Somatic survival and organ donation among brain-dead patients in the state of Qatar

In 1995, the AAN published practice parameters for diagnosis of brain-death [7]. The parameters emphasize on irreversible coma (with a known cause), absence of brain-stem reflexes and irreversible apnea. The diagnosis of brain-death is a clinical one and supplementary tests are only recommended in the presence of confounding factors. The AAN issued an evidence-based guideline update in 2010 [8] that concluded absence of any published reports of recovery of neurologic function after a diagnosis of brain death using the 1995 AAN criteria. Following brain injury, the initial care is usually directed towards preservation and restoration of neuronal function to prevent more serious consequences such as brain death [9]. In Qatar, the strict criteria of the AAN are used for the diagnosis of brain death and require confirmation by two independent senior physicians. Organ donation and discontinuation of medical support are usually discussed with patient’s family after confirmation of brain death. The finding of a median somatic survival of 3 days in brain-dead patients in the current study is comparable with the findings in other countries. In a study of 609 brain-dead patients conducted in the United Kingdom, the median somatic survival of these patients was 3.5–4.5 days [10]. Another study conducted on 73 brain-dead patients in Taiwan found that 81% of these patients developed cardiac asystole in 3 days and 97% in 7 days despite continued cardiorespiratory support [11]. A recent study from Kuwait showed a median survival of 6 days in 40 brain dead patients. A meta-analysis of brain-dead patients who survived one week or longer found that the longest survivors were all young children. In addition, all patients aged more than 30 years survived for less than two and half months [12]. A study conducted by Wijdicks et al., revealed similar findings to the current study with regard to the timing of diagnosis of brain death (within 24 h of presumptive brain death in 30% of the patients and within 3 days in 62%) [13]. The most common etiology of brain death in the current study was primary structural brain damage, causes of which being intracranial hemorrhage (cerebral and subarachnoid), followed by ischemic stroke and traumatic brain injury. This finding with regard to the etiology is in consensus with findings from previous studies where direct traumatic injury to the head (e.g. road accident), subarachnoid hemorrhage and ischemic stroke were found to be the most common causes of brain death [14]. Other causes include intra-cerebral hemorrhage, hypoxic-ischemic encephalopathy and infections. These pathologies result in severe damage of the brain by causing cerebral edema and rise in intra-cranial pressure (ICP) that in turn reduce cerebral perfusion leading to trans-tentorial herniation and coning at the foramen magnum with damage to the brainstem as a consequence [15]. Many previously published case series found that traumatic brain injuries and intracranial hemorrhage to be the most common etiologies of brain death [13, 16]. Cardio-pulmonary arrest from other causes was responsible for 9% of causes of brain death. Brainstem death is relatively rare in cardio-pulmonary arrest as the commonly affected parts of the brain are the cerebral cortex and cerebellum if resumption of circulation fails beyond 5 min [17, 18]. Being a center for organ retrieval and transplantation, organ donation rates among brain-dead patients in our hospital were low during the study period. Out of the total number of patients deemed suitable as organ donors, family refusal was observed in nearly 93% of the cases. This is likely due to complex factors including religious, cultural, population dynamics (majority expatriates) and poor understanding of organ donation. This strongly points to the need to enhance public education with regards to organ retrieval and transplantation. Despite the fact that the concept of brain death was introduced more than 40 years ago and has been widely accepted, differences continue with its concept and justification [19]. A minority of health care individuals worldwide, still debate the importance of organ donation and mind the unintended consequences for dying patients such as diagnostic errors during expedited process of brain death prior to retrieval of transplantable organs [20]. In Qatar and other Gulf Cooperation Council (GCC), there is an increasing trend of end-stage liver and renal disease with high need for increased organ donors to fulfill the increasing demands [21, 22]. The acute need of rapid evaluation, family discussion and timely retrieval of organs in brain-dead patients cannot be overemphasized. While there is legal precedent for discontinuing life support over the family’s objection, many rightly advocate delay, education, support, and negotiation in such cases [23‐26].