641
TABLE III-PERCENTAGE LOW BIRTHWEIGHT IN 1973 below 2500 g belong to the big group with a gaussian
more in Cuba, whereas there is almost no change in
Sweden (table 111).
Comparison of weight groups below 2500 g has
revealed higher perinatal mortality rates in Sweden than
in the U.S.A. (six States) and Hungary.7 With the new
definition this confusing result may now be explained. In
Sweden, those with a birthweight below 2500 g belong
to an abnormal population and are not part of that
population which has a gaussian birthweight distribu-
tion. The latter population is the one which accounts for
the low perinatal mortality. By contrast, in Hungary
about half of the 10-8% infants with a birthweight
Practice
Hospital
A BRAIN-DEATH PROTOCOL
JOHN SEARLE CHARLES COLLINS
Intensive Therapy Unit, Royal Devon and Exeter Hospital,
Barrack Road, Exeter EX2 5DW
A protocol for the management of pa-
Summary
tients thought to have suffered brain
death includes a list of questions to aid the diagnosis of
brain death and guidelines for dealing with relatives
competently and compassionately. If the relatives give
permission for the removal of organs for transplan-
tation, the protocol enables the procedure to be carried
out quickly. In the two years from July, 1977, 22 pa-
tients in one intensive-therapy unit suffered brain death,
and kidneys were donated from 11 of these patients and
eyes from 4. The management of brain death and the
provision of organs for transplantation are best dealt
with by one department in a hospital.
INTRODUCTION
AN average of 72 kidney transplants per month were
carried out in the United Kingdom in the first six
months of 1979. The average number of patients await-
ing a kidney transplant during that time was 1320. Thus
there is a wide gap between the number of kidneys pro-
vided, despite reliable criteria for the diagnosis of brain
deathl-2 and enthusiastic campaigning by transplant
surgeons. Furthermore, it has been estimated that there
is a considerable surplus of potential donors over pa-
tients awaiting a kidney transplant.3
Probably few doctors would be unwilling to provide
organs from suitable donors, and the inadequate supply
of donor kidneys is no doubt due to a widespread lack
of straightforward protocols for the management of
brain-death patients. Following the statement on the
birthweight distribution and should then have the low
perinatal mortality of this "normal" group.
Arguments against this new standard for low birth-
weight will undoubtedly be brought forward. If the
result is a more valid new standard, well and good.
Meanwhile it is clear that many countries could gain
much useful information by examining their data in the
way I propose here.
REFERENCES
1. Lechtig A. Low birth weight babies. World wide incidence, economic cost
and program needs. In: Perinatal care in developing countries. Geneva:
WHO, 1977.
2. World Health Organisation. Report on social and biological effects on perina-
tal mortality. Geneva: WHO, 1978.
3. Fryer JG, Harding RA, Ashford JR, Karlberg P. Some indicators of matur-
ity. In: Falkner F, ed. Fundamentals of mortality risks during the perina-
tal period and infancy. Basel: Karger, 1978.
4. Medical birth registration in 1973 and 1974. Stockholm: National Central
Bureau of Statistics, 1977: 16.
5. Karlberg P, Priolisi A. Clinical evaluation of similarities and dissimilarities
between the two city surveys. In: Falkner F, ed. Fundamentals of mortality
risks during the perinatal period and infancy. Basel: Karger, 1978.
6. WHO Tech Rep Ser no. 457, 1970.
7. Rooth G. Socio-economic aspects of perinatal medicine. In: Rooth G, Brat-
teby L-E, eds. Perinatal medicine. Stockholm: Almqvist & Wiksell, 1977.
diagnosis of brain death issued by the honorary secre-
tary of the Conference of Medical Royal Colleges and
their Faculties in the United Kingdom,I a protocol was
drawn up for the management of such patients in the in-
tensive-therapy unit (ITU) of this hospital. We report on
its operation over the past two years.
METHODS
When brain death is suspected the patient is examined by
the consultant in charge of the ITU and another doctor
(usually the duty anaesthetic registrar or a member of the
admitting team). The results of this examination are recorded
on a special form, on which the criteria for the diagnosis of
brain death are tabulated in question form such that the diag-
nosis of brain death can be made only if the answers to all the
questions are "no". There are separate questions about the
presence of apnoea, depending on whether or not arterial-blood
gases have been analysed. The questions included on the form
and the explanatory notes which accompany them are as
follows: .
