What kind of death has doctors debating? Who will 'save' the brain death dilemma?

"My husband has been brain dead for 10 months, what should I do?

"Remove the tube and let him go with dignity." --This is a question and answer on Zhihu. Short, but shocking.

In the process of medical theory and clinical practice in China, the discussion on the diagnostic criteria of death has never ceased, and the discussion on the legislation of brain death has been repeated, even causing disputes and conflicts among various sectors of society and various sciences.

Although brain death is now universally recognized and socially defined at the medical level, legislation on brain death is still as uncertain as Schrödinger's cat, even though everything seems to be "ready.

"The time has come for brain death legislation." Wang Ying, former president of a tertiary hospital in Beijing and chief neurosurgeon, said in an interview with the health sector that he strongly supports brain death legislation because in clinical practice, there are few patients who are still maintained by machines after brain death and are unable to breathe on their own. These patients can easily be confirmed as brain dead and will stop their heartbeat and breathing as soon as the relevant instruments for maintaining vital signs are withdrawn.

Although they no longer have any value in terms of treatment, because many families have the mentality of "living as long as their loved ones can, no matter how much it costs," these patients will therefore remain in the ICU for another period of time, which will only "last" for a few months at most, but cost a lot of money. "The care of brain-dead patients requires professionals, not family members, and therefore takes up and wastes limited quality medical resources," Wang said. This also takes away and wastes limited quality medical resources," said Wang Ying.

In addition to the deep bond with the family, there are a few families who want the patient to live for the money. Wang Ying admits that, for example, in the case of publicly funded medical patients, the family not only does not bear much of the cost of treatment, but also receives the patient's pension on a monthly basis, which is also a "stumbling block" that prevents doctors from declaring brain-dead patients to be dead.

When life and death and money are directly linked here

Currently, 13 countries, including the United States and India, have legislated brain death, and 35 countries, including South Korea and Thailand, use it as a basis for death in clinical practice. The clinical term brain death is used for patients who have a heartbeat but are not breathing on their own and have permanent loss of brain function that will eventually lead to death. The concept of brain death/death by neurological criteria (BD/DNC) was first accepted in 1959 and subsequently described as "brain death" in a clinical definition first published in 1968, often referred to as the "Harvard Brain Death Criteria". Since then, many other guidelines and protocols have been approved and revised around the world, and there has been widespread acceptance by major medical groups, and major religious organizations.

In an interview with the health sector, Chan Wing-keung, ICU Fellow of the Hong Kong College of Nursing Specialists and Associate Professor of the School of Health Sciences at Caritas-Hong Kong, revealed that the criteria that have been followed in Hong Kong since the 1970s in terms of patients' brain death to date were published by the Royal College of Physicians in the United Kingdom in 1976. In addition, the Hong Kong Society of Critical Care Medicine (HKSCCM) also mentioned in its two editions of guidelines in 2009 and 2015 that the detection and determination of brain death is legal in Hong Kong.

Chan Wing-keung said that in Hong Kong, whether a patient is certified to have brainstem death is all confirmed by experienced ICU doctors, and neurosurgeons. Medical staff perform cranial nerve testing and response to pain at the patient's bedside, and look at the patient's brainstem function and respiratory function to see if there is respiratory capacity and dilated pupils, etc. If the relevant tests show that the patient is brain dead, the same tests are performed again approximately one hour after the examination. If the results are the same on both occasions, the patient's brainstem death is confirmed, the patient is declared dead, and the time of brain death is written down on the patient record, rather than relying on the patient's cardiac arrest to confirm death. Because the heartbeat of a patient with a dead brainstem will eventually stop, there is no longer a possibility of successful resuscitation.

Chen Yongqiang said there are three main reasons for confirming a patient's death by brainstem death, rather than cardiac arrest.

First, it allows the patient to die with more dignity, avoiding the stress of care and internal suffering for the family by continuing to maintain vital signs through instruments after brain death but continuing to deteriorate bodily functions.

