A Summary Of Tk’s Autopsy Report
At the time of his brain-only autopsy, TK’s body measured approximately 3½ feet long with an approximate weight of 155 pounds. His extremities were symmetric, but poorly developed with muscles of severely reduced mass. His head was disproportionately small for his body size, probably because he did not have a growing brain to keep expanding the skull.
When the skull was opened, the autopsy revealed a hard, nearly spherical mass of approximately four inches in diameter with an irregular surface. No definite posterior brain structures including neither the cerebellum nor the brain stem were identifiable. CT analysis revealed irregular densities and signal changes consistent with calcification throughout the interior of the mass. MRI of the same sample revealed no identifiable specific anatomic brain structures. Sectioning of the mass with a saw revealed that the specimen consisted of a hollow hard-calcified shell containing semisolid material resembling clotted blood surrounding cyst-like spaces. There were no identifiable cerebral structures within the mass. Microscopic examination revealed mineralized deposits and material that resembled blood clots that had become, as the autopsy described it, mummified. No nerve cells or nerve cell structures were recognizable under the light microscope. No signals for any neuronal specific markers were detected by immunohistochemistry.
Brain Death And Organ Donation
In some cases, a person who is brain dead may be a candidate for organ donation. If the person was a registered organ donor, or if their family knew of their wish to be an organ donor, their death is declared, but the ventilator is left on. Drugs that help preserve the internal organs are still given. The dead person then undergoes an operation to remove viable organs such as kidneys. After the operation is complete, the ventilator is switched off. Funeral arrangements can then be made by the family.
It Was Pretty Much A Miracle Says T Scott Marr After Recovery
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A man who doctors believed would never recover consciousness woke up after his family took the decision to take him off life support and said their goodbyes.
Father-of-four T Scott Marr was diagnosed with a stroke after being found in bed in his Nebraska home, unresponsive but breathing, on 12 December.
Doctors saw no improvement in his neurological state, with significant brain swelling leading them to conclude he would end up brain dead with little hope of recovery.
Mr Marr had been explicit with his family that he did not want to be kept alive through mechanical resuscitation, but after his unexpected recovery they have taken to calling him the miracle man.
He had always said, I never want you guys to see me lying in a hospital bed, lying in a nursing home, Mr Mars daughter, Preston Marr, told a press conference. They told us he was on his way to brain death, so we said our goodbyes before extubating him, all the monitors were shut off and we waited by his side.
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How Brain Death Is Diagnosed
There is more to the loss of consciousness than not being awake. Sleep and coma, for example, each involves the loss of consciousness and are largely defined by the time it takes to return to consciousness. Even a person in a persistent vegetative state has the possibility, albeit slight, of waking up.
Brain death is different. As the term suggests, brain death indicates that there is no brain activity and, as such, no hope of recovery. Medically speaking, brain death is the definitive diagnosis of death.
How Is It Decided That An Individual Is Brain Dead
A doctor will do tests to make a diagnosis of brain death. These tests are based on sound and legally accepted medical guidelines. Tests include a clinical examination to show that an individual has no brain reflexes and cannot breathe on his or her own. In some situations, other tests may be needed. You can ask your doctor to explain or show you how brain death was determined for your loved one.
Possibly, an individual may show spinal activity or reflexes such as twitching or muscle contractions. Spinal reflexes are caused by electrical impulses that remain in the spinal column. These reflexes may happen even though the brain is dead.
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Identifying Organismal Integration In Tk
I propose that there are at least three bodily functions described in TK’s autopsy report that demonstrate that he is still an integrated whole: blood pressure homeostasis, a robust immune response, and proportionate growth. Significantly, both defenders and critics of the neurological criteria for death agree that the first two functions are indicative of organismal integration. Tonti-Filippini, a defender of the TBD criterion for death, argues that integration is mediated in the human body by the hormonal, i.e., endocrine, system:
The transfer of information merely between one part of the body and another is insufficient to establish that the soul has not separated from the body. For instance, circulation in itself is not a transfer of information that integrates the body. Rather it is a means by which information might be transferred such as happens through the endocrine system.
In brief, my argument is the following: If TK had retained his integration after total brain failure, then we would expect that his three organismal functions would be comparable pre- and post-brain death. In contrast, if TK had lost his integration, then we would expect that his three organismal functions, after the tragic destruction of his brain, would be defective or unreliable or faulty in some way.
Other Brain Death Testing
After completing the physical assessment, the physician may elect to order additional testing. While it is typical for both a physical assessment and an apnea test to be done, some people who are not brain dead cannot tolerate apnea testing. Often, in those cases, a flow study will be done. These studies are done to see if blood is traveling to the brain through the bloodstream. If the study shows that no blood is reaching the brain, the test is consistent with brain death.
Some physicians will use an EEG, or electroencephalogram, which is a test that measures brain waves. A person who is brain dead will have a “flat” EEG, as brain waves will be absent.
