S'pore has strict brain death criteria: MOH

By K.C. Vijayan And Maryam Mokhtar, The Straits Times, 26 Mar 2013

THE Ministry of Health (MOH) has made it clear that stringent medical criteria are used in determining if a patient here is brain dead and should be taken off life support systems.

And two specially trained and certified doctors, one of whom is independent and uninvolved in the patient's care, are required to certify the condition.

It also stressed that if brain death is diagnosed correctly, the condition is irreversible.

The ministry made these points in a Forum letter commenting on a Sunday Times report recounting the recovery of Singaporean lawyer Suzanne Chin, who regained consciousness suddenly despite being diagnosed as brain dead in a Hong Kong hospital.

At the time, Ms Chin's husband and family members were faced with the prospect of pulling the plug on her life support systems based on medical advice. But she recovered on the third day, and was on her feet 36 hours later.

MOH said it was "happy that Ms Chin has made a recovery", but urged caution against concluding that correctly diagnosed brain death can be reversed.

"When brain death has occurred, blood flow and oxygen delivery to the brain ceases irreversibly, and all brain functions are lost and will never return again," it noted. "Once diagnosed, it is recognised both medically and legally as death of the person in Singapore."

MOH also emphasised that brain death is determined according to strict clinical criteria.

These include absence of pupillary response to light, corneal reflex and respiratory drive or spontaneous breathing.

"When one or more of these tests cannot be done, additional tests to demonstrate the absence of brain circulation need to be performed," it said, adding that the criteria to certify brain death here is the same as in countries such as Australia, Canada, Britain and the United States.

Senior consultant neurologist Lee Kim En of the National Neuroscience Institute told The Straits Times that "death by neurologic criteria" requires two pre-requisites to be satisfied.

These two involve determining whether there is "catastrophic" brain damage like massive bleeding, and checking for other issues like poisoning or drug intoxication. The doctors then go through seven steps that check responses, reflexes in various body parts and breath levels, he said.

Dr Lee said the public should be aware that "brain death" is different from "deep coma", and the terms may be confusing.

"There has been no published report of neurologic recovery once 'brain death' or 'death by neurologic criteria' has been diagnosed following the careful expert application of these very stringent criteria," he said.

"The challenge is, given the advanced medical systems that are able to keep the hearts beating and lungs breathing, how will we know if our patients are not alive any more?" he asked.

"Put simply, will we hence be guilty of keeping the dead looking alive? This is a very serious issue, and it is certainly not ethically correct to do so. A patient, as soon as he or she has passed on, must be accorded dignity, respect and grace."

Private practice consultant neurologist G. Devathasan, whose editorial "Brain Death: Concept, Controversies and Guidelines" in a past issue of the Annals Of The Academy Of Medicine is widely referred, said yesterday that the term "brain death" may have been used wrongly in any reported recovery case.

"We lay common guidelines in order that no mistake is made in certifying brain death in a patient who could subsequently live," he wrote in the editorial.

MOH said that it was not able to comment on Ms Chin's case as it did not have access to specific information on her medical treatment in Hong Kong and what exactly was diagnosed and communicated to her family.

But it added: "We would like to reassure the public of the high standard of medical practice in our hospitals."

Brain-death diagnosis based on stringent clinical criteria: MOH

THE Sunday Times reported on the case of Ms Suzanne Chin, who recovered from a coma ("Back from the dead: 'I have been blessed with a second chance'"; Sunday).

We are happy that Ms Chin has made a recovery. However, we are not able to comment on the case as we do not have access to specific information on her medical treatment in Hong Kong and what exactly was diagnosed and communicated to her family.

Brain death is diagnosed only when there is catastrophic brain injury. When brain death has occurred, blood flow and oxygen delivery to the brain ceases irreversibly and all brain functions are lost and will never return again.

Brain death is determined according to strict clinical criteria.

Once diagnosed, it is recognised both medically and legally in Singapore as death of the person.

This definition is similar to those used in countries such as Australia, Canada, Denmark, Britain and the United States.

Brain death implies the irreversible cessation of consciousness, loss of capacity to breathe and other brain stem functions, and is accepted as the termination of a human's life; correspondingly, the diagnosis of brain death is very important.

The neurological criteria for diagnosing brain death in Singapore are based on current best medical evidence and knowledge, and are similar to those adopted by countries such as the US, Australia, and Britain.

In Singapore, all criteria have to be fully met for the diagnosis of brain death, including absence of pupillary response to light, absence of corneal reflex and absence of respiratory drive or spontaneous breathing, to cite a few; and when one or more of these tests cannot be done, additional tests to demonstrate the absence of brain circulation need to be performed.

In addition, two doctors are required to certify brain death, at least one of whom has to be independent and not involved in the care of the patient.

Doctors accredited to perform brain-death certification in our hospitals are specialists who have had appropriate training to certify brain death.

We would like to reassure the public of the highest standard of medical practice in our hospitals, and that correctly diagnosed brain death is not a reversible medical condition.

Kwek Tong Kiat (Clinical Associate Professor)
Senior Consultant,
Ministry of Health, Hospital Services Division
Head and Senior Consultant
Dept of Anaesthesiology, Intensive Care and Pain Medicine
Tan Tock Seng Hospital

Lee Heow Yong (Dr)
Acting Director/Hospital Services Division, Health Services Group
Ministry of Health
ST Forum, 26 Mar 2013

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