Doctor Given Grant to Study Infant Brain Death Testing
For more years than she cares to remember, Dr. Joan Hodgman, director of the newborn service at County-USC Medical Center, has been troubled by the knowledge that she and other physicians who care for dying infants lack a simple, safe and effective method of telling when their patients are brain dead.
The need for such a test is great, she said in a recent interview, because modern technology enables doctors to maintain an infant’s heart beat and respiration long after the brain has stopped working.
“Our difficulty is in telling when brain death has occured, which is not as obvious as when the heart and the lungs stop functioning,” said Hodgman, who is responsible for the postnatal care of the 17,000 babies born annually at the medical center’s Women’s Hospital.
Hodgman said she believes that the lack of a simple and reliable method of determining brain death is sometimes responsible for babies being treated longer than is necessary or desirable.
The Los Angeles chapter of the American Lung Assn. has awarded Hodgman a grant to study the reliability of a brain death test that she has developed and that she believes may be simpler and at least as effective as any of the present methods.
Combination of Methods
Doctors generally rely on a combination of methods to tell whether the brain has ceased functioning to the extent that it is ethically and legally justifiable to turn off life-support systems. At many centers, stopping mechanical life support--even after doctors have made the decision to do so--is done only with the approval of the parents and often after consultation with a hospital ethics committee.
In addition to a neurological exam and their clinical judgment, most doctors rely heavily on the use of an electroencephalograph, which measures brain waves, to determine how well the brain is functioning.
But, physicians point out, even a flat brain wave reading--a strong indication of brain death--is not a positive assurance that the brain is no longer functioning.
“This is a very problematic area,” said one Los Angeles neonatologist who asked not to be identified. “Doctors are very gun-shy (in making determinations of brain death). We tend to do as many tests as we can in order to support our decision. But I know of a baby who, after being asphyxiated, had a flat EEG. But life support was continued and soon that baby will be going home. He won’t be an Einstein, but he’s OK.”
Hodgman hopes to be able to overcome some of the shortcomings of electroencephalograms by substituting close clinical observation of the baby and by monitoring heart rate and respiration instead of brain waves.
The region of the brain that controls heartbeat and respiration is called the brain stem. Hodgman said that by attaching the baby to an instrument called a heart-rate and breathing monitor, physicians may be able to determine whether the stem, located at the base of the brain, is still doing its job or whether technology is doing it for the brain.
‘An Issue of Compassion’
In a situation in which the baby is on a ventilator for assistance in breathing and in which drugs are maintaining the heart beat, it is possible that the brain stem may in effect already be dead, according to Hodgman. It is in such cases that overtreatment may take place.
“I feel that we should try not to give care that is futile,” she said. “Here at County-USC we run out of everything except patients. I don’t see futile care in terms of dollars and cents--which in one sense it is--but as an issue of compassion that is centered on appropriate care.”
Besides the electronic monitoring, another part of Hodgman’s study is to closely observe infants for indications that the brain stem may be damaged.
For example, Hodgman said, if a baby is not able to breathe spontaneously or does not show spontaneous movement, there is reason for concern. This concern may increase if the infant fails to show the kind of reflexes that are known to be controlled by the brain stem. These reflexes include a response to pain and a change in pupil size under bright light.
The final criterion is whether the baby’s heart beats at a fixed rate for hours at a time, regardless of any stimulation the baby experiences. A fixed heart rate, Hodgman said, is an indication that the heart is being driven by centers within the heart itself, rather than by the brain.
According to Hodgman, the study financed by the lung association will be the first to test these criteria for brain death. The study, which began April 1, will involve the expected 200 to 300 babies who will be born at Women’s Hospital this year weighing less than 3.2 pounds and who must be placed on a ventilator for at least 24 hours.
She added that if the criteria prove to be reliable when applied to babies, they should work for any age group. Hodgman, however, is specifically interested in the issue as it applies to babies.
“I remember vividly the day when I began struggling with this issue of overtreatment in dying babies,” Hodgman said. “It was a Saturday morning in 1979. When I walked into the unit the team was working vigorously on a 3-day-old baby on a ventilator who was responding very badly.
“They were in the middle of the third or fourth heart resuscitation: They would get the heart to beat and then it would gradually peter out and they would resuscitate it again. Seeing all those people pounding on that poor (baby) gave me a violent physiological reaction.
“I said, ‘Stop! What in the world are you doing?’ They looked at me and then at the baby, and then they all slunk away. At that point we all began talking of the ethics of this sort of thing.”
