246 M. Coombs and M. Woods
Case 1: Clinical Practice Commentary
Susan’s story raises issues about the nature of brain death and the pro-
cess of organ donation in this context, highlighting two key issues that
will be explored in more depth. The first of these is that a person who
is brain dead may look ‘healthy’—their skin may have a normal colour,
their chest appears to rise and fall with breathing, and they may feel
warm to the touch. Second, after brain death has been certified, patients
who are organ donors are taken from the intensive care unit into the
operating theatre for surgery.
Our understanding of what death looks like has historically been
informed by circulatory death; that is, the cessation of cardiac and res-
piratory functions. Circulatory death is associated with absent palpable
pulses, absent heart sounds, absent breath sounds, and the absence of
respiratory effort or chest wall motion (Shemie et al. 2014 ). This type
of death results in the person looking pale and feeling cold to the touch.
Susan’s story makes apparent how different brain death is to circulatory
death in these respects.
One of the challenges for families in intensive care is that patients
who are brain dead may not look physically any different to how fami-
lies last saw them. This is due to the effect of the intensive care inter-
ventions these patients require, and the mechanism of brain death itself.
Due to the loss of brain function and spontaneous breathing in those
who are brain dead, mechanical ventilation is required. Oxygenating the
person maintains their warmth and colour, giving the impression that
the person is alive and breathing. A further challenge for families is that
brain death often results from non-traumatic primary brain injuries,
cerebrovascular accidents, cerebral bleeds, and anoxic/hypoxic^2 brain
damage (Escudaro et al. 2015 ). These patients may therefore have no
obvious external injury or trauma marks and, again, appear ‘normal’ to
their families.
On being informed that the patient is brain dead, families (and
sometimes staff) can become anxious when noting movement in the
patient’s limbs, as in Susan’s story. While there is no cerebral activity
following brain death, there may still be spinal reflex activity, passing
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