Doctors receive new guidelines for testing patients after deathbed battles with families and 'miracle' recoveries

Published on Saturday 18 October 2008 19:41

DOCTORS have been issued with strict new guidelines on how to confirm death amid growing public concern that some medics are too quick to switch off life support.

The new code of practice – the most detailed ever issued in the UK – requires all doctors to conduct an extensive battery of tests to confirm death and to then discuss the results and next steps with relatives.

Although medics already follow a similar routine, health chiefs say the new code will stamp out occasional "idiosyncratic" diagnoses by doctors and the bitter rows with families that follow.

The new rules also follow lurid stories around the world about patients waking from 'death' having been taken to a morgue, on the way to their own funeral or even as they are about to undergo postmortem examination.

The new guidelines have been drawn up over the past five years by experts from the Academy of Medical Royal Colleges.

Sir Peter Simpson, who chaired the group writing the code, told Scotland on Sunday: "Every doctor was carrying out the procedures in a slightly different way and we didn't want people to say that is that doctor's idiosyncratic way of doing it. The main reason is to have a clear picture written out in words of what constitutes death.

"I wouldn't like to give the impression that a lot of people are diagnosed as dead when they are not, but internationally you read about someone who was resuscitated, then it was stopped, they were declared dead and they woke up. If doctors follow this guide that shouldn't happen."

The guidelines provide two series of tests to confirm death. The first is used when the heart has stopped, starving the brain of oxygen. The second covers cases when the brain has stopped, meaning the heart no longer receives the messages that make it beat.

Five sensory response tests must be carried out in the first case, including shining a torch in the eye, injecting ice-cold water into both ears and putting a spatula against the back of the throat to see if the patient gags. If there is no response, the doctor must wait five minutes before declaring the patient dead.

In cases where the brain has stopped, patients can often be kept 'alive' by life-support equipment. In these cases an extra two tests must be carried out, one on breathing and the other on the movement of the eyes as the patient's head is turned to see if the brain stem is functioning.

Simpson said: "What's crucial in governing whether you can exist as an independent person is whether you have an intact brain stem. The main part of the brain could show miniscule activity, but with no brain stem it could never support life.

"Everything goes through the brain stem to the body, so even if there is activity in the cortex it could not reach the body if the brain stem is dead."

Simpson said the new procedures will help families understand that signs of miniscule brain activity do not necessarily mean the patient can recover.

He said: "We felt the previous code helped families understand how death was defined, but it needed to be more specific.

"In order to diagnose death you have to know why the person has died, whether there are any circumstances that would make it difficult to diagnose death, such as the patient being under the influence of drugs, and whether the patient is responding to tests.

"There should not be a quick way around diagnosing death. This must be a rigorous and open process that everyone can understand. This will help improve the relationship between doctor and relatives."

Brainhelp, a Scottish charity for victims of head injuries and their families, said families faced a difficult decision with coma patients, which would be made easier by having all the information provided under the new guidelines.

Founder Walter Baxter said: "When people are in a coma there are techniques that give neurosurgeons a fantastic idea of what's going on, but the family should be involved in all aspects of it, because if you are sitting in a waiting room wondering what's the next step and not being informed, that's worse than the truth sometimes. It clears away the needless worrying."

However, Margaret Watt, spokeswoman for the Scotland Patients Association, said: "It's a double-edged sword because families always want to believe something can be done. But sometimes their emotions cloud their judgment. The decision on whether or not to switch off a life-support machine should be taken by a professional."

Remarkable stories of patients "waking from the dead" continue to emerge. In May this year a 59-year-old American woman stunned doctors in West Virginia by recovering after her heart stopped beating three times and she was clinically brain dead for 17 hours. Her son agreed to turn off life-support machines, and 10 minutes later she regained consciousness.

Other cases include the story of 33-year-old Carlos Camejo, a Venezuelan who was declared dead after a car accident in Caracas in September last year. It was reported he did not wake from his coma until the excruciating pain of the pathologist's knife cutting into his forehead caused him to scream in agony.

The case of a 16-year-old Romanian boy being mistakenly diagnosed dead was also reported in 2005. Bogdan Georgescu was taken to a morgue after collapsing and showing no signs of life, but regained consciousness.

Against all odds

Three years ago, Sharron Russell received a late-night visit that every parent dreads.

The police knocked on her door to say that 20-year-old Lisa, her eldest daughter, had been in a serious car accident.

Lisa had been driving around with friends when her car crashed into another vehicle. Lisa was rushed to hospital with head injuries.

One day, the brain monitor shot up to 90 (it should read around 20) and doctors took Sharron aside and told her that Lisa's brain was swelling, and the pressure could push down to her spinal cord and kill her. They asked her what she wanted to do, as Lisa was unlikely to survive.

"They said she won't pull through, but I said she would because she was a fighter," said Sharron. "I refused to allow them to switch the machine off."

Within a few days Lisa showed signs of recovery, and after a month in a coma she woke up.

Lisa, who was told she may never walk or talk, went home to the small town of Troedyrhiw, South Wales, on April 15, four months after the accident, and now leads an independent life.

Lisa, pictured above since the accident, said: "I think it would be great if these guidelines helped other families make that difficult decision about whether or not to switch off the machines, otherwise I would not be here to tell the tale."