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The Nasty Side of Organ Transplanting.

Chapter 3

The Apnoea “Brain Death” test may kill the patient

The possibility of donors feeling pain during organ harvesting isn't the only problem. One body of scientific research opinion suggests the “brain death” test not only falsely attributes death to the donor but also injures the patient and delays crucial treatment.

Associate Professor Cicero Galli Coimbra, Head of the Neurology and Neurosurgery Department at the Federal University of Sao Paulo, Brazil has completed the study, “Implications of ischemic penumbra for the diagnosis of brain death. Apnoea testing may induce rather than diagnose brain death”.^[20]

The study discovers that where there is brain damage there may be an area of the brain that is destroyed plus an uninjured section (even if there is no apparent function) and between the two a penumbra where brain cells are not functioning but recoverable. In severe cases a person may be wrongly declared “brain stem dead” or “brain dead”.

Coimbra’s research shows that the testing for “brain death” both delays treatment for the patient and that the actual apnoea test may bring on that state.

Coimbra shows there are two ways of treating severe brain injury that may produce recovery in apparently hopeless situations. One is hypothermia that reduces the brain’s use of oxygen and gives doctors more time to treat the patient before further damage occurs due to lack of oxygen.

Another is the controversial, and some say unproven, hyperventilation that is intended to increase the amount of oxygen reaching the brain. Both treatments are intended to minimise oxygen deprivation in the brain, hyperventilation by maximising oxygen reaching the brain and hypothermia by minimising the brain’s oxygen requirements by slowing the metabolism.^[21]

Coimbra and other critics claim apnoea “brain death” testing produces the opposite of recuperative treatment and accelerates brain damage.

This is because tests to establish “brain death” require normal body temperature and removal of ventilator support resulting in increased carbon dioxide levels in the blood. Coimbra shows this combination may be fatal to otherwise recoverable brain cells.^[22]

Healing Treatments Denied To Potential Donors

Dr Yoshio Watanabe is an academic and cardiologist at the Cardiovascular Institute, Fujita Health University School of Medicine in Toyoake, Japan. He says that applying the apnoea test before hyperventilation and hypothermia treatment may constitute murder or at least a malpractice suit. He says a large fluid drip and drugs to increase blood pressure to maintain organs for donation accelerate brain injury. He cites examples of apnoea testing repeated many times.^[23]

In one instance, Dr Watanabe says, a woman was brought to the Kochi Red Cross Hospital with a subarachnoid (and perhaps cerebral) haemorrhage. Instead of giving drugs to lower high blood pressure and using surgery to remove an intracranial hematoma doctors told the family, who needed to give permission for harvesting, that she was in the state of “impending brain death”. A clinical diagnosis of “brain death” was made despite Phenobarbital administration that makes an accurate evaluation of brain function difficult. Surgeons removed her heart, liver and two kidneys.

In another incident at Osaka University Hospital in 1990 a crime victim was brought in with brain injury and three days before diagnostic tests were done for “brain death” doctors put him on a brain damaging treatment regime to keep his organs transplantable. This included drugs that elevate blood pressure, large amounts of drip infusion that “aggravate brain oedema, increase intracranial pressure and accelerate the process of 'brain death'”. They threatened his wife to agree to donate organs without telling her that the treatment to keep the organs transplantable would increase brain damage.^[24]

Hypothermia

Dr Watanabe shares the view of associate Professor Coimbra of Brazil that hypothermia treatment should precede apnoea testing.

He cites reports from a team of neurosurgeons in the emergency care department of Nihon University Hospital in Tokyo. ^[25]

They used computer controlled brain hypothermia with maintenance of adequate intracranial pressure to treat 20 cases of acute subdural hematoma with diffuse brain injury (collections of blood within the skull) and 12 cases of global cerebral ischemia due to cardiac arrest (lack of oxygen to the brain because of heart failure). They were on the verge of brain death and going downhill but the team avoided the apnoea test in the fear of aggravating the brain damage. 14 of the 20 and 6 of the 12 recovered. Watanabe says this implies the hypothermia treatment gives a clear shift away from the point of no return and “brain death”.

Dr Watanabe says, based on the Coimbra conclusions 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.

Organ Donors may be denied protective Barbiturates

Barbiturates, for unknown reasons, protect the brain from damage when circulation has slowed or stopped due to brain injury or heart failure. People experiencing barbiturate overdoses have been known to go up to an hour without a heartbeat then revived without noticeable brain damage.

Barbiturates and other drugs also mask reflexes and brain activity making a living brain appear dead so a requirement for “brain death” diagnosis is that the patient isn’t on these brain-protecting drugs. Therefore, patients registered as donors may be deprived of certain protective drugs so doctors can, with more ease, later declare them “brain dead”. This denial or withdrawal of protection allows the brain to become further damaged, pushing it closer to “brain death” and making it a disadvantage to be a registered organ donor. A brain injured patient listed as a non-donor or organ keeper may get superior treatment in a hospital trauma unit.

A second problem is that barbiturates and other reflex depressing drugs may already be present in the donor candidate. This might result in sluggish reflexes wrongly interpreted as brain damage.

Dr David Wainwright Evans says,

“Barbiturates are protective – but the protocols envisage that such therapeutic measures will have been abandoned ere (before) testing for brain stem death is undertaken. That was the case in the early days. There was much discussion about how long one should wait to be sure that all such drug influence had cleared. Clearance can be very slow in some cases. Nowadays there is such haste to certify death for transplant purposes that barbiturate therapy is unlikely to be tried – but such (reflex-depressing) drugs may be present for other reasons and their presence may not always be suspected.”^[26]

Some further comments about the treatment of life-threatening head injury may be found in Appendix Two.

Back from the brain dead

The difficulty in ascertaining whether a potential organ donor is dead was exemplified in a University of Bonn Medical Center study where 2 of 113 who were initially thought to be mortally brain-damaged defied the fatal prognosis and made recoveries. The study involved neurosurgical patients mostly suffering brain trauma injury (bangs to the head), and intracranial haemorrhage (strokes).

The decisions to terminate further treatment were made after stringent and extensive brain activity testing. Yet despite this, two such “end of life” diagnoses were subsequently reversed and the patients made unexpected recoveries.^[27]

When such misdiagnosis are made despite comprehensive testing, one might also doubt similar diagnoses, in patients identified as organ donors, when those diagnoses are made solely on the basis of “…simple bedside tests (performed) after only a few hours' of ventilator-dependent coma…”^[28]

One might logically conclude that some patients previously harvested for their vital organs could have survived if organ removal hadn't been rushed as Dr David Evans sagely notes:

“The additional test, which saved these two, was the passage of time – one of the 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.”^[29]

Professor Coimbra echoes this wisdom with a knell of mourning:

“… a review of the literature shows that some of even the most severely head-injured patients (GCS of 3 or 4, with pupils fixed to light) who are not subjected to apnoea may recover to normal life. Early labelling of these patients as dead (for transplant purposes) during the past 3 decades has diverted medical researchers away from developing novel therapeutic resources that could already have saved many thousands of human lives throughout the world.”^[30]

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