1. RESPIRATION*:
a. Was the PACO, below 45 mm Hg before the ventilator
was disconnected?
b. Is there any spontaneous ventilation within 5 min of dis-
connecting the ventilator?
c. Is there any spontaneous ventilation within 10 min of dis-
connecting the ventilator?
2. BRAIN STEM REFLEXES:
a. Do the pupils react to light?
b. Is nystagmus present when each ear in turn is investi-
gated with ice-cold water for 1 min?
c. Does any response occur when each cornea in turn is
touched?
* If arterial blood-gas analysis can be performed answer (a) and (b). To establish
the answer to (b):
i. ventilate the patient with 100%
oxygen for 15 min.
ii. disconnect the patient from the ventilator.
iii. administer oxygen, 61/min, through a catheter in the trachea.
If arterial blood-gas analysis cannot be performed answer (c). To establish (c):
i. ventilate the patient with 100% oxygen for 10 min.
ii. ventilate the patient with 5% carbon dioxide in oxygen for a further 5 min.
ni. disconnect the patient from the ventilator.
iv. administer oxygen, 61/min, through a catheter in the trachea.
642
d. Is any movement present in the head and neck, either
spontaneously or in response to any stimulus?
e. Is there a gag reflex or reflex response following bronchial
stimulation by a suction catheter passed down the tra-
chea ?
3. BODY TEMPERATURE?
Is the rectal temperature below 35°C?
4. DRUGS?
Have any drugs which may affect ventilation of the lungs or
the level of consciousness been administered during the pre-
ceding 12 h?
5. Is coma due to a metabolic or endocrine cause?
If muscle-relaxant drugs have been given to the patient in
the 12 h before the examination, normal neuromuscular acti-
vity has to be demonstrated with a nerve stimulator before the
examination is carried out. The results of appropriate bio-
chemical tests are available at the time of this examination.
The opinion of the neurologist is obtained only when the pri-
mary cause of brain death is in doubt.
If the examination indicates brain death the time of a second
examination is decided. The gravity of the prognosis is
explained to the relatives. If the patient is a possible kidney
donor, blood is sent for tissue typing, and hepatitis-B antigen
testing. The transplant surgeon is told that the patients kid-
neys may become available.
When the second examination has confirmed brain death,
the futility of continuing treatment with mechanical ventila-
tion is explained to the relatives. A formal request for permis-
sion to remove the patients kidneys is not made during this in-
terview. However, the subject is broached gently, and the
relatives are asked if they would agree to see a member of the
transplant team. The transplant surgeon, having satisfied him-
self that the donor is suitable and that his brain is dead, then
asks the relatives for permission to remove the kidneys. When
this has been given, the donor is taken to the operating theatre,
the kidneys are removed, and mechanical ventilation is discon-
tinued. If the patient is not a suitable donor or permission is
refused, mechanical ventilation is discontinued in the ITU.
Throughout this period an adequate urine output is main-
tained. If there are nurses working on the ITU who have not
looked after possible donors before, the problem of brain
death is explained to them by a member of the medical staff.
Any press inquiries about the patient are dealt with by the hos-
pital administrator. Lately, two to three weeks after the pa-
tients death, the units social worker has written to the next
of kin to offer help or an opportunity to "talk things over".
RESULTS
In the two years from July, 1977, 22 patients suffered
brain death (see table). In 10 patierits the core tempera-
ture was below 35 ° C at the second examination. In 1
patient it was below 35°C at the first examination.
Head injury was the cause of brain death in 16 pa-
tients.12 of these had had a road-traffic accident, 2 had
fallen from considerable heights, and 2 had been shot.
1 patient had overwhelming fat embolism after a road-
traffic accident. 2 patients had a subarachnoid haemorr-
DATA ON 22 CASES OF BRAIN DEATH
hage and 2 had a massive intracerebral hxmorrhage. 1
child had a meningococcal septicaemia. Necropsy con-
firmed the cause of death in 21 patients. Necropsy was
not done in 1 patient who had a subarachnoid hxmorr-
hage.