Second, limited medical resources can be conserved so that very expensive instruments can be used to save patients who have hope of being saved.

Third, it helps with organ donation, as organ transplants require functioning organs. By proving brainstem death, the patient can be wheeled directly into the operating room to take the organs as a donor, without waiting for the heart to stop before doing so. After cardiac arrest, those organs are already ischemic & non-functional.

With medical advances, many of a patient's vital signs can be maintained with advanced equipment. However, if irreversible structural damage to the brainstem occurs, even if the heartbeat and other organ functions are maintained with advanced instruments, the patient's life cannot be saved.

Wang Yue, a professor at Peking University's Institute of Medical Humanities, told Healthworld that brain death diagnostic criteria are a "more scientific and respectful" approach than traditional, or mixed criteria, death.

It is not difficult to see that the feasibility and necessity of brain death have been well documented, but there is still no shortage of conflicting views: even though the diagnostic criteria for brain death are indeed more scientific, objective and reasonable than the traditional criteria for determining death, if we rashly replace the traditional diagnostic criteria for death with the diagnostic criteria and methods for determining brain death, or if we proceed to legislate the diagnostic criteria for brain death, we will simply put the objective life and death of individuals into The law is not a clear-cut regulation. Such an approach may not be wise.

Wang Yue told the health community that brain death legislation has been adopted by the vast majority of developed countries, and brain death is the standard standard of death. While many medical scholars in China advocated brain death legislation in the early days, brain death legislation has been in a state of insufficient social consensus in China, so some disputes have arisen.

Another point that cannot be ignored is that a series of ethical and moral domino effects, caused by brain death, still exist objectively.

The traditional criteria for death are the logical conclusion of the heart as the life center of the organism, the cessation or disappearance of heartbeat, respiration, and blood pressure, followed by a drop in body temperature. However, with the continuous development of biomedicine, the determination of the traditional criteria of death is constantly challenged and impacted. For example, a person is judged to be brain dead and his or her relatives make the decision to donate his or her organs in order to save the life of the person. This is still criticized by people with traditional moral values, especially in China, where there is no explicit regulation that defines brain death as death.

A man in his 50s carries a bag full of cash while his wife lies in the ICU, having been repeatedly confirmed by doctors as brain dead.

Money often causes great distress in hospitals," lamented Qin Bo, the general director of the second season of "Human World", "In the ICU, keeping a person alive is enough to put those around him in great distress, because life and death and money are directly linked here.

The middle-aged man "still has a lot of money". The couple came to Shanghai to work in the early years and had a lot of savings, but now the money has become his original sin.

He carried a bag full of cash and begged the doctors to use the best medicine, hoping they would save his wife at any cost, but all was to no avail.

"Now the money has become a burden to him, and he told me that if there was no money, he could instead make up his mind to terminate the treatment," he said. Qin Bo said. This sad story is the epitome of how traditional ideology subconsciously influences people's behavior.

The Yellow Emperor's Classic of Internal Medicine, written more than 2,000 years ago, states: "A short pulse and the extinction of Qi means death". Today, a person with a heartbeat and breathing is ruled dead and deprived of medical treatment. It is not easy to make the general public agree with "brain death" and adjust their behavior. Even if the experts keep promoting the scientific view, once the relatives of the patients and many people in the society do not accept the determination of brain death, the obstacle to the "brain death legislation" can be imagined.

In other words, whether brain death can be used as an objective criterion for determining an individual's death is not only a matter of biomedical science, but also whether it can be accepted by the public in terms of emotion and morality is still open to question.

Chen Yongqiang, who is also the deputy director of the Intensive Care Unit (ICU) Committee of the Chinese Nursing Association, believes that in terms of brain death legislation, in addition to good patient education in mainland China, medical and nursing staff should also be trained to know the significance of brain death, "which is clearly not enough at the moment".

As former Vice Minister of Health Huang Jiefu pointed out years ago, "Nowadays, even many doctors are not clear about the concept of brain death, coupled with the relatively tense relationship between doctors and patients in China and the ongoing medical reform, it is very dangerous to promote legislation before the public has a good understanding of brain death.

