The Mystique of Brain Death

‘‘No one wants to die. Even people who want to go to heaven don’t want to die to go there. And yet death is the destination weall share.No onehaseverescapedit. Andthatisasitshould be, because Death is very likely the single best invention of life.’’ 1 ‘‘Those who have the strength and the love to sit with the dying patient in the silence that goes beyond words will know that this moment is neither frightening nor painful but a peaceful cessation of the functioning of the body.’’ 2 ‘‘If you don’t know how to die, don’t worry. Nature will tell you what to do on the spot fully and adequately. She will do this job perfectly for you.’’ 3 These three direct quotes give us the essence of death: certainty, loss of all bodily function and always perfect. Death remained unquestioned until 1958, when Mollaret et al., 4 in Paris, France published a paper describing a condition which comes after irreversible coma and before death and called it, Coma DE ‘passe. Not much attention was paid to this new condition, though the like minders noticed it. He had described brain death, which can come in few cases prior to cardiopulmonary arrest. It was only in 1968 that a Harvard group came out with criteria for brain death, which caught the public eye. Its significance cannot beunderstated.Braindeathisveryrelevanttothe processof organdonationand transplantandthe timing couldnot be betterasChristiaan Bernardhad justsurprisedthe worldby doing first human to human heart transplant surgeries in SouthAfricain 1967. Heart transplant cannotbe done with live donor. Death is a necessity, brain death being ideal. Article in this issue by Pawar et al. 5 addresses the important aspect of organ transplant: awareness about brain death. Cardiac Death can be recognized easily as there is cessation of all functions. No heart beat or spontaneous breathing effort during observation for at least for 3 min is considered enough to pronounce death in absence of hypothermia or toxicity. Cause for brain death is usually quite apparent: severe head trauma, anoxic brain injury or acute toxicity account for the most. Though definition and procedure to follow may vary in different regions, generally accepted guidelines are used here. After cerebral cortex and brain stem stops functioning, cardiopulmonary system can still function for minutes to a couple of days, giving a window for organ harvest. After brain death, the body can be medically maintained to continue perfusion and keep the organs safe and viable for transplant. 6 It is of critical importance that a person is dead before organs are harvested instead of organ harvest leading to death 7 ; hence, in most of the jurisdictions, two well-trained neurologists, not involved with the care of the person being evaluated for brain death nor with the transplant process, are required to complete the physical examination, repeating in 24 h in doubtful cases and certify brain death.Inadditiontothephysicalexamination,headtiltand cold caloric testing should be checked. Head tilt normally causes eyes to move towards the tilt, in vegetative state eyes move opposite to head tilt giving it a name Dolls eye. In person withbrain death, nomovementofeyesisnotedwith head tilt. In cold caloric testing, normal brain will have slow phase towards the cold water and fast return to medial, and in brain death, there are no eye movements. EEG recording done for 30 min shows flat line, and PET scanning and angiography confirm no circulation in the brain.