Kerala issues brain death certifying norms

Kerala has become the first state to adopt a standard operating procedure (SOP) for determining brain death cases.

All government and private hospitals in the state will have to follow these guidelines for organ donation in such cases.

The state health ministry on Saturday formulated the SOP in view of a rising concern among the public over possibilities of manipulation or coercion to make organs available for transplant.

According to the SOP, a medical board comprising four doctors — at least from government service — will be authorised to declare a patient brain dead. According to the Transplantation of Human Organs Act, two experts are required for brain death certification.

The SOP also states that the main condition for declaring a patient brain dead would be that

he/she is 100% out of a reversible cause of coma. To check any misuse, the SOP defines brain death and state of coma in detail.

“Coma is a state of unconsciousness triggered by a damage to a particular nerve of the brain. But brain death is a state of permanent destruction of brain cells caused by excessive bleeding in brain,” said the SOP.

The use of intoxicants, neuromuscular

relaxants, depressant drugs, hypothermia or some endocrine disorders may induce coma which may be reversible and these should not come under the ambit of brain dead, it said.

Only when a patient is in coma and on ventilator support can the medical team initiate steps to determine the possibility of brain death.

To determine brain death, the team should perform an Apnea test twice six hours apart. The aim of the Apnea test is to establish death of the respiratory centre in the brainstem. The test results will show if the patient can breathe by himself/herself at any stage in the future.

If any member of the team feels that the residual neuromuscular block should be tested, they may perform the peripheral stimulation test, the SOP said.

After the first round, there is another round of Apnea, and all results of the procedure should be communicated to the immediate relatives of the patients. All four members of the team should sign the brain dead certificate unanimously.

The guidelines prepared by a team of expert doctors are based on international recommendations on brain death.

These recommendations have been divided into three parts — first, precautions to be taken for declaring one brain dead, then, analyses of reflective actions of brain, and finally, apnea tests.

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