PERSISTENT VEGETATIVE STATE, BRAIN DEATH AND ORGAN DONATION

    Efforts to improve access to organs for critically ill individuals whose lives can be saved by organ transplantation have, ironically, also restricted organ harvesting and have made the recognition of medical futility due to severe brain injury more difficult. The very narrow historical definition of “brain death” as loss of all brain electrical activity (flat EEG) made those individuals clear candidates for living organ donation but, in effect, eliminated the larger group of individuals with severe, irreversible brain injury. Furthermore, the rigid brain death definition may have contributed to an inappropriate distinction between brain death and permanent vegetative state with regard to medical futility.

    The diagnosis of death is uncontroversial when made at the bedside by establishing the irreversible cessation of heart, lung, and brain functions. However, when CPR and life support systems are used, brain death may occur despite the reversal of cardiac and respiratory arrest. In this situation all brain function has irreversibly ceased, but air is pumped into the chest via a ventilator and the heart has, in most cases, been restarted via CPR. Because such a person is medically and legally dead, any continued or proposed intervention is, by definition, futile.(1),(2) Objections to stopping futile intervention in these patients typically come from families who do not accept that their loved one is dead(3) and from physicians who do not accurately diagnose brain death, but instead continue to regard the patient as alive, albeit severely injured.(4)

    “Successful” CPR can also result in a persistent vegetative state. Such individuals have severe, permanent high brain damage to the extent that there is no responsiveness or awareness, and yet low-level brain function allows them to breathe on their own, unlike patients with total brain death.  Unconsciousness (and, thus, medical futility) in patients with persistent vegetative state may be especially difficult for families to understand because the patient may appear "awake" due to spontaneous movements and open eyes. An estimated 5000 patients with persistent vegetative state in the United States at any given time(5) are kept “alive” for several years with artificial feeding and meticulous nursing care. Some physicians have proposed that the brain death concept should be expanded to include permanently vegetative patients by defining death as the permanent failure of the brain areas responsible for consciousness and cognition.(6) Proponents of this view see the current brain death standard as too narrow and as a legal obstacle to the discontinuation of futile treatment.(7) Expansion of the definition of death, however, has not met with wide acceptance.(8) Fortunately, hundreds, possibly thousands of patients with persistent vegetative state are allowed to die with dignity by their physicians and surrogates each year. The protracted, inconsistent treatment of many others (sadly) remains a major problem in the United States in that their treatment beyond futility often perpetuates emotional suffering for families and poses an extremely high cost to relatives and society.(9),(10)

^[1] Anonymous. A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA. 1968;205:337-340.
^[2] Report of the President’s Commission for the Study of Ethical Problems in Medicine & Biomedical & Behavioral Research, Defining Death: Medical, Legal & Ethical Issues in the Determination of Death. Washington, D.C., U.S. Government Printing Office; 1981.
^[3] Kirkland LL. Family Refusal to Accept Brain Death & Termination of Life Support: Physician Responsibility. J Clin Ethics. 1991;2:171.
^[4] Harrison AM, Botkin JR. Can pediatricians define & apply the concept of brain death? Pediatrics. 1999;103:e82.
^[5] Mitchell KR, Kerridge IH, Lovat TJ. Medical futility, treatment withdrawal & the persistent vegetative state. J Med Ethics.1993;19:71-76.
^[6] Youngner SJ, Bartlett ET. Human death & high technology: the failure of the whole-brain formulations. Ann Intern Med. 1983;99:252-258.
^[7] Veatch RM. The impending collapse of the whole-brain definition of death (published erratum appears in Hastings Cent Rep. 1993;23:4). Hastings Cent Rep. 1993;23:18-24.
^[8] Bernat JL. A defense of the whole-brain concept of death. Hastings Cent Rep. 1998;28:14-23.
^[9] Guardianship of Browning, 543 So.2d258 (Fla.2dDCA 1989).
^[10] Doty WD and Walker RW. Medical Futility. Clin Cardiol 2000:Vol. 23 (Suppl. II);II-8.

 

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