Diagnosis of brain death is mainly clinical and is based on highly specific neurological examination of the patient. Diagnosis of brain death by neurological criteria requires the presence of coma, absent brain-stem reflexes and apnea. Probable brain death case is defined by:

• Diagnosis of irreversible SND (Severe Neurological Damage)
• Glasgow Coma Score GCS= 3 (No sedation)
• Progressive absence of, at least, three out of six brain stem reflexes.

Confirmed brain death case is defined by:

• brain death diagnosed following local protocol and legislation.
• the diagnosis is written in the medical record of the patient.

However, according to the anecdotal reports, in intensive care units, not all probable brain dead cases have become confirmed brain dead cases. It would be because final confirmation of brain death is hindered by numerous hospital barriers. In addition, some confirmed brain dead cases might not have become organ donors. So the objectives of the current project were to identify the probable and confirmed brain-dead cases during the study period, to study the progress of these cases and to identify barriers for the diagnosis of confirmed brain death. By understanding the current hospital situation regarding brain dead diagnosis and identifying the limitations and barriers contributing to confirmed brain death, we hope we can find solutions in future, which will enlighten us opportunities for improvement and help us applying the competencies acquired in the fields of donor detection, donor preparation and organ donation.

Consecutive probable and confirmed brain-dead cases in the main intensive care unit (ICU) and neurosurgical ICU of Yangon General Hospital were identified prospectively for 6 months from 20th February to 19th August 2020. Inclusion criteria were probable and confirmed brain dead cases where probable brain death case is defined by:

• Diagnosis of irreversible SND (Severe Neurological Damage)
• Glasgow Coma Score GCS = 3 (No sedation)
• Progressive absence of, at least, three out of six brain stem reflexes and confirmed brain death case

It is defined by:

• Brain death diagnosed following local protocol and legislation.
• The diagnosis is written in the medical record of the patient.

Inpatient admission records of probable and confirmed brain-dead cases have been studied to monitor what happened after defining as probable brain-dead cases and to identify the causes of why probable brain death did not progress to confirmed brain death. Permission was obtained from medical superintendent as well as heads of the respective departments before the study. Data collection, entry and analyses were done by Microsoft Excel.

Total 7 probable brain-dead cases were recruited from two intensive care units of Yangon General Hospital (YGH) during the study period of 6 months (table 1): 71.4% from main ICU and the rest 28.6% from neurosurgical ICU. Among all, 42.8% were under care of general surgical wards, 28.6% under neurosurgical ward, 14.3% under care of medical wards, and 14.3% under neuromedical ward. Among the study population, 57.1% were male and 42.9% were female. Mean age was 35±10.77 years. All cases were Myanmar and majority of them (85.7%) were Buddhists but 14.3% were Islams.

Table 1: Distribution of probable brain dead patients according to timeline in the study population.