What kind of death has doctors debating? Who will 'save' the brain death dilemma?

Problematic clinical application?

However, according to Wang Yue, China has developed to a point where the discussion of death legislation is now "more mature" than it was 20 years ago, both at the level of clinical expertise and at the level of society's awareness of the concept of brain death.

Chen Jingyu, vice president of the Second Hospital of Zhejiang University School of Medicine and director of the Jiangsu Provincial Lung Transplant Center of Wuxi People's Hospital, reiterated her call for accelerated brain death legislation at the National Congress in 2022. On this most attention-grabbing and controversial topic, he told the health community that brain death legislation firstly reflects respect for citizens' human rights, secondly brings about changes in basic education and clinical practice of brain death medicine in China, and finally will bring about progress in many aspects such as life and property, economic benefits, organ donation and organ transplantation, as well as human rights and national reputation.

Part of the reason for Chen Jing Yu to mention "brain death legislation" again is that she is confident that China has a certain degree of mass base - "More and more people now recognize brain death, and from the current donation situation, the proportion of brain death donations accounts for about 2/3, which is a very high proportion, and basically Nowadays, all the donations come from brain dead people.

For comparison, 4,080 and 5,136 heart and brain-dead patients in China made loving organ donations in 2016 and 2017, respectively, of which at least one-third of the patients' families accepted brain death.

Even though the status of the traditional criteria for determining death has been somewhat impacted and challenged with the proposed diagnostic criteria for brain death and the development of medical technology, in the process of clinical practice, hospitals still issue the diagnosis of death with cardiopulmonary respiratory arrest and loss of systemic function as the main way to confirm the diagnosis.

Does this mean that we do not actually have clear diagnostic criteria for death at this time? Wang Yue explained that the current clinical criteria for death are referred to as a transitional state between the traditional heart and brain, which is actually a hybrid criterion that determines a patient's death through respiratory heartbeat plus a portion of neurological reflex examination.

"Some tertiary care hospitals are using brain death criteria to determine patient death for the purpose of organ transplantation. However, the brain death criterion is not currently legally recognized and cannot simply be applied to the clinical setting; it must be confirmed through legislative and judicial processes."

So, what are the clinical requirements for determining brain death? What are the requirements for the corresponding doctors? In Wang Ying's opinion, qualified doctors in clinical settings, including critical care medicine, can confirm whether a patient is brain dead by analyzing the patient's EEG, which is not a complicated process, but in some primary care institutions, it is not easy to confirm a patient's brain death due to imperfect equipment and insufficient personnel qualifications.

Wang Yue said that the criteria for brain death must have the appropriate specialist, the indicators of judgment and many conditions that many primary hospitals outside of tertiary hospitals can not do. He admits, "China's medical level varies, especially between the tertiary hospitals and the grassroots township health centers and county hospitals there is a large gap.

"In fact, any doctor can now pronounce a patient dead, which is problematic in itself." Wang Yue suggested that the problem can be solved by legislative techniques, making the declaration of patient death the most sacred, serious and demanding professional skill in the whole medical service activity, gradually promoting it from tertiary hospitals, urban hospitals to primary hospitals, certifying and assessing doctors, and only doctors who pass the assessment have the right to confirm the death of patients, Wang Yue stressed that the determination of death should not be defined in the institution, but In people, qualified doctors can be in both tertiary hospitals and primary hospitals.

Why has brain death not been assessed? Wang Yue thinks it has to do with the interest orientation: "In hospitals, all the treatment behaviors with chargeable items are generally more standardized, and all the items without charge and only cost payment are often not taken seriously by hospital management, such as geriatrics, hospice, pediatrics, and general medicine are in a state of being marginalized and squeezed by other disciplines. Public hospital reform should return to the public welfare-oriented assessment and evaluation mechanism, otherwise, if guided by economic interests, it becomes what is most profitable to develop."

