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TABLE III-PERCENTAGE LOW BIRTHWEIGHT IN 1973 below 2500 g belong to the big group with a gaussian
birthweight distribution and should then have the low
perinatal mortality of this "normal" group.
Arguments against this new standard for low birth-
weight will undoubtedly be brought forward. If the
result is a more valid new standard, well and good.
Meanwhile it is clear that many countries could gain
much useful information by examining their data in the
way I propose here.
REFERENCES
more in Cuba, whereas there is almost no change in
Sweden (table 111).
1. Lechtig A. Low birth weight babies. World wide incidence, economic cost
and program needs. In: Perinatal care in developing countries. Geneva:
Comparison of weight groups below 2500 g has WHO, 1977.
2. World Health Organisation. Report on social and biological effects on perina-
revealed higher perinatal mortality rates in Sweden than tal mortality. Geneva: WHO, 1978.
in the U.S.A. (six States) and Hungary.7 With the new 3. Fryer JG, Harding RA, Ashford JR, Karlberg P. Some indicators of matur-
definition this confusing result may now be explained. In ity. In: Falkner F, ed. Fundamentals of mortality risks during the perina-
tal period and infancy. Basel: Karger, 1978.
Sweden, those with a birthweight below 2500 g belong 4. Medical birth registration in 1973 and 1974. Stockholm: National Central
to an abnormal population and are not part of that Bureau of Statistics, 1977: 16.
5. Karlberg P, Priolisi A. Clinical evaluation of similarities and dissimilarities
population which has a gaussian birthweight distribu- between the two city surveys. In: Falkner F, ed. Fundamentals of mortality
tion. The latter population is the one which accounts for risks during the perinatal period and infancy. Basel: Karger, 1978.
6. WHO Tech Rep Ser no. 457, 1970.
the low perinatal mortality. By contrast, in Hungary 7. Rooth G. Socio-economic aspects of perinatal medicine. In: Rooth G, Brat-
about half of the 10-8% infants with a birthweight teby L-E, eds. Perinatal medicine. Stockholm: Almqvist & Wiksell, 1977.
1. RESPIRATION*:
eyes from 4. The management of brain death and the
a. Was the PACO, below 45 mm Hg before the ventilator
provision of organs for transplantation are best dealt was disconnected?
with by one department in a hospital. b. Is there any spontaneous ventilation within 5 min of dis-
connecting the ventilator?
INTRODUCTION c. Is there any spontaneous ventilation within 10 min of dis-
d. Is any movement present in the head and neck, either hage and 2 had a massive intracerebral hxmorrhage. 1
spontaneously or in response to any stimulus? child had a meningococcal septicaemia. Necropsy con-
e. Is there a gag reflex or reflex response following bronchial firmed the cause of death in 21 patients. Necropsy was
stimulation by a suction catheter passed down the tra- not done in 1 patient who had a subarachnoid hxