Dr. Yonatan Halevy
Director of Shaare Zedek Hospital
[4 minutes 53 seconds]
Since the publication of the Harvard Criteria in the late 60’s, the medical community accepts brain death as death in every respect. You asked me right now if the medical community is unanimous.
I would say that physicians who have reservations are, first of all a very, very small, tiny minority. (B) The reservations stem from ignorance, usually. And anyone who learns the stages of assessing brain death today, and is familiar with the clinical material, will accept immediately. And, as I said, there is a small, tiny minority in our efforts – – when I say ‘our’, I mean the Israel Transplant Center’s efforts to educate physicians around the country as to the brain death – – sometimes we are overwhelmed by the amount of ignorance. And those who question the validity of brain death as death in every respect are usually ignorant, never touched the subject. Once they are educated, they unanimously accept it.
How confident we feel about our ability to assess unequivocally that brain death is there, today, the answer is 100%; more than ever in the past. If you consider that the medical community around the world accepts brain death as death for over 35 years now. The technology that is at our hand today to verify that it is brain death is so much better than we had in the past: By evoked potential, the famous Bera test, the transcranial doppler sensor that proves no blood supply, not to the brain and not to the brainstem. This is the ultimate proof. So if you combine clinical bedside criteria to criteria that have to do with the respirator – – you disconnect the patient from the respirator, the apnea test, and you add to this the ultratechnological assessment manifested by the visually evoked potential, measuring electrical activity in various regions of the brain after stimulation of these specific regions, and the proof that there is no blood supply to the brain and to the brainstem, I feel fully confident that our assessment is accurate, and I will have no hesitancy to pronounce a patient based on these assessments as brain dead and consider him dead as if his heart stopped pumping and stopped beating for a few minutes.
No one in history has woken from brain death the way we assess it, according to the rules that we have today to assess brain death. It would be in my eyes more plausible that someone who is pronounced as cardiac death, and that it was not assessed long enough, and this has been reported, that the heart will beat again if the resuscitation process was not long enough than after brain death.
Anyone who witnessed a patient who passed away from brain death will not even consider the possibility of coming back from this situation.
Coma is a prerequisite for brain death, but it is not enough. I mean, patients in coma wake up all the time. I mean, coma is a wider, where there are various degrees of damage to the brain, many of them reversible. I mean, if we take what we call persistent vegetative state today (PVS), this is very far from brain death. These are the stories that you read in the papers, that after 9 years, the patient woke up.
Most of these patients are not even on a respirator. In order to even consider brain death, you have to have a deep coma; the most basic reflexes are absent, like the corneal reflex, the reaction of the pupils to life which are very basic; you need the patients to be in extremely deep coma in order to have this; you have to have no spontaneous respiration; as I said, you disconnect the patient from the respirator, and for 5 minutes, you don’t see any spontaneous respiration; of course, a flat curve of the electrical activity of the brain (the electrocephologram); no response to any external stimuli – – to the IO region and the E region represented in the brain; and no blood supply to the brain.
So, coma is only one prerequisite. And most patients in coma are not brain dead. But all brain dead patients definitely have to be in deep coma.