Geven en nemen - dr Erwin JO Kompanje

patients having been treated with barbiturates. Exclusion of sueh patients as
potential donors, will definitely have a negative influenee on the potential number
of donors. Furthermore the criteria of an iso-electric electroencephalogram and a
no-flow angiography are disCllssed. The demand for denlOnstrating complete
absence of all electric activity on the eleetroencephalogram, is considered unnecessar}'
for the declaration ofbrain deth. The presence of very minimal cortical
activity, which can not be considered evidence of an}' functioll, is not eonsidered
relevant to causing possible harm to the patient as a person. In Britain, electroencephalography
is not required for the diagnosis ofbrainstem death. In absence of
brainstem function, death of the brain as a whole is presumed. Although maybe
form a scientific perspective an iso-electric EEG may not be absolutely required,
from asodal perspective it is considered important, because of the extra anel
objective certainty provided. Exclusion of patients who have been treated with
barbiturates, as potential organ donors is not considered reasonable. Four vessel
angiography can confirm cessation of intracranial circulatioll, thereby providing
convincing evidenee for death of the brain, irrespective ofbarbiturates. Exclusion
of sueh patients will have a negative effect on donor potential, which is eonsidered
Ullelesirable from the perspeetive of transplantation medicine.
A COlnmon misconception is that irreversible circulatory arrest wi1l follow
within hOlUS to at most a few da}'s aftel' the eliagnosis of clinical brain death,
despite optimal treatment. The pathophysiology ofbrain death is described and
the question raised whether current treatment of the brain dead patient may
always be eonsidered optimal. It is eoncluded that in modern intensive care
(including hormonal substitution) the cardiovascular and hemadynamie stability
of a c1inieally brain dead patient maybe maintained over mueh more extended
periods than previously supposed.
In practiee, a potential organ donor is deelared brain death after clinical
neurologie examination and registration of an iso-electric EEG, but sueh rigorous
procedures are not officially required for the deelaration of death in a patient who
is not a potential organ donor.
Strong points of the memorandum brain death criteria of the Dutch Health
COUllCil (1996) are that the physician is required to follow the brain death
protocol and that a description is given for standardized application of the
apneu test. Weaker points however are the inconsistencies in requiring complete
loss of function, exclusion of patients treated with barbiturates anel the unneeessarily
striet requirement that all tluee elements must be met completely.
The moral pespective on elinically brain dead patients is further discussed.
Important aspects are that the presence of minimal hypothalamic function is
irrelevant to the questioll if a patient as a person may be hanned by procedures
in preparation for organ explantation. The situation ofbrain death, despite
remaining hypothalamie function, is irreversible and may be considered the end
ofhuman life. It would perhaps be more appropriate to talk about death of the
410 su M MAR Y