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NRL News
Man
Diagnosed as Brain Dead Recovers In a case raising serious questions about procedures used to determine brain death, a man declared brain dead was found to be very much alive just four hours after that diagnosis, just as his family was getting ready to pay their respects and say goodbye. A mere four months after 21-year-old Zach Dunlap crashed his four-wheel ATV, leaving him with “catastrophic brain injuries,” he appeared on the NBC’s Today Show, able to recount his ordeal, on his way to recovery. So what had happened? Following the November 2007 accident, the doctor involved informed Zach’s parents and family of what he described as Zach’s “catastrophic brain injuries.” He showed them two sets of CT scans that indicated no blood flow whatsoever to the brain, according to Dateline NBC. As the young man was being prepared for organ transplantation, his cousins, who were both nurses, noticed that his vitals appeared to be improving and that he did not match their experience of typical brain dead patients. As another nurse was removing life support, Zach’s cousin ran two reflex tests on his own—one on the bottom of Zach’s foot, and the other by pinching the tender area under the fingernail. Both elicited a voluntary reaction. This was contrary to a diagnosis of brain death, as there could be no voluntary movement whatsoever once brain dead. Since “brain death” demands that the condition is irreversible, the probable error lies in the diagnosis. They summoned Dr. Leo Mercer, director of trauma services at United Regional hospital. Mercer told Dateline NBC that he agreed Dunlap was making “purposeful movements.” The organ transplant process was halted immediately. However, Dr. Mercer told Dateline NBC, “I still didn’t think that Zack was going to have a good outcome. I thought, well, OK, well, he’s not brain dead, but he’s pretty close to it.” Dr. Mercer’s pessimistic diagnosis begs the question: if brain death is a definitive diagnosis, you either are or you are not—how can you be close to it? Even after acknowledging that he was not brain dead, doctors warned the family that Zack could have profound brain damage that would prevent his leading anything resembling an active life. Luckily for Zack, it was only five days after he was saved from being used as a source for organs that he opened his eyes. Within 12 days, he began to speak and took his first steps. He has been steadily, if slowly, improving since then. It is becoming increasingly common for families to be given sloppy diagnoses due to the complex and still misunderstood functions of the brain and become pressured to make decisions contrary to the life of the patient. With improper information, how can a family make informed medical decisions? The case of Zack Dunlap raises legitimate concerns about the procedure for diagnosing brain death. The medical community is well aware of the fact that from hospital to hospital, there are variations in how brain death is diagnosed. It is commonly accepted among lay persons and among medical providers that a person is dead when the individual has sustained “irreversible cessation of all functions of the entire brain, including the brain stem,” in the words of the Uniform Determination of Death Act. The requirement that all functions must have ceased, “including the brain stem” (rather than, as some advocated, just the functions of the cortex, to which consciousness and thought are attributed), was largely due to the efforts of the late pro-life luminary Dennis J. Horan, then chairman of the American Bar Association’s Medicine and Law Committee. The act, however, does not define any of the specifics of the clinical diagnosis. It states only, “A determination of death must be made in accordance with accepted medical standards.” This means that there is a set of criteria a person must meet to be declared brain dead, but that there is no uniform procedure by which to test whether one meets those criteria. This lack of uniformity can end up making a life-and-death difference. Earlier this year, a report featured in the medical journal Neurology reported, “There are substantial differences in practice that may have consequences for the determination of death and initiation of transplant procedures.” After conducting a national survey, the study’s authors, led by Dr. David M. Greer of Boston’s Massachusetts General Hospital, found significant discrepancies in brain death guidelines used by major U.S. hospitals. The study found relatively low adherence to practice parameters established by the American Academy of Neurology. These included the following variations: less than half required a neurosurgeon (instead of any attending physician) to perform the examinations; nearly all had variations in the time required between exams; one-third of physicians failed to stipulate a cause of the brain death as required; and physicians had notable failures in ruling out interfering disorders. “Of concern was the variability in the apnea testing,” Dr. Greer and his colleagues wrote, “an area with the greatest possibility for inaccuracies, indeterminate testing, and potentially even danger to the patient.” (The apnea test is intended to determine the patient’s ability/inability to breathe unaided.) The article suggested that “the American Academy of Neurology, the American Neurological Association, and Child Neurology Society jointly impanel a task force to draft evidence-based guidelines including specific recommendations for conducting the clinical and confirmatory tests for brain death.” Commenting on the study in an editorial in the journal, Dr. James L. Berna from Dartmouth Medical School in Hanover, New Hampshire, warned that current guidelines demonstrate a “disturbing pattern of non-uniformity.” It is unclear from the published facts of Zach Dunlap’s case whether or not such uniform procedures for determining brain death could have prevented his misdiagnosis. Dunlap appeared on the Today show March 24. He told interviewer Natalie Morales that he heard doctors pronounce him brain dead, and that it made him angry. “I’m glad I couldn’t get up and do what I wanted to do,” he said. “Probably would have been a broken window they went out.” |