Bottleneck after Brain Death Certification in India - Why Second Post Mortem for Brain Dead Donors

Deepak Gupta, Professor Neurosurgery - All India Institute of Medical Sciences, New Delhi, India; Joanna Mary Roy, Medical Student - Topiwala National Medical College, Mumbai, India

We burn or bury, we don't donate: We need to understand importance of organ donation to save life of others. Each year in India, over 200,000 end stage kidney, >50,000 heart failure and >25000 of liver failure patients are waiting for organ transplants to survive and lead a healthy life.

The Transplantation of Human Organs and Tissues Act (THOTA Act , 2011) governs rules on organ donation and transplantation in India. Organ donation statistics in India remain lowest in the world with 550-700 brain dead donors per year [ 0.4 per million population c.f. global organ donation rates of 5 per million population]. In a country of 1.39 billion population with 1 person dyeing from road traffic accident every 3 minutes, there is a huge potential for meeting up with needs of patients waiting for end stage renal/liver/heart failures for organs Post mortem is needed in all road traffic accidental deaths in India. Post mortem is linked to accidental insurance claim benefits as it certifies that it is accidental death. Its mandatory for ICU doctor to check for brainstem death , proceed for brain death certification and request for organ donations for all potential donors admitted in ICU in India.

This article aims to identify areas in the process of brain death certification and organ procurement that contribute to the bottleneck phenomenon and suggest measures to overcome these.

Once brain death has been certified by the appropriate team of four medical professionals (consisting of a Registered Medical Practitioner in charge of the hospital, an intensivist, a neurologist/ neurosurgeon, and a medical officer), an Investigating Officer (IO) is notified (Figure 1). At the discretion of the IO, a postmortem is performed to further determine the exact cause of death. A potential donor's organs are harvested in the operating room.

If a family decides not to donate organs of their patient, brain dead patient is kept on ventilatory support and vasopressors/inotropic drugs to maintain blood pressure giving a false impression to families that patient may still recovery as they see heart rate and blood pressure displays on monitors.. There is no law to withdraw ventilatory support from certified brain dead patients in most states in India despite the very fact that Brain Death is IRREVERSIBLE and PERMANENT and it equals DEATH of an individual as per Indian Law.

If a family consents to donate organs of their patient, no objection permission is taken from Investigating officer (IO) to go ahead with organ retrievals in operation theatre by transplant team. After organs are harvested, chest and abdomen is closed in layers by transplant surgeons. Deceased body is then shifted to mortuary facility.

The current norm in India is to conduct a postmortem examination after the organs have been harvested from a donor. Most public hospitals in India do not conduct a postmortem examination after sunset. Thus, postmortem examinations are often performed the next day. Once IO arrives, patient is again sent to mortuary for post mortem where body is reopened , reexamined , reclosed and re packed. For any death occurring in night, post mortem is done in morning hours although there is a ruling that post mortem can be done in night also if needed.

Figure showing the steps involved in procurement of an organ after the declaration of brain death

SLK belongs to the large group of kinases. These enzymes are extremely important: They attach phosphate groups (which are small molecular residues with a phosphorus atom in the center) to proteins and thus alter their activity. Kinases are involved in the regulation of almost all life processes in animals.

The kinase SLK was already known to play an important role in embryonic development: One of its effects is on the growth of cells and their migration in the body; these processes are also essential for the maturation of neurons. We have inhibited the production of the SLK protein in neurons of mice. The dendrites, which are the extensions that receive signals from other neurons and conduct them to the cell body, branched less. The dendrites resemble a kind of tree dotted with tiny contact points, the synapses.

This is where extensions of other nerve cells dock and transmit electrical impulses to the tree. The observed "thinning" did not affect the thick main branches, but exclusively the smallest shoots. The synapses on these small branches are called excitatory: Signals received there have an arousing effect. This means that they increase the probability that the neuron will in turn generate an electrical signal, in other words, that it will "fire".

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