Atropine, a prescription medication that causes the heart rate to increase, an also be administered as an ancillary test for brain death because it is not effective in brain dead individuals. If the heart rate increases notably after the medication is given, this suggests that a person is not brain dead.
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Causes Of Brain Death
Brain death can happen when the blood and/or oxygen supply to the brain is stopped.
This can be caused by:
- cardiac arrest when the heart stops beating and the brain is starved of oxygen
- a heart attack when the blood supply to the heart is suddenly blocked
- a stroke when the blood supply to the brain is blocked or interrupted
- a blood clot a blockage in a blood vessel that disturbs or blocks the flow of blood around your body
Brain death can also be caused by:
Responsibilities Of Physicians Determining Brain Death
The diagnosis of brain death is primarily clinical. No other tests are required if the full clinical examination, including each of two assessments of brain stem reflexes and a single apnoea test, is conclusively performed. In the absence of either complete clinical findings consistent with brain death, or confirmatory tests demonstrating brain death, brain death cannot be diagnosed and certified. These guidelines apply to patients one year of age or older.
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Tests To Confirm Brain Death
Although rare, a few things can make it appear as though someone is brain dead.
These include drug overdoses and severe hypothermia, where body temperature drops below 32C.
A number of tests are carried out to check for brain death, such as shining a torch into both eyes to see if they react to the light.
Was It Really Brain Death
Twenty-one-year-old Zack Dunlap from Oklahoma appeared on NBC’s Today Show in 2008 to tell an incredible story of hearing a physician telling his parents that a PET scan confirmed that he was brain dead after a catastrophic brain injury. While he was being prepared for organ donation, however, he moved his arm purposely in response to stimuli. Dunlap recovered, went to a rehabilitation hospital, and ultimately went home 48 days later, very much alive.
Earlier this year, 13-year-old Trenton McKinley from Alabama and his parents hit the media circuit to talk about the miracle of Trenton awakening after being declared brain dead from a vehicle accident1 day before his organs were scheduled to be harvested.
The likely explanation for such “recoveries” from brain death, according to experts, is that these individuals were never brain dead in the first place. “Errors have been made where people declared brain dead were later found to have spontaneous movement that should not have been possible,” says Robert M. Sade, MD, professor of surgery and director of the Institute of Human Values in Health Care at the Medical University of South Carolina in Charleston. “In virtually all those cases, brain-death determination was not done correctly. If you don’t go through the exact protocol for brain-death determination, you’re likely to have patients diagnosed as being dead by neurologic criteria who are, in fact, not brain dead.”
- Was It Really Brain Death?
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Establishing The Absence Of Brainstem Reflexes
Brainstem reflexes are automatic responses that are no different to the knee-jerk tests given at the doctor’s office. They are reflexive actions that indicate whether a person’s neurological functions are normal, abnormal, or absent.
A person is considered brain-dead if he or she fails to respond to all of the following reflex stimuli:
- Lack of pupillary reflex means that the person’s pupils do not respond in any way when a light is shined on them. If the person were alive, the pupils would get smaller.
- Lack of corneal reflex means that the person does not blink and have any response when the doctor touches the eye with a cotton swab or a drop of water.
- Lack of oculocephalic reflex means the person’s eyes will not fixate on the examiner’s face when his or her head is moved from side to side.
- Lack of the gag reflex means that the person will not gag, cough, or react when the back of the throat is touched with a cotton swab or a suction device.
- Lack of response to cold caloric testing means that the person will not respond when ice water is squirted into the ear. If the person were alive, the stimuli would cause the person’s eyes to move in the opposite direction as it effectively “tricks” the inner ear into thinking that the person is spinning.
Brain Death Significantly Reduces Isolated Pancreatic Islet Yields And Functionality In Vitro And In Vivo After Transplantation In Rats
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After Brain Death Is Declared What Happens Next
A health care professional will talk with you and your family about certain decisions that need to be made at this time. Among those decisions could be removing the ventilator and the possibility of organ and/or tissue donation.
Remember, the individual is already legally dead and removing the ventilator does not cause death.
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Scientists Are Giving Dead Brains New Life What Could Go Wrong
In experiments on pig organs, scientists at Yale made a discovery that could someday challenge our understanding of what it means to die.
A few years ago, a scientist named Nenad Sestan began throwing around an idea for an experiment so obviously insane, so wild and totally out there, as he put it to me recently, that at first he told almost no one about it: not his wife or kids, not his bosses in Yales neuroscience department, not the dean of the universitys medical school.
Like everything Sestan studies, the idea centered on the mammalian brain. More specific, it centered on the tree-shaped neurons that govern speech, motor function and thought the cells, in short, that make us who we are. In the course of his research, Sestan, an expert in developmental neurobiology, regularly ordered slices of animal and human brain tissue from various brain banks, which shipped the specimens to Yale in coolers full of ice. Sometimes the tissue arrived within three or four hours of the donors death. Sometimes it took more than a day. Still, Sestan and his team were able to culture, or grow, active cells from that tissue tissue that was, for all practical purposes, entirely dead. In the right circumstances, they could actually keep the cells alive for several weeks at a stretch.