Kidneys were removed from 11 patients and eyes
from 4. Kidneys were not removed from 11 patients for
the following reasons: 4 patients had poor renal func-
tion ; in 3 cases the police were conducting inquiries into
the circumstances in which the injuries had been recei-
ved ; 1 patient was only 3 years old; the relatives of 2 pa-
tients refused permission; and 1 patients relatives were
not asked.
DISCUSSION
The aims of this protocol are: to provide proper care
for patients with severe brain damage; to allow accurate
diagnosis of brain death as soon as possible; to provide
kidneys for transplantation in the best possible condi-
tion ; to ease the anxiety and distress of relatives; to clar-
ify the problem of brain death for medical and nursing
staff; and to maintain good relations between the hospi-
tal and the public. These aims are more likely to be
achieved when the system is administered always by one
department (in this case the department of anaesthesia)
in consultation with the admitting firm, rather than by
different firms occasionally.
Recording the results of tests for brain death in tabu-
lar form means that the same examination routine is
always followed. Furthermore, the tests are carried out
in accordance with the criteria laid down by the Confer-
ence of Medical Royal Colleges and their Faculties in
the United Kingdom.This is essential if public confi-
dence in the ability of doctors accurately to diagnose
brain death is to be maintained. The recording of the
results of the tests is unequivocal.
There was a wide range in the interval between tests,
although in no case was it more than 24 h. A longer per-
iod between tests would add to the relatives distress and
to the strain on the nursing staff. In 1 patient the inter-
val was only 10 min. Maintenance of an adequate circu-
lation was becoming increasingly difficult because of tor-
rential haemorrhage from his head injuries, and it was
necessary to confirm the diagnosis of brain death as
quickly as possible if the kidneys were to be obtained in
a reasonable condition. Although it is tempting to do
only one examination in such circumstances, it is prob-
ably wise to do two examinations even though the inter-
val between them may be very short.
The conference recommends that the body tempera-
ture should not be below 33°C before the tests for brain
death are carried out. This was not so at the time of the
second examination in 10 cases in this series. However,
the diagnosis of primary hypothermia had been excluded
by the presence of a normal central body temperature on
admission. An adequate arterial carbon-dioxide tension
at the time of the apnoea test was confirmed by arterial
blood-gas analysis. These patients demonstrate how dif-
ficult it is to maintain central body temperature in the
presence of brain death although all patients were
nursed in an ambient temperature of21°C and covered
with a heat-reflecting blanket. Our brain-death form
requires modification to take account of this difficulty.
Probably all patients who may have suffered brain

death should be nursed on a heated water mattress.
1 patient, a 10-year-old boy, had a central body
temperature of less than 35 °C at the time of the first
examination. He had been perfectly well before his
intracranial haemorrhage.
8 patients were unsuitable as kidney donors.4.5 Only
2 of 13 next of kin asked refused permission for the
removal of the kidneys.
If there is a local active policy of corneal grafting it
is also important to ask permission to remove the eyes
as well. This can be done at the same time as asking for
permission to remove the kidneys.
The most difficult problem is handling the relatives,
whether or not permission to remove the kidneys is
sought. The almost invariable suddenness of the catas-
trophe plunges the relatives into bewilderment and dis-
tress, and they need competent and compassionate hand-
ling. A clumsy approach will not only add greatly to their
distress but may also result in a refusal to allow the kid-
neys to be removed. It is important that.relatives under-
stand the hopelessness of the prognosis.6 We find it help-
ful to use such phrases as "the person you knew and
loved has already gone-it is just his shell that we are
keeping alive".
It is essential that a doctor other than those looking
after the patient makes the formal request for the remo-
val of organs. In this way there is seen to be complete
separation between the immediate interests of those
looking after the potential donor and those who may be
looking after a potential recipient. Exeter has an active
renal-transplant programme, and permission for the
removal of organs is requested by a member of the trans-
plant firm. Where there is no such programme we
believe that the smooth running of a system such as ours
elsewhere would be greatly enhanced if two or three peo-
ple were always available to ask relatives for permission
to remove organs.
