The advancements in transplantation over the last 20 years have been remarkable. Procedures once considered fantasies have now become routine. In addition to common transplants such as kidney, liver, heart, and cornea, recent years have seen the introduction of lung, pancreas, small intestine, limb, and face transplants. In our country, progress in organ transplantation accelerated after 2000, supported significantly by the Ministry of Health.
Brain death is defined as the irreversible loss of all brain functions. The concept of brain death was first described in 1959, and the Harvard Criteria were developed in 1968 to standardize the diagnosis (1). Over the last 20 years, the importance of brain death and organ donation has grown due to the shortage of available organs despite advancements in organ transplantation.
There are two ways to obtain organs: from live donors or cadavers. While organ procurement from live donors is a safe procedure, it inevitably puts a healthy individual at risk. The shortage of cadaveric donors has led to a reliance on live donors. However, cadaveric donation is the safest source. Additionally, organs such as the heart, pancreas, lungs, small intestine, and cornea can only be obtained from cadavers. Therefore, increasing the number of cadaveric organ donations is essential. In Europe, the average number of cadaveric donations is 20–30 per million people, while in our country, it is 3 per million. An ideal rate of 50 per million has been suggested in some studies (2).
The most significant centers for cadaveric organ procurement are trauma centers with intensive care units. In cases of isolated head trauma or multiple traumas, brain death is often the most severe outcome. Healthcare teams must be prepared to address such situations and understand the steps for determining brain death.
In Turkey, this issue is regulated by the Ministry of Health under the law dated June 1, 2000, and numbered 24066. Brain death determination is described in detail in the regulation dated March 5, 2010, and numbered 27512 (3).
This study aims to share our experience with determining brain death, the challenges faced, the role of trauma, and the experience of our team.
Materials and Methods
Records of 62 brain death cases identified between September 2007 and January 2012 at Okmeydanı Training and Research Hospital were retrospectively analyzed. Among these, the records of 18 cadavers whose organs were distributed to transplant centers were also reviewed. Patient age, gender, length of hospital stay, cause of death, and blood type were recorded.
Results
A total of 62 patients were diagnosed with brain death, and organ donation occurred in 18 cases (donation rate: 29%). Among those diagnosed with brain death, 45 were male, and 17 were female, while 15 males and 3 females donated their organs. The age of brain death cases ranged from 2 to 84 years, with an average of 41 years. The time to brain death diagnosis ranged from a minimum of 16 hours to a maximum of 600 hours, averaging 106.2 hours. Excluding three patients who had extended ICU stays, the average time was 85 hours. Apnea tests were performed on all patients. Two patients were lost while awaiting family consent after brain death was diagnosed.
Thirty-six patients experienced brain death due to trauma, and 26 due to non-traumatic causes, with trauma accounting for 58% of cases. Among trauma patients, traumatic subarachnoid hemorrhage was the most common issue. Non-traumatic causes included spontaneous subarachnoid hemorrhage and intracerebral hemorrhage. Blood group distribution was as follows: blood group A: 33 patients; blood group B: 7 patients; blood group O: 19 patients; blood group AB: 3 patients.
Discussion
Raising awareness about organ transplantation is critical. It is challenging for a healthy individual to understand the need for an organ unless they experience such a situation personally. Therefore, the issue should not be left to individual discretion but addressed through clear, comprehensible, and applicable rules (4).
The attitude of healthcare personnel is crucial, especially in ICUs, neurosurgery, and neurology clinics, and emergency trauma doctors. In cases of brain death, the family’s decision is significantly influenced by the primary healthcare team’s demeanor, credibility, and trustworthiness. A hesitant healthcare team is unlikely to obtain consent for a cadaveric donor.
Globally, family consent rates for organ donation range from 30% to 40% (5). Patients identified as brain death candidates are typically intubated in ICUs and managed according to ICU principles. These patients are often monitored by intensivists, neurosurgeons, or neurologists. Every patient is evaluated using the Glasgow Coma Scale (GCS). Patients with a GCS score below 7 should be monitored for potential brain death.
In Turkey, the brain death determination committee legally comprises four specialists: a neurosurgeon, a neurologist, a cardiologist, and an anesthesiologist. The apnea test is mandatory and conducted by an anesthesiologist. Patients under sedation in the ICU must have been free of sedatives for at least 24 hours before evaluation for brain death (6).
After brain death is determined, confirmatory methods may be needed, including intracranial Doppler ultrasonography, CT or MRI angiography, brain scintigraphy, or electroencephalography (7,8). In many countries, a waiting period of 6–24 hours is applied after brain death determination. However, no such waiting period exists in our country (9).
Brain death was first identified at Okmeydanı Training and Research Hospital in September 2007. A healthcare professional was appointed as the organ transplant coordinator, supported by a volunteer general surgeon specializing in transplantation.
Initially, healthcare staff were reluctant to acknowledge brain death diagnoses. Reasons included a lack of knowledge, unwillingness to take responsibility, and concerns about increased workload. The hospital organ transplant coordinator often serves as the first point of contact for resolving such issues. With support from designated medical staff, these challenges were largely overcome, resulting in 62 brain death diagnoses and 18 organ donations within four years.
Our cases show that most brain death cases, as seen worldwide, involved trauma patients (10). Trauma centers with neurosurgery departments should approach this issue more seriously. Brain death diagnoses can typically be made within the first 72 hours of hospitalization, depending on the severity of the patient’s condition.
Our hospital’s protocol for determining brain death is shown in Figure 1.
Cases diagnosed with brain death and approved by the family are reported to the regional organ coordination center. Necessary tests, such as blood group typing, hepatitis markers, liver and kidney function tests, and blood cultures for long-term ICU patients, must be completed promptly to avoid delays.
In two of our cases, patients were lost during family discussions despite brain death being confirmed. Therefore, quick action is crucial, and unnecessary delays should be avoided. Preparing necessary tests beforehand can reduce delays.
In conclusion, raising awareness among healthcare personnel alone is insufficient. Active involvement and clear authority from the Ministry of Health, provincial health directorates, and hospital administrations are essential. A lack of guidelines makes the process dependent on individuals. Brain death determination is the responsibility of the healthcare team, which must act professionally and strive to increase the number of brain death diagnoses and organ donations.