Regarding the diagnosis, the majority of cases (71.4%) were traumatic brain injury, 14.3% were central nervous system infection and 14.3% were stroke (massive cerebral infarct).  All traumatic brain injury cases were very severe with polytrauma including multiple bones fractures, gut perforation, splenic rupture, haemopneumothorax etc., out of which 14.3% was due to fall from height due to alcoholism and others were due to road traffic accidents. Average time from hospital admission to ICU arrival was 18.2 ± 20.7 hours, mean duration of ICU stay was 4.8 ± 2.8 days with average hospital stay 5.7 ± 2.8 days. Among those who had observation period which is the time from absent brain stem reflexes were suspected to the time of first brain dead determination, average observation period was 8.9 ± 8.5 hours and the range was 0-23 hours. Average time from GCS 3 (probable brain-dead) to first set of brain dead determination was 13.39 ± 12.2 hours. All had undergone confirmed brain dead determination two times according to local guidelines with average length in-between the two determinations being 13.4 ± 19.8 hours except one patient from neurosurgical ICU in whom brain dead determination was recorded only once and finally ventilator was taken off only after circulatory arrest. Ventilator was taken off after an average time of 42.04 ± 38.8 hours from second brain dead confirmation. It was quite long duration because all 100% were taken off ventilator only after circulatory death. Average duration between brain death and circulatory death among our patients was 41.9 ±38.8 hours. At the time of ICU admission, 85.7% of patients were apparently medically suitable for organ donation but later in the course of admission, 42.9% of all patients were found no longer suitable. The latter was due to hepatitis C virus infection, septicemia or disseminated active tuberculosis.  Oculocephalic reflex nor oculovestibular reflex was not done in 28.6%. Facial movement to noxious stimuli was not recorded in 57.1%. Although local guidelines recommended, apnea test was not done in 4 out of 7 cases (57.1%) and the second set of brain-stem tests was not recorded in 14.3%. Most of the brainstem reflexes were recorded as absent but there was no written medical record of writing down as “brain dead” even after performing and confirming absent brain-stem reflexes. In all cases, death was recorded only at the time of circulatory death. After applying the definitions set in this study, it was astonishingly found out that all probable brain death cases had not become confirmed brain death. Some barriers in reaching the diagnosis of confirmed brain death were identified. Most of the medical personnels dealing with brain dead cases were not familiar to local brain-death guidelines. They also had limited time to do the tests as well as limited manpower. In addition, there was inadequate equipment because in neurosurgical ICU, there was no otoscope which is necessary to check for any contraindication before doing oculovestibular reflex and that might be the reason why some patients did not have oculovestibular reflex recorded. Some doctors involved in brain death determination of these patients did not have enough expertise especially in doing oculovestibular reflex and apnea test. Although recommended by the local guidelines, apnea test was not done in some cases because of unstable patient’s condition, time factor or financial concern on the cost of repeated arterial blood gas (ABG) tests involved in apnea test. Another reason of skipping apnea test in one patient was the patient having septicaemia and surely he/she could not become an organ donor

Among 6-month period of the study, only 7 patients were included because of limited ICU beds in our hospital and Covid-19 situation. Although Yangon General Hospital is a 2000-bedded crowded hospital, ICU is relatively small. Bed availability of main ICU is 20 and that of neurosurgical ICU is 4. Anecdotal reports of some doctors have also suggested that some patients with brain death have ended up at emergency department and others at their respective wards while waiting for availability of ICU beds. Myanmar’s COVID-19 first wave started on 23rd March and second more powerful wave began on 16th August 2020. This would be reason that we had very few patients in our study and had no patients during the COVID-19 peak periods as shown in figure 1. In addition, during data collection, we have noted that most of the possible organ donors with severe brain damage had polytrauma and multiorgan damage with unstable blood pressure and they had not fulfilled prerequisites for brain-dead determination, subsequently they ended up in the list of circulatory death rather than brain death. 

Figure 1: Distribution of probable brain dead cases in ICUs comparison with COVID-19 cases in Myanmar.

