Activity 3: What are some of the ethical implications of these definitions of death? Provide some real-life examples

Brain Death 

▻ Final cessation of activity in the central nervous system especially as indicated by a flat electroencephalogram for a predetermined length of time
(http://www.merriam-webster.com/)

Ethical implications:

Before the advancement we have now, a body with missing internal organs was often proclaimed dead. Now, we have organ transplants and blood transfusions which allows the patient to survive when they are about to die. 
This ethical issue has to do with the idea of either saving someone or letting them die in the name of the religion. As certain religions object to the use of blood transfusions due to the idea of impurity.

"A 46-year-old Muslim female patient with IgA nephropathy was seen for an annual review on the renal transplant waiting list. She had started peritoneal dialysis in 2007, and we had listed her for a renal transplant in 2008. When seen now in spring 2010, she was very well indeed, and there were no new issues regarding transplant listing. At the end of the consultation, we asked for potential donors, as per our unit policy. She mentioned that she was born in Pakistan. It then transpired that several young and healthy relatives from her large family were available. All of them, however, were of the Muslim faith and believed that organ donation was not in keeping with Islam. They had therefore decided not to see the live donor team in the first place. The patient herself was not sure what to do and asked us for help, saying ‘Does Islam forbid organ donation?’ The doctor in our clinic (AW) had to admit total ignorance but promised to investigate."
(http://ndt.oxfordjournals.org/content/early/2010/10/20/ndt.gfq628.full)

The right to refuse medical treatment is well established in medicine and in law. The legal tradition of the right to be left alone has deep roots. When cases arose asserting that a patient has a right to be free of unwanted medical intervention, the right was readily recognized and clearly affirmed. 

◘ These legal cases can be categorized into four classifications:
▫ patient with decision-making capacity
▫ patient without capacity but who had earlier expressed treatment preferences for end-of-life care either verbally or in a written advance directive document
▫ patient without capacity who had made no prior expression of treatment preferences
▫ patient who never had the capacity to make treatment decisions. 

In cases of patients with intact decision-making capacity, courts have ruled that such patients have the right to refuse medical interventions even when those interventions are life-sustaining. 

"Abraham and his parents refused the additional chemotherapy recommended by his physicians at a children's hospital because of the adverse effects he had suffered previously." 
(http://pediatrics.aappublications.org/content/120/6/1357.full)

There is an ethical issue over discontinuing medical interventions when, a patient correctly diagnosed as having lost brain functions permanently and will never regain consciousness. He or she will experience no pleasure or pain, enjoy no social interaction, and be unable to pursue or complete his or her life's projects.

Part of the public concern over employing a brain-based standard to determine death seems to arise from fear that this may cause medical treatment to be withdrawn from some patients who might have regained consciousness. This fear is expressed in patients who have resumed normal lives after long periods of coma or even after having been pronounced dead. The ethical question is whether a new, brain-oriented definition of death would lead to abandonment of patients who might have responded to continued medical care. Those who press this objection to "redefinition" of death insist that death should not be pronounced until it is certain that recovery is impossible.

Activity 3: What are some criteria the medical community uses to determine if one is “brain dead”?

What is Brain Death?

                        

By definition, "brain death" is "when the entire brain, including the brain stem, has irreversibly lost all function." The legal time of death is "that time when a physician has determined that the brain and the brain stem have irreversibly lost all neurological function.

- HowStuffWorks.com

The concept of brain death can be very confusing because the person's heart is still beating and their chest will still rise and fall with every breath from the ventilator. Brain dead patients can be kept ‘alive’ by an automated ventilator. This machine mimics the action of breathing, causing the heart to continue to beat. Therefore, skin is warm and the person may appear to be resting comfortably, rather than critically ill and without brain function. This is because the worst of the physical damage is actually hidden in the brain, rather than visible on the body.
When the brain is injured, it responds like other injuries—it swells. However, the brain is confined in the skull and has no room to swell. This leads to brain death.

Once the brain is pronounced dead, the family has to decide whether to stop the ventilator from providing breathable air into the lungs and bury the patient or whether to continue and keep the heart pumping so that the patient can donate his organs to other people. 

There are 3 main types of Brain Death
- Cortical / cerebral death
- Brain stem death
- Whole brain death

How to test for Brain Death?

Criteria for Brain Dead

- Unresponsiveness

- Absence of reflexes

- Apnea (inability to breathe without a ventilator)

Various Tests for Brain Death
1) Patient has no response to commands- Verbal, visual or otherwise
2) The patient is flaccid, with areflexic extremities. The patient has no movements -- the arms and legs are raised and allowed to fall to see if there are adjacent movements, restraint or hesitation in the fall.
3) The pupils are unreactive (fixed). The patient's eyes are opened and a very bright light is shined into the pupil. The light will activate the optic nerve and send an impulse to the brain. In the normal brain, the brain will send an impulse back to the eye to narrow the pupil. In the non-viable brain, no message will be sent. This is performed in both eyes.
4) The patient has no oculocephalic reflex. The patient's eyes are opened and the head rotated from side to side. The active brain will allow a roving motion of the eyes; the non-functional brain will not. The eyes remain fixed.
5) The patient has no corneal reflexes. A cotton swab is pulled across the cornea while the eye is held open. The functioning brain will want the eye to blink. The dead brain will not. This is performed in both eyes.
6) The patient has no response -- either purposeful or posturing -- to supra-orbital stimulation.The patient's eyebrow ridge is compressed with the thumb. The resulting stimulation pressure will cause motion of the extremities, either purposeful or primitive posturing, in the living-brain patient, but none in the brain-dead patient.
7) The patient has no oculovestibular reflex. The patient's ear canal is checked to ensure an intact tympanic membrane and that the ear is free of wax. While holding the eyes open, ice water is injected into the ear canal. The sudden change in ear temperature will cause a violent eye twitching by the intact brain but no reaction in the brain-dead patient. This is performed in both ears.
8) The patient has no gag reflex. The movement of the breathing tube (in and out) or the insertion of a smaller tube down the breathing tube will cause a gag reflex in a comatose patient, but will not draw out a reflex in the brain-dead patient.
9) The patient has no spontaneous respiration. The patient is temporarily disconnected from life support. With the cessation of breathing by the machine, the body will immediately begin to build up metabolic waste of carbon dioxide in the blood. When the CO2 level reaches a level of 55 mm Hg, the normal brain will cause the patient to breathe spontaneously. The dead brain gives no response because for brain dead patients, the brain is unable to send the signal to breathe.

Done By: Jie Yi, Yi Chieh, Ada, Sylvia, Rui Zhi

Welcome!

Dear Biologists,

A very warm welcome back to school. This blog will be an avenue where we will post our class activities as well as any additional materials to aid you in your understanding of the things covered in class.

First announcement I'd like to make is that there'll be a diagnostic test during this week's last Biology class. The topics covered are

1) Classification of Living Organisms
2) Cells
3) Nutrition in Humans
4) Transport in Humans
5) Ecology

Thank you and I wish you a very fruitful year.