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Bengaluru: Kerala has given doctors the right to decide whether a patient certified as brain dead needs to be taken off life support. Consent of family won’t be required.

The rule was introduced through a government order dated 19 January. With this move, Kerala becomes the first state in India to have well-defined clinical protocols for brain-death certification.

“The new GO (government order) should guide all clinicians in pronouncing brain death in ICUs and how to move forward,” Kerala Principal Secretary (Health) Rajan Khobragade told the media Tuesday.

“Clinicians can now take charge in ICUs, without any fear of future litigation, to terminate all life support if the patient is certified brain-dead, rather than leave the decision to the traumatised family. It is a responsibility that they have to fulfil, keeping in mind the dignity of the deceased,” he added.

“This would also help in setting up an evidence-based model on brain-death certification.”

Doctors have lauded the move, saying it will help maintain the dignity of patients and free their family of additional mental and financial burden. It is also seen as a crucial intervention to ensure timely availability of organs for transplants.

This is a trendsetting order, said Dr A.V. Jayakrishnan, a member of the Indian Medical Association’s ethics committee and a former chief of the body’s Kerala chapter.

“Currently, a brain-dead declaration procedure is directly linked to organ transplant. So there was a need to define brain death and bring into force a universal procedure,” he added.

“There is nothing unethical about this and any challenge will not stand in court. This initiative will take away the stigma of brain death connected with organ transplant and also help in organ donation.”

Also Read: How I led the team that carried out India’s first hand transplant

What the order states

Doctors in Kerala will be expected to follow a 10-step procedure before they take a call on removing life support. It includes establishing the three essential conditions that determine brain death — coma, absence of brain-stem reflexes and apnoea.

The conditions are:

Clinical evidence of an acute central nervous system catastrophe… compatible with a clinical diagnosis of brain death should be established before subjecting a person to further tests for evaluating brain stem death. Medical practitioners should speak to the relatives and caregivers about the medical status and prognosis of the patient on whom the brain-stem death test is to be conducted. Assessment of brain-stem reflexes should be done using a series of tests… which are to be repeated after an interval of six hours by a panel of four doctors. The apnoea test ( meant to “show the lack of function of the respiratory centres of the brain stem when physiological stimulus takes place”) is the last brain-stem reflex test to be performed, “and that too, only if all other tests confirm the absence of brain-stem reflexes”. All prescribed tests to be conducted twice by the panel of doctors “to ensure there has been no observer error”. A neurophysiological or imaging study to prove the absence of electrical activity or blood flow should be carried out if doctors who are certifying are in doubt about the diagnosis of brain stem death. If the criteria for brain death are met after the required tests are completed, the patient must be declared “brain dead”, and the date and time recorded. Time of death is the time when the arterial PCO2 (pressure of carbon dioxide) has reached its target value in the second apnoea test. Family member of the patient should be provided with the brain stem death confirmation report signed by all four panel doctors. All treatment including cardio-respiratory support must be discontinued once brain stem death is pronounced.

Dr Noble Gracious, the nodal officer for the state government’s Kerala Network for Organ Sharing, said this was “a procedure that is followed by all developed nations”.

“It is time medical professionals in India also follow the same,” he added.

Speaking to ThePrint, Dr Noble said doctors had for years found themselves in a bind when relatives of patients refused to allow organ transplant.

“When a patient is declared brain dead, we ask where they would like to go for organ donation. If they say yes, it’s fine, but if they say no, then the life-support care continues,” he added. “Isn’t that a paradox? Knowing well that the patient is brain dead, the care continues.”

Kerala sets the trend

For the past few years, the Kerala government has been in consultation with neurologists, critical-care specialists and legal experts to develop a universal brain-death certification process that can become a standard ICU practice and norm for quality healthcare.

In 2018, Kerala became the first state to adopt a standard operating procedure (SOP) on declaring a person brain dead and organ transplant.

The state health ministry formulated the SOP following rising concern over alleged manipulation and coercion to make organs available for transplant.

According to the SOP, a medical panel consisting of four doctors, including one government service practitioner, should be present to authorise and declare a patient brain dead.

It states that doctors should be 100 per cent convinced that a patient’s coma condition is irreversible.

Also Read: Euthanasia debate is back in court — petition in SC seeks provision for rabies patients

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