As far as possible the same relatives should be seen by
the same doctor when the patients prognosis is dis-
cussed. In this way at least some understanding can be
built up over the relatively short time available. It also
helps to ensure that different information is not given to
different relatives. (On one occasion, one set of relatives
was told that death had occurred when the diagnosis of
brain death was established and another set was told
that death had occurred when mechanical ventilation
had been discontinued an hour later.) The presence of
a member of the nursing staff at doctors interviews with
relatives also helps to ensure that there is no conflict
between "what the doctors said" and "what the nurse
said".
The medical staff have a responsibility to see that the
nursing staff understand what brain death is, how it is
diagnosed, and how it is managed. Nurses are with the
patient for long periods during which they are expected
to maintain the highest standard of care, knowing that
there is no chance that the patient will recover. They
bear the brunt of the care of the relatives. They cope
well when they are well informed and supported by the
medical staff. Indeed, such nurses are essential for the
humane and efficient management of patients with brain
death.
Switching off a life-support system is still news-
worthy, and reporters are often persistent in their in-
quiries about accident victims. Newspaper reports can
643
have asignificant influence on the publics view of a
local hospital. Health administrators should strive for
good relations with local press and broadcasting agen-
cies. When an inquiry is received from the media about
a patient in whom the diagnosis of brain death has been
made the sector administrator should provide a state-
ment which has been approved by the appropriate con-
sultant. He should provide such a statement only when
he has received an assurance from the media that it will
be published without any alterations.
We thank Dr C. Gardner-Thorpe for his help in putting the criteria
for the diagnosis of brain death into tabular form, the physicians and
surgeons of the Royal Devon and Exeter Hospitals for their coopera-
tion in administering this protocol, and Mrs Andrea Foster for her
help in analysing case records and for typing the manuscript.
Requests for reprints should be addressed to J. S.
REFERENCES
1. Conference of Medical and their Faculties
Royal Colleges (UK). Diagnosis
of death. Br Med J 1976, i: 1187-88.
2. Conference of Medical Royal Colleges and their Faculties (UK). Diagnosis
of death. Br Med J 1979; i: 332.
3. BritishTransplant Society Report. The shortage of organs for clinical trans-
plantation. Br Med J 1975; i: 251-55.
4. Slapak M. Is my patient a potential donor for kidney transplantation? Br J
Hosp Med 1979: 21: 627-32.
5. Luksza AR. Brain-dead kidney donor: selection, care and administration. Br
Med J 1979; i: 1316-19.
6. Morton JB, Leonard DRA. Cadaver nephrectomy: an operation on the
donors family. Br Med J 1979; i: 239-41
Round the World
From our Correspondents
Canada
SCREENING FOR BREAST CANCER
THE National Cancer Institute of Canada, the Department
of Health and Welfare, and the Canadian Cancer Society are
about to launch an inquiry into the effects of early diagnosis
in breast cancer. It is hoped to attract 90 000 volunteers
between the ages of 40 and 59. The programme is expected to
run for five years and eight different centres are to take part.
The two main objectives are: to ascertain whether screening
for breast cancer needs to include mammography; and to find
out whether screening in women under 50 is beneficial. All
volunteers will undergo an initial physical examination. The
population selected will then be randomised and half will be
offered mammography, while the other half will be taught to
palpate their breasts. Those women in whom no abnormalities
are detected will then have an annual follow-up, half receiving
a physical examination only, and the other half having a physi-
cal examination plus mammography. The study is starting in
a glare of publicity. Findings from the Health Insurance Plan
in New York have indicated that women under 50 do not benefit
from mammography screening. There has also been concern
about the risks of radiation, and while the director of the
-Canadian study, Dr Anthony Miller, of the National Cancer
Institute of Canada, in an interview with the Toronto Globe
and Mail, stated categorically that the benefits of mammogra-
phy in the under-50 group exceed the dangers, his opinion has
been disputed by Dr Irwin Bross, of Roswell Park Hospital,
New York. Dr Bross has appreciable circumstantial evidence
in favour of his views, and he cites the decision of the Cancer
Institute of the National Institutes of Health to suspend mam-
mographic screening in women below 50. Dr Miller declares
that he knows the benefits of mammography outweigh the risk,
so it is being asked why he wants to press on with the trial.