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Three case reports appeared lately in
the literature (25). The
three cases represented fatal mistakes
in diagnosing brainstem death. In the
first
case the patient began to breathe
spontaneously upon receiving
a dose of neostigmine. It was too late because the liver had already been
removed. In the second
case, during organ harvesting, the
anesthesiologist noticed that the donor was breathing
spontaneously.
When he inquired about that the answer
was: "the donor was not going
to recover, he could be declared brain
(dead". In the third case, the patient
was suffering from eclamptic fits
for
which she was receiving
magnesium sulfate and esmolol. A
neurologist determined that the
patient had suffered "a catastrophic neurologic insult"
and declared her
brainstem dead. During organ retrieval, the anesthesiologist noticed
small reactive pupils together with weak
corneal and gag reflexes. Upon
stopping of magnesium infusion and receiving edrophonium,
the patient
recovered and was eventually discharged
home. Such fatal mistakes
appear in the literature repeatedly(57-58)
and cannot be explained by
mere negligence or ignorance. Several
causes can be proposed to explain
these
repeated errors:
1.
The controversial nature of the
concepts, and hence criteria, defining
brain death.
2.
The difficulty to interpret the tests
for verifying the diagnosis. This is
better appreciated if we know that about 45% of brain stem dead renal
donors (in such a developed country as
the UK) came from centers
where there
were no neurosurgical facilitics(60). It is then
expected to
have a
high degree of error.
3.
The shortness of time available for excluding drug intoxication or
metabolic errors before
retrieving organs from a dying donor for
a,,
desperate receipient. Dr. David
wainwright Evans(61) , an English
cardiologist in cambridgeshire, states
that “ the additional test , which
saved these two, was the passage of time
– one of most powerful diagnostic
weapons available to the doctor, yet
one which is almost casually set aside
when neurologists are under pressure to
provide viable organs for
transplantation.
4.
Regarding
brainstem failure patients as hopeless
(considering them dead
already,
one
cannot benefit them ) and focusing on
preserving
their organs (being potential
organ donors). Dr. Watanabe, (62) a
leading Japanese
cardiologist says that “ a
hastened judgment of brain death
without trying such new
therapeutic measures would well
constitute murder , or at least a
malpractice case.
If all transplant protagonists try
to ignore these observations, while at
the same time
claim the validity of current
diagnostic criteria of brain death,
and continue to give
apnoea tests to aggravate
ischaemic brain injury, I must conclude
that the use of
terms such as biomort or heart-
beating cadaver is nothing but a
sophism to disguise
their real intention that the
only thing they want is transplantable
organs. They are
not at all interested in saving
those donor candidates. Other critics in
Japan claim the apnoea test has been
performed there
repeatedly to achieve “ brain death “
rather than diagnose it .
5.
The potential reversibility of
brainstem failure. Recovery in such
cases
would
be wrongly attributed to false diagnosis.
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