Brain death diagnostic criteria and methods are more complex than traditional death diagnostic criteria and determination methods. Since the introduction of the Harvard Brain Death Criteria in 1968, the inadequacy of the brain death diagnosis and determination method itself has indeed caused misdiagnosis of clinical death in patients.

On November 19, 2007, an American man, Zach Dunlap, was involved in a car accident and was declared brain dead after doctors tried their best to save his life to no avail. However, the man suddenly came to life when his family said goodbye to his body. Scientific research has shown that brain damage is irreversible and irrecoverable in the case of total brain death, and even with the aid of medical devices, a breathing shell is all that is maintained. It can be seen from this case that the patient was not brain dead.

The incident has led some scholars to question the diagnosis of death through brain death diagnostic criteria: the patient was not actually brain dead, but the diagnosis of death according to the current U.S. brain death diagnostic criteria and determination method resulted in a misdiagnosis of death, does this indicate that there are problems with the diagnostic criteria and determination method?

"Is it possible that only brain death can occur in this case?" In Wang Yue's opinion, in fact, there may be similar cases under any death criteria, "but the very small probability should not affect our judgment of things, if the decision is affected for a very small risk, then there is no one thing in the world to do, we don't drive because we may have an accident in a car and don't ride because of a plane crash.

So in the absence of legislation, who will be held responsible if clinical errors are determined and bring about doctor-patient disputes?

In the absence of legislation, death is recognized under the current mixed criteria for all patients except organ transplant patients. This standard is set through an industry association, and with a clear standard, if a hospital does not declare a patient dead according to this standard, the responsibility should be on the hospital.

"But it's not a question of standards," Wang emphasized, adding that a standard operating procedure (SOP) has not yet been established to specify who has the right to declare a patient dead, whether the physician of interest, such as the organ transplant surgeon or the patient's attending physician, should recuse himself or herself, and whether there is a review process.

"Declaring a patient dead is a very serious matter in the clinic, but the procedure makes the patient or family feel too hasty and not strict enough, so it is necessary to establish SOPs.

Why is the "east wind" slow to blow?

In China, there are no technical difficulties in brain death legislation, and international standards are well defined in clinical practice. 1980s, medical experts in China started to discuss the issue of brain death determination criteria, and in 2003, the drafting group of brain death determination criteria of the Ministry of Health formulated the "Brain Death Determination Criteria (Adults) (Draft for Comments)" and "Technical Specification for Brain Death Determination (Adults) (Draft for Comments)".

In 2012, the former Ministry of Health commissioned Xuanwu Hospital of Capital Medical University to establish the "Brain Injury Evaluation Center of the Ministry of Health", now renamed "Brain Injury Evaluation Center of the National Health and Family Planning Commission", which is responsible for the revision of brain death criteria and training of related medical personnel, etc. In 2013, the center published the "Brain Death Determination Criteria and Technical Specifications (Adult QC Version)" in the "Chinese Journal of Neurology", and the "Brain Death Determination Criteria and Technical Specifications (Child QC Version)". Brain Death Determination Criteria and Technical Specification (Child QC Version)". Since then, China has had the first industry standard for brain death determination.

Back in 2018, Chen Jingyu's 'proposal on brain death legislation' made at that time received a response, with the UNESCO Committee of the National People's Congress stating in its response letter, "We believe that it is necessary to define and express the criteria for death in the law. We agree with your suggestion that instead of necessarily taking the form of separate legislation, we can adopt a binary standard of death and add brain death and heart death to the existing law to give the families of the deceased some choice. It is recommended that the relevant parties give serious consideration to this when formulating or revising the relevant laws."

Since there is no technical problem, the aforementioned data also proves that the public acceptance is improving year by year, and has even received an official reply, so everything is "ready", why is the "east wind" slow to blow? What are the obstacles and difficulties in the middle?

There is a difference of opinion, with one view being that a specific brain death law should be enacted, and another view that the criteria for death is a technical standard that does not require legislation," Wang Yue told the health community. That is, it does not need to be set by a national legislature, but by industry and autonomous organizations, as well as guilds, to introduce relevant technologies. From this perspective, the latter view is currently more accepted."

