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Brain Death & Ethical issues

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Brain Death & Ethical issues. Dr. Ashraf Hussain. overview. What is death? History of death Clinical death, brain death Islamic perspective of death Ethical issues. When a human being is dead? Why it is important?.

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overview
overview
  • What is death?
  • History of death
  • Clinical death, brain death
  • Islamic perspective of death
  • Ethical issues
slide6
When a human being is dead?
  • Why it is important?
slide9

Advances in medical Sciences have made the determination of the time of person’s death less simple than it used to be

history of death
History of death
  • Before 1816, physicians were not well trusted in their ability to diagnose death
  • Fear of being buried alive
in ancient rome
In ancient Rome
  • Call out deceased person’s name 3 times
  • If no response-- finger amputated
  • If no bleeding– declared deceased
fear to be buried alive
Fear to be buried alive

In 14th century

  • Duke of Lancaster left instructions to keep his body in bed for 40 days
  • If doctors still believed he was dead then to be buried
magic words 1790
Magic words (1790)

written on mirrors in invisible ink (silver nitrate)

Decomposed body produced hydrogen sulfide, writing became visible as silver sulfide was produced

“I am dead”

patented coffin to alert 1897
Patented Coffin to alert (1897)

If death was misdiagnosed

  • If presumed deceased awoke from sleep beneath the ground
  • A device was rigged to light a lantern, raise a flag and ring a bell
clawed forceps
Clawed forceps

By French physician

  • Designed to clamp around the nipple of the presumed corpse to confirm death
  • No response---dead
slide18
“…I know when one is dead, and when one lives. She is dead as earth. Lend me a looking glass. If that her breath will mist or stain the stone, why then she lives”

King Lear; Act V, Scene III

William Shakespeare

slide19
Invention of stethoscope (1816)
  • Physician were began to be trusted in their ability to diagnose death
primary modes of confirming death
Primary modes of confirming death
  • Respiration
  • Heart sound
  • pulse
death criteria
Death criteria

In beginning of 20th century

  • Cardiorespiratory criteria

Clinical Death

  • Cessation of blood circulation and breathing
change
Change
  • Change started in 1952 with an outbreak of polio in Copenhagen, 12 year old girl under went tracheostomy & put on ventilator
  • Pierre Mollaret (French) in 1957 reported on patients who had developed brain injury and were on mechanical ventilation
  • No brainstem reflexes were present and post mortem examination revealed brain liquefaction
a new diagnosis of death
A new diagnosis of death
  • In 1968 Harvard Brain Death Committee published report on how to diagnose death on new criteria
  • Criteria proposed that patient could have no brainstem or spinal cord reflexes.
  • A confirmatory test was also required i.e. EEG
  • In essence, committee said a person is dead if the brain is dead
death
Death
  • Clinical death
  • Brain death
clinical death
Clinical Death

Cessation of blood circulation and breathing

  • When the heart stops beating in a regular rhythm. Condition is called cardiac arrest
  • The absence of blood circulation and vital functions related to blood circulation was considered to be the definition of death
slide26
“Clinical death is now seen as a medical condition that Precedes death rather than actually being death”
slide27
During clinical death, all tissues and organs in the body steadily accumulate a type of injury called Ischemic injury
factors for change
Factors for change
  • Increasing availability of mechanical ventilation—legal implications of disconnection
  • Rapidly advancing field of organ transplantation
death1
Death
  • Permanent and irreversible cessation of vital functions of heart, brain and lungs

(C.K. Parikh; Text book of forensic medicine and toxicology)

slide30
If we have a human body being ventilated on a respirator, but in which there is no sign of brain activity, ought we to regard that person dead or alive?
slide31
How should we regard a person in permanent coma?
  • When should we cease to persist with life prolonging treatment?
  • Under what circumstances can patients decline life-saving measures?
types of brain injury
TYPES OF BRAIN INJURY
  • Coma
  • Brain death
  • Vegetative state
  • Locked-in state
  • Minimally conscious state
slide33
Coma
  • Prolonged state of unconsciousness, in which patient is alive, but unable to move or respond to environment.
slide34
Coma