Nearly half of our patients were found to have active infection and it was noted that since communicable diseases are still common in Myanmar, this might be barrier to the rate of organ transplantation in our country. Moreover, in our hospital, majority of doctors are used to defining death by circulatory criteria because of poor knowledge on brain death and awareness on possibility of organ donation. Although above cases in the study were legally dead, ventilation was continued unnecessarily until circulatory arrest and it was not justifiable for our limited resources. Furthermore, it was not in accordance with the fact that they have already died and they have no chance of recovery [1]. On the side of patients’ family, they were also reluctant to withdraw artificial life support even after brain dead and it might be related to cultural and religious beliefs. Actually, neither specific orders, procedures nor family consent is required for cessation of treatment in a patient declared brain dead, and cessation of medical services is advisable unless these are required to support organs functions for donation [2]. Public awareness of brain dead and its implications are important to establish in our situation. There was no patient being confirmed brain death in this study mainly because of poor documentation, which may be due to high workload of health care personnels as well as it was not well stated in local guidelines. Another possibility is that the respective doctor might think brain dead documentation was not important since the patient’s death would be certified and documented at the time of circulatory death finally. Similarly, documentation of brain dead was shown often incomplete and poor in other studies [3, 4]. Other various reasons for not ending up as confirmed brain death include lack of enough knowledge of brain dead determination, lack of enough expertise, lack of adequate equipment and cost in doing apnea test. Apnea testing is costly since arterial blood gas (ABG) testing has to be done repeatedly and most of our patients in our poor resource settings are not affordable. And since it is a part of organ donation purpose, there is dilemma who will bear the cost and it may be unfair if donor side takes the cost, so finally doctors had to take the cost in our setting. Although all our recruited cases did not have indications for ancillary testing, availability and feasibility of ancillary testing in our hospital are limited because of limited equipment, limited human resource and less expertise such as lack of 24 hour availability of CT angiogram, lack of 24 hour availability of electroencephalography (EEG) because of the presence of only one EEG technician, lack of expertise in doing transcranial Doppler, etc. Even though local guideline recommends a minimum of 4 hours observation period, no observation period was noted in 2 out of 7 patients in our study, and among those who had observation period, mean duration was longer than that is recommended in the guideline [5].  This may be because there was no urgency in these cases where they were not expected as organ donors.  Undoubtedly, there is an urgent need to provide access to local brain dead standard operating procedures (SOP) and guidelines and training on brain dead determination because brain dead determination requires a special skill set. Inexperience of doctors in brain death determination may lead to inappropriate or deficient assessment of brainstem reflexes and inadequate performance of the apnea test.  Various training methods including online courses with videos and simulation-based training can be used to educate practitioners about determination of brain dead. Those health care providers in the field of managing patients with devastating brain injuries should be educated on comprehensive brain dead determination and awareness on organ donation. In addition, importance of documentation in brain dead determination should be emphasized in their education. To make sure this, using a standardized checklist for death determination and its documentation is suggestible. Local hospital standard operating procedures (SOP) on brain dead determination was established in 20165 but it was not being well-aware by most physicians and doctors, and on reviewing, it has some weak points in the perspectives of defining the extent of liver and renal dysfunction among the preconditions before brain dead determination, specifying temperature measurement as core temperature, pointing out the necessity of neuroimaging, suggesting ancillary testing for those where metabolic, acid-base, and endocrine derangements are uncorrectable and clarifying the number of apnea testing [6]. Local guideline states that three cardinal findings in confirmed brain death were coma or unresponsiveness, absence of brain stem reflexes and apnea, but it does not indicate writing brain dead diagnosis in medical record of the patient which is essential to become confirmed brain death diagnosis. In our study, there was no documentation for confirmed brain dead even after performing all procedures for brain dead determination. Surely, our hospital needs improvement in documentation of brain dead determination which may further reduce any nonmedical consequences resulting from diagnosis of brain death and it is high time to revise the current local guideline.

Through this 6-month study, we have studied the monitoring death by neurological criteria and identification of barriers for confirmed brain death diagnosis at local hospital ICUs. The main barrier was lack of proper documentation. Others include reduced awareness of local brain dead guidelines, lack of human resources, lack of equipment, time and cost limitations and expertise in doing special tests. To overcome these barriers, our health care personnels dealing with brain dead determination need to improve existing knowledge and acquire appropriate training. Current Myanmar guideline for brain death determination should be revised according to situations that we have found in this study and in accordance with the latest consensus statement published internationally [6] and last but not least, it is in essential need to reinforce to adhere for practice.

This study has helped us to understand the current hospital situation regarding monitoring brain death by neurological criteria and the main barriers to establish confirmed brain dead diagnosis, and it subsequently has improved awareness of organ donor recruitment, practice and skills required in brain dead certification process. We would like to propose revising local brain death guideline and providing training of trainers (TOT) courses on determination of brain-dead by neurological criteria and subsequently, we hope brain-dead determination and recoding will be systematic and consistent among our practice. Development in diagnosing death by neurological criteria will also help improve the field of transplant medicine and organ donation in future.

It was carried out as the on-the-job improvement project under Postgraduate Programme for Organ Donation Innovative Strategies for Southeast Asia (ODISSeA), University of Medicine 1.

Financial support:

Nil

Conflicts of interest:

None.

1. Coronavirus (COVID-19). Brain death. 2020.
2. Guidelines for terminating treatment. University of Michigan. 2020.
3. Wang MY, Wallace P, Gruen JP. Brain death documentation: analysis and issues. Neurosurgery. 2002; 51: 731-735.
4. Kashkoush A, Weisgerber A, Dharaneeswaran K, Agarwal N, Shutter L. Medical training and the brain death exam: a single institution’s experience. World Neurosurg. 2017; 108: 374-378.
5. Brain death guideline, University of Medicine 1, 1078. Myanmar, 2016.
6. Greer DM, Shemie SD, Lewis A et al. Determination of brain death/death by neurologic criteria: The World Brain Death Project. JAMA. 2020; 324:1078-1097