In his opinion, although brain death involves a standard issue of death, it affects many civil rights of citizens. According to the Civil Code, the civil capacity of a natural person finally dies, therefore, death is the only cause of the extinction of civil capacity. Therefore, it would be better to pass the legislation of the National People's Congress.

There is also a pressing need to create a new cross-sectoral organ transplant law. At present, China has become the world's second largest organ donor country, achieving more than 6,000 donations and acquiring more than 20,000 organs every year. According to Wang Yue, the existing Regulations on Human Organ Transplantation has limitations. Organ transplantation, whether in terms of its donor acquisition, cost sharing, insurance and other aspects, is by no means a simple issue and should define the rights and responsibilities of all parties such as donors, executors and receiving units.

Shi Weiyun, director of the Institute of Ophthalmology affiliated with Shandong First Medical University and president of Shandong Provincial Eye Hospital, likewise sees limitations in the current Regulations on Human Organ Transplantation. He said, "The transplantation regulations do not have a specific superior law as the basis for their formulation. Without the law as a basis for behavior, China's body (cornea) and organ donation work will always lack comprehensive legal protection, and will not enable donors, doctors, recipients, medical institutions and other parties to enjoy clear, clear, necessary rights and responsibilities. The hundreds of thousands or millions of donations that will be realized in the future will always 'move forward with disease'. It is urgent for China to improve the legislation of body, organ and tissue donation."

Wang Yue also noted that with the rapid development of artificial intelligence, artificially intelligent cars have emerged, so there will be fewer and fewer organ donors obtained from traffic accidents, "In fact, the United States also faces the same problem of organ donor shortage, so they have begun to study and experiment how to combine human and pig genes through genetic engineering, and then quickly produce pigs with genetic information of kidney, liver, heart and human recipients. . Once the new technology is applied, it will be a double-edged sword, therefore, the application of genetic engineering in organ transplantation should be regulated by legislation to clarify the legal responsibilities of the parties, delineate the legal boundaries, simple ethical constraints, there may be a collective silence."

It is widely accepted in the industry that the brain death stage is the best time for organ transplantation, and that maintaining blood circulation and heartbeat through extracorporeal ventilators ensures that organs are in optimal use. And after legislation that enables scientific and efficient organ transplantation, more dying patients will be able to get a chance to live again.

China's first brain-dead case for organ transplantation occurred in July 2001 at the Changzheng Hospital of the Second Military Medical University in Shanghai, where the hospital successfully transplanted the kidney of a brain-dead person, kidney to two uremic patients.

In the past, people were reluctant to accept the reality that their loved ones had passed away prematurely due to cultural and traditional beliefs that "it is better to die than to live". Compared with the past, modern people's understanding of the value of life has been greatly enhanced, and it has become easier to understand and more and more acceptable for brain-dead patients to complete their final journey in time, so legislation on brain death is "just in time," said Wang Ying.

She hopes that in the future, legislation can be passed to give clinicians more autonomy, that is, to give them the right to declare brain-dead patients dead.

"If only the family can decide whether to remove the machine that maintains vital signs for a brain-dead patient, it is tantamount to leaving this dilemma to the family, which is still difficult for the family to accept at this stage, which also shows that it is necessary to increase education in life education.

However, it is also necessary to face the fact that, after the legislation, it is foreseeable that it is still difficult to reverse people's perceptions in a short period of time. From questioning to acceptance, Huang Jiefu has suggested that the concepts of cardiac arrest and brain death can co-exist, and the public can choose one or both when selecting the criteria for death, allowing a gradual process of awareness.

The fastest footsteps are not sprinting, but persevering. No matter when the brain death legislation will be realized, even if there is a long road ahead, medical progress will always be an irreplaceable force that drives the wheel of life to roll forward.

(At the request of the interviewer, Wang Ying is a pseudonym in the text)

Health sector production

By|Niu Huili Li Zijun