Most serious brain injuries begin with a coma

  • “Eyes-closed unconsciousness.”
  • It is as if the patient is sleeping but cannot be aroused.
  • Coma is usually not permanent.
  • Some patients go on to become brain dead; others enter the vegetative stage, become “locked in,” or enter the minimally conscious state; still others recover completely
brain death
Brain death

Irreversible loss of the clinical function of the whole brain:

  • The cortex (responsible for motor and cognitive function)
  • The midbrain (which might be thought of as integrating higher and lower centers in the brain)
  • Brain stem (responsible for vegetative functions such as sleep-wake cycles and breathing).
slide36
Brain death is a product of modern technology, made possible by mechanical ventilators and cardiopulmonary resuscitation
brain death criteria
Brain death criteria
  • Absence of eye opening
  • Absence of verbal or motor response to pain
  • Loss of brain stem reflexes (such as pupil response, corneal reflexes, caloric response to vestibular stimulation, cough reflexes and hypercapnia)
brain death criteria cont
Brain death criteria cont;
  • Total unresponsiveness to these tests, combined with good evidence that it is caused by irreversible structural damage to the brain means that person will never regain consciousness
vegetative state
Vegetative State:
  • Refers to plant life i.e. without locomotion)
  • It is a brain injury resulting from Trauma or Diseases, where higher functions of brain are lost while the non-cognitive functions, like breathing and heart beating are retained.
vegetative state1
Vegetative state
  • “Eyes-opened unconsciousness”
  • There is a disassociation between wakefulness and awareness.
  • While patients may appear awake, there is a lack of evidence that the upper brain receives or projects information.
  • The upper brain and the midbrain are not integrated in function with the brain stem or the rest of the body, although the brain stem continues to manage the vegetative functions.
vegetative state2
Vegetative state
  • “Sustained and reproducible voluntary response” is important in the diagnosis

Prognosis is determined by the

  • Cause of the injury
  • Length of time the patient has been in the vegetative state
  • Comorbid conditions.
duration of the vegetative state also affects nomenclature
Duration of the vegetative state also affects nomenclature
  • A duration >1 month is said to be persistent.
  • When the cause of the vegetative state is nontraumatic —such as an anoxic injury after cardiopulmonary resuscitation a duration >3 months is said to be permanent

BUT

  • When the cause of the vegetative state is traumatic a patient must remain vegetative for >12 months before the condition is defined as permanent.
locked in state
Locked-in state
  • Consciousness is preserved but the patient is paralyzed except for eye movement and blinking.
locked in syndrome
Locked in Syndrome
  • Paralyzed from head to toe, the patient, his mind intact, is imprisoned inside his own body, but unable to move or speak.
  • “In my case blinking my left eyelid is my only means of communication….My heel hurt, my head weighs a ton, and something like a giant invisible diving-bell holds my hole body prisoner”

Jean-Dominique Bauby describing his experience in The Diving Bell and the Butterfly, a book dictated entirely by eye movements

minimally conscious state
Minimally conscious state
  • Sleep-wake cycles exist, just as in the vegetative state.
  • Arousal levels range from obtundation to normal arousal.
  • There is reproducible but inconsistent evidence of perception, communication ability, and/or purposeful motor activity.
  • Visual tracking is often intact but typically inconsistent.
  • Communication ranges from none to unreliable, with inconsistent yes-no responses, verbalizations (typically fewer than six words), and gestures
islamic perspective
Islamic perspective
  • Unanimous approval of whole brain death criterion and its permissibility within Islam

(Acdemy of Islamic jurisprudence, Jordan1986}

pakistan
PAKISTAN
  • Brain death is widely accepted
  • Legislation?
famous cases for legal battles
Famous cases for legal Battles
  • Karen Quinlan
  • Nancy Cruzan
  • Theresa Schiavo
readings
Readings
  • Bioethics for clinicians: 24 Brain death by Neil M. Lazar et al
  • The final diagnosis of brain death: David C. Kaufman www.sccm.org
  • Ethical & social dimensions of brain death. F.Moazam. Pakistan journal of neurological sciences
  • wikipedia.org