"How can you be sure he is dead?" and "how do you know he will not wake up?" are questions commonly asked by families.

"In this difficult situation, communication by the medical team needs to be conducted sensitively and honestly, providing information at a pace the families can cope with and understand. It is important to give them support, ample time and space to cope with the sudden loss," explained Dr June Goh, Senior Consultant and Director of Neuro-Anaesthesia at SGH.

Accepting brain death is hard because it often follows sudden events such as a stroke, brain neurysm or severe head injury. However, Dr Goh observed that it is not just the deceased's family who has difficulty coming to terms with brain death, but possibly junior staff as well.

 

"In this difficult situation, any communication by the medical team needs to be conducted sensitively and honestly, providing information at a pace the families can cope with and understand."
– Dr June Goh, Senior Consultant and Director of Neuro-Anaesthesia, SGH

"Junior doctors and nurses with less experience in the ICUs can find it hard to understand the concept of brain death.

The ventilators support breathing and drugs keep the vital functions running. Spinal reflexes can also cause the body to make slight movements," Dr Goh added.

When brain death has occurred, blood flow and oxygen delivery to the brain ceases irreversibly and all brain functions (including the capacity for consciousness and ability to breathe spontaneously) are lost and will never return.

To bring medical students, SingHealth residents and nurses working in the ICUs up to speed, Dr Goh and her team have been organising lectures on the diagnosis of brain death to equip them with the necessary knowledge and communication skills.

To reach out to more staff, the team has gone one step further to develop a seven-minute video with animation to help staff understand brain death diagnosis through eLearning.

Understanding brain death and organ donation

Under the Human Organ Transplant Act (HOTA), in the event of death from any cause, an individual's kidneys, heart, liver and corneas can be removed for the purpose of transplantation.

HOTA covers all Singapore Citizens and Permanent Residents 21 years old and above, who are not mentally disordered, unless they have opted out by filling up the required form and sent it to the National Organ Transplant Unit.

To help doctors, nurses, medical social workers and transplant coordinators better manage the process of facilitating organ and tissue donation, Dr Goh is working closely with SingHealth Transplant to redesign the ICU workflow to streamline and clarify the steps and roles involved after a patient is certified brain dead.

Mr Bay Qin Yao, Senior Executive, SingHealth Transplant, explained, "Under HOTA, stringent clinical criteria and steps must take place before organ recovery. In situations where the deceased's family has concerns about the donation of organs, our priority is to attend to their concerns. Together with the medical social worker and transplant coordinator, the medical team will take time to explain and provide emotional support and counselling".

WHAT IS INVOLVED IN THE CERTIFICATION OF BRAIN DEATH?

There are well-defined and internationally accepted clinical criteria and tests for certification of death, including brain death.

The clinical criteria for death must be met, as observed by two doctors, before death can be certified. Should the two doctors have differing opinions, death would not be certified.

The two doctors who examine the patient must:

• Not have been involved in the care or treatment of the patient being certified

• Not belong to the team of medical practitioners who will remove the organ from the body

• Not have been involved in the selection of the proposed recipient of the organ

• Not be involved in the care or treatment of the proposed recipient of the organ during his  hospitalisation for the transplant