exhibit cerebral herniation. In such cases, if an irreversible arrest of all brain functions, including the brainstem is observed, then the patient may be diagnosed as medically brain dead. However, in such a case, a declaration of death cannot be made with this determination of BD…

The MHLW report “Research regarding Determination of Brain Death in Children and Organ Donation” found that chronic BD (long-term BD; it took at least 30 days to reach cardiopulmonary arrest after determination of BD) accounted for 20% of all cases. Baker et al. have hypothesized that developments in intensive care medicine have lengthened the time from BD determination to cardiopulmonary arrest. Currently, respiratory and circulation management is proactively performed even on brain-dead patients, and if care is taken with respect to elements such as prevention of infection and nutritional management, it is generally accepted that a heartbeat can be maintained over a long period. Chronic BD was previously considered to be specific to children, but this was greatly attributable to a report by Shewmon. In this report, he analyzed 56 brain-dead patients who survived for at least a week after diagnosis and concluded that patients who met the clinical criteria for BD have not necessarily lost integrated physical functioning, and many cases do not require intensive care equipment to stabilize their organs other than their brain. Wound healing, improvement from infection, fever, and growth can be observed even in brain-dead patients. Furthermore, integration of the individual is built on a reciprocal relationship between each part of the body, and it does not work in the way that the most important organs forcibly control other organs in a top-down manner. Because some of the reported cases of “BD” included cases that did not strictly meet the determination criteria, the precision of such diagnoses was criticized. Even to date, no conclusion has been reached regarding whether chronic BD should be considered as a pathology peculiar to a child or a result from the influence of intensive care medicine.

In 2008, when the President’s Council on Bioethics (PCBE) compiled the white paper “controversies in the determination of death,” cases of chronic BD were investigated. Results indicated that there are clear differences between the linguistic representation of the conventional definition of BD and the clinical state of patients diagnosed with BD, which is candidly accepted. Shewmon’s evidence required the abandonment of reasoning relying on the premise that the brain conferred integrative unity on the organism as a whole. He showed there was no necessary connection between brain activity and some integrative somatic unity. The white paper admits that if expressions of integrative somatic activity were sufficient to indicate the presence of a whole living organism, then the neurological criteria would have to be abandoned as a standard for ascertaining human organismic death. However, the white paper finally does concede Shewmon’s point about the role of the brain in mediating integrative unity and rejects the conclusion that some expressions of somatic integrative unity are expressions of a living whole. Eventually, it was determined that the term “brain death” was inappropriate, and they proposed to change it to complete brain failure. It is highly commendable that the PCBE considered a preconceived idea in its own country to be “unreliable” and redefined it.

BD in children based on certain criteria is determined in only a few countries around the world, and it is difficult to perform scientific analysis on pediatric patients. However, the amount of detailed information available regarding the epidemiology and pathology of BD in children has recently increased. In Japan, the perception that the BD diagnosis is performed for the purpose of organ donation remains strong. Furthermore, in many cases, BD is not determined and the family members are given explanations based on the practitioner’s subjective view such as “almost brain dead,” “a brain-dead state,” or “infinitely close to brain dead.” Therefore, the “limitations of life-saving” are presented before a diagnosis of BD and intent to donate organs by the family is confirmed at this point. The overuse of the term “BD” not only affects medical care but also legal interpretations and may eventually impede the understanding of the patient’s family and influences the trust of doctor–patient relationship.

Courtesy of Researchgate

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