Doctors call for global consensus on diagnosis of death
There needs to be international agreement on when and how death is diagnosed, two leading doctors suggest.
At a European meeting of anaesthetists they said improvements in technology mean the line between life and death is less clear.
They called for precise guidelines and more research to
prevent the rare occasions when people are pronounced dead but are later
found to be alive.
The World Health Organisation has begun work to develop a global consensus.
In the majority of cases in hospitals, people are pronounced
dead only after doctors have examined their heart, lungs and
responsiveness, determining there are no longer any heart and breath
sounds and no obvious reaction to the outside world.
'Permanent damage to brain'
But Dr Alex Manara, a consultant anaesthetist at Frenchay
Hospital in Bristol, said more than 30 reports in medical literature,
describing people who had been determined dead but later found to be
alive, had driven scientists to question whether the diagnosis of death
can be improved.
At a meeting of the European Society for Anaesthesiology he
said that on some occasions doctors do not observe the body for long
enough before someone is declared dead.
"Italians and Brits are probably built in the same way - it makes sense to have the same criteria for death for both” Dr Jerry Nolan Consultant in intensive care, Bath Royal United Hospital, UK
Dr Manara called for internationally agreed
guidelines to ensure doctors observe the body for five minutes, in order
not to miss anyone whose heart and lungs spontaneously recover.
Many institutions in the US and Australia have adopted two
minutes as the minimum observation period, while the UK and Canada
recommend five minutes. Germany currently has no guidelines and Italy
proposes that physicians wait 20 minutes before declaring death,
particularly when organ donation is being considered.
Dr Jerry Nolan, consultant in intensive care at the Royal
United Hospital in Bath, who is not involved in the conference, said:
"In hospitals, where patients are monitored closely, and after the
appropriate resuscitation has taken place, waiting five minutes to
observe the body is a good idea.
"There is evidence to show that once you start going beyond
five minutes without a circulation or oxygen to the brain you start
seeing permanent damage to brain cells."
At the conference, Ricard Valero, professor of anaesthesia at
the University of Barcelona, considered the rarer scenario of patients
in intensive care units whose hearts and lungs are kept functioning by
machines.
In such scenarios, doctors use the concept of brain death -
often conducting neurological tests to monitor any brain activity in the
patient.
'Variations don't seem logical'
But the criteria used to establish brain death have slight variations across the globe.
In Canada, for example, one doctor is needed to diagnose
brain death; in the UK, two doctors are recommended; and in Spain three
doctors are required. The number of neurological tests that have to be
performed vary too, as does the time the body is observed before death
is declared.
"These variations in practice just do not seem logical," Prof Valero said.
He proposed further research to support a global consensus on the most appropriate criteria to diagnose brain death.
Dr Nolan said: "In principle an international guideline on
death is a very good idea. It is likely to help in terms of the movement
of doctors between countries and, importantly, with public confidence.
"Italians and Brits are probably built in the same way. It makes sense to have the same criteria for death for both."
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