The Nasty Side of Organ Transplanting
                         
Second Edition
                                  
Norm Barber
                                  Copyright


                                    Chapter 3

     The Apnoea Brain Death Test
               May Kill The Patient



As disquieting as the possibility that donors may feel pain during organ harvesting is a body of scientific research opinion that says 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". 14

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 even in apparently hopeless situations. One is hypothermia that reduces the brainís 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 brainís oxygen requirements by slowing the metabolism.15
Coimbra and other critics claim apnoea brain death testing produces the opposite of the recuperative treatments and accelerates brain damage.

Tests to establish brain death require a normal body temperature and by taking the patient off the ventilator (though still pumping oxygen into the trachea) result in increased carbon dioxide levels in the blood. Coimbra shows this combination may be fatal to otherwise recoverable brain cells. 16

For a more technical description by Dr David Evans see Appendix Two

Healing Treatments Denied To Potential Donors

Dr Yoshio Watanabe, an academic and cardiologist at the Cardiovascular Institute, Fujita Health University School of Medicine in Toyoake, Japan, writing in Beyond Brain Death16a, states his considered view that applying the damaging 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 harvesting actually accelerate brain injury. He says there are examples of apnoea tests repeated many times. In one instance 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 harvested her heart, liver and two kidneys. 17

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 fresh and transplantable. This included drugs that elevate blood pressure, large amounts of drip infusion which rather than healing an injured brain "aggravate brain oedema, increase intracranial pressure and accelerate the process of brain death". Then they threatened his wife to agree to donate organs without telling her that the treatment to keep the organs transplantable would increase brain damage.18

                            
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 19

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 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,

"Öa 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 say the apnoea test has been repeatedly performed there to achieve brain death rather than diagnose it.

Barbiturates Protect Brain Cells But Potential Organ But
                     Donors May Not Get Them

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 isnít 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 making it a disadvantage to be listed as an organ donor. A brain injured patient listed as a non-donor or organ keeper may get superior treatment in a hospital trauma unit than a potential organ donor.

A second problem is that barbiturates and other reflex depressing drugs may already be present in the donor candidate. This could allow sluggish reflexes, due to drugs taken before the injury, to be wrongly interpreted as brain damage.

Dr David Wainwright Evans says,

"Barbiturates are protective Ė 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 Ė but such (reflex-depressing) drugs may be present for other reasons and their presence may not always be suspected."20
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