Dont forget the Kanye, Daniele joked.
Our soundtrack, Vrselja said with a grin.
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Evolution Of The Criteria For Brain Death
Historically death was defined by the presence of putrefaction or decapitation, failure to respond to painful stimuli, or the apparent loss of observable cardio respiratory action. The widespread use of mechanical ventilators that prevent respiratory arrest has transformed the course of terminal neurologic disorders. Vital functions can now be maintained artificially after the brain has ceased to function. In 1968, an ad hoc committee at Harvard Medical School reexamined the definition of brain death and defined irreversible coma, or brain death, as unresponsiveness and lack of receptivity, the absence of movement and breathing, the absence of brain-stem reflexes, and coma whose cause has been identified.
The Challenges Of Defining And Diagnosing Brain Death
A new Johns Hopkins support team helps clinicians and families understand a difficult diagnosis.
A woman lies in a bed at The Johns Hopkins Hospital. Aided by a ventilator, her lungs inflate, deflate, and fill again. Her heart beats and her skin is warm. But her eyes stay closed and she does not react to stimuli such as pain and light.
Is she alive or dead?
If youre unsure, or if the question makes you uncomfortable, youre not alone. The hypothetical case described here reflects a real problem: the inherent difficulties of diagnosing and accepting brain death.
The topic was the focus of a September Ethics for Lunch discussion in the Chevy Chase Bank Auditorium of The Johns Hopkins Hospital, hosted by the Berman Institute of Bioethics.
The panel was moderated by anesthesiologist and critical care specialist Robert Stevens, who says the line between life and death, once clearly perceptible in the form of a beating heart, is now sometimes harder to see because of advances in lifesaving technologies.
The modern intensive care unit can keep a person with severe brain injuries alive, he says, but may also mask evidence that the person has died. The shift from a deep coma to brain deathpermanent cessation of all brain functionmay not be immediately obvious to an untrained observer. Yet recognizing this transition from life to death is critical for families, the medical team and potential organ recipients.
Watch the Ethics for Lunch panel discussion.
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Establishing The Irreversibility And Cause Of The Coma
Before a doctor can determine whether the coma is irreversible, he or she must find if there is any way to reverse it. To do so, the medical team must first pinpoint the cause of the coma.
Moreover, the team must exclude any condition that could potentially mimic brain death, such as hypothermia, drug toxification or poisoning, metabolic abnormalities, or neuromuscular agents that can cause “death-like” paralysis. All of these, by varying degrees, are potentially reversible.
Establishing the irreversibility of a coma requires that the doctor wait an appropriate amount of time based on the known or proximate cause. The determination that must meet both medical and legal standards. From this perspective, the term “proximate” indicates that the cause must be sufficiently established and supported if it is not already known.
A Summary Of Tk’s Clinical History
TK’s autopsy report includes a narrative of his clinical history with medical details that will be relevant for the philosophical analysis of brain death that follows below. In brief, TK was born in 1979. When he was four years old, he contracted Haemophilus influenzae meningitis that put him into a coma. While staying in a Nebraska hospital for treatment, he experienced an increase in intracranial pressure so severe that it separated the bony plates of his skull. An EEG revealed no electrocerebral activity, but his family was opposed to his removal from life support.
For several weeks following his initial infection, TK experienced severe temperature and blood pressure fluctuations that required days of dopamine infusion to support his blood pressure. Urine output fluctuated tremendously suggesting that he had diabetes insipidus. There were also dramatic shifts in his serum sodium. After this period of crisis, however, TK’s temperature, blood pressure, urine output, and serum sodium levels became stable.
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Responding To An Important Objection: The Probative Value Of Tk’s Case
On February 34, 2005, the Pontifical Academy of Sciences, in cooperation with the World Organization for the Family, hosted a conference at the Vatican to discuss the validity of the brain-related criteria for death. In its final report on the proceedings of the meeting, the Pontifical Academy of Sciences raised an important objection to TK’s case. Basically, its final statement defending the validity of the neurological criteria for death suggests that TK’s case is an outlier, an exception to the rule, that is not relevant to the brain-death debate:
If was a valid documented case of brain death, it makes the point that in extraordinarily rare exceptions this kind of case occurs. However, many years have passed since this case, there is a great deal of uncertainty about it, and one cannot generalise from it to invalidate the criteria for brain deathThe neurological community does not believe that this case disturbs the conceptual validity of brain death as being equivalent to human death.
To put it another way, given the exceptionality of TK’s case, the Pontifical Academy is proposing that TK’s autopsy report is not probative for understanding the state of all/most/more than a few patients diagnosed with total brain failure.
If being alive as a biological organism requires being a whole that is more than the mere sum of its parts, then it would be difficult to deny that the body of a patient with total brain failure can still be alive, at least in some cases.