Dead or Alive: That is the Question

NurseHeart&Soul, MSN

Dead at 0252 hours. I charted, "Pronounced dead by Dr. Smith at 0252 hours. No spontaneous respirations. No visible rise and fall of the chest. Absent breath sounds. No apical heart tones audible via stethoscope. No visible signs of life." During the 45 minutes of cardiopulmonary resuscitation (CPR) on this 55-year-old woman there was no inkling of life. This was enough for the emergency department physician to determine it was time to stop resuscitative efforts. The woman's frail husband sat in a quiet room waiting to hear the status of his wife.

I spent the next couple of minutes preparing the room before bringing the husband in. The scattered wrappers from supplies used were picked up off the floor. The intubation tray removed. A fresh gown replaced the blood-stained gown and crisp white sheets were delicately draped over the woman. Only her face and neck were visible along with her left hand that I gently positioned on top of the sheet.

Standing at the foot of the bed I gave one last look at the room, and then placed my eyes on the dead woman. Taking that last look to ensure everything appeared presentable to a soon-to-be grieving husband was critical. I was ready to bring the husband to the bedside until I discovered one issue...she was not dead. Or was she? The sheets began rising and falling. I listened for an apical pulse. There was a very regular and rather strong heartbeat.

Situations like this make you wonder, how will they know when I'm dead...if I'm really dead? Will someone take my organs for donation if I'm not really dead?

This is part 3 of a donation education series that focuses on how brain death and cardiac death is determined. If you haven't read the previous two parts, pause for a moment and read part 1 titled 8 Organ and Tissue Donation Myth Busters and part 2 titled Organ and Tissue Donation: The Facts of Donating Life.

Identifying Types of Organ Donors

In part 2 we discussed that there are two types of potential organ and tissue donors. These include:

Donation after brain death (intubated, on a ventilator, but heart is still beating)
Donation after cardiac death (heart has stopped beating)

Let's focus first on brain death, because brain death is very confusing to many. The patient will be on a ventilator, the cardiac monitor will often show a beautifully normal heart rhythm, the person looks pink, and appears like they are sleeping. If a person is brain dead by definition they have an irreversible cessation of brain function. They are not sleeping, but rather they are clinically dead. This visual of a loved one can make it difficult for family and friends to process that the person lying on the hospital bed with an often peaceful appearance is actually dead.

Determining Brain Death

The American Association of Neurology (AAN) uses three cardinal signs to define brain death and this includes:

Cessation of brain functioning including the brainstem
Coma or unresponsiveness
Apnea

Understanding the Prerequisites to Brain Death

The clinical prerequisites to consider brain death determination include:

Clinical condition incompatible with life like trauma, intracranial bleed
Neurological imaging that confirms the diagnosis like a CT or MRI
Absence of a reversible medical condition like electrolyte or metabolic abnormalities
Absence of drug induced coma
Normalized core body temperature

Evaluating Brain Death via Clinical Testing

The clinical assessment to determine brain death requires an absence of all reflexes that includes:

Corneal reflex
Pupillary light reflex
Absent reflexes in the face and maxillary areas
Absent cough and gag reflexes
Absent occulocephalic reflex known as testing for Doll's eyes
Absent occulovestibular reflex (absent nystagmus when cold water is injected into the ear)

If there is even a subtle presence of any one of these reflexes then a person is not brain dead. Once all the primitive neurological reflexes are absent, a confirmatory test can be performed to further validate brain death. Confirmatory tests are often what is needed for a family to fully understand that their loved one is brain dead.

Performing Confirmatory Testing

Two primary tests that are performed to confirm brain death are the following:

Testing for the absence of Cerebral Blood Flow with cerebral angiography
Performing an apnea test, to confirm the absence of spontaneous respirations

Practice Parameter - American Academy of Neurology

Determining Brain Death: Who Performs the Declaration of Death

Brain death is determined by a medical physician. The requirements for determining brain death vary by state and country. In some areas, one physician can determine brain death and in other areas two physicians are required, often one of those physicians must be a neurologist. A standard practice seen is that these two brain death exams take place six hours apart.

Determining Cardiac Death

A person can also be declared dead once there is cessation of spontaneous respiratory and cardiac function. This may occur following natural causes, cardiac arrest or, possibly a grim prognosis that leads to the withdraw of life support. Whatever the circumstance, donation of organs or tissues would never occur until after a licensed medical physician declared death.

Should you be worried about donating organs prior to death? Absolutely not...unless of course, you willingly consent to be a live donor donating a kidney or liver. Should you be worried donation after cardiac death will occur but you aren not really dead? Maybe you or your loved one are the person who will spontaneously begin to breathe and move the sheets. Don't be worried. Donation after cardiac death does not occur until a person has been declared dead for a minimum of 5 minutes. In the case at the beginning of this article, it turned out the woman was eventually determined brain dead due to anoxia from prolonged down time prior to the onset of CPR. She ultimately became an organ donor.

So dead or alive? The answer is clear as long as clinical guidelines are used to determine brain death and an adequate timeframe passes before donation after cardiac death occurs.

In part 4 of this series we will learn about donation from the perspective of a donor mother who made the decision to donate her son's organs during the most horrific time in her life.

Until next time...Embrace the Journey...wherever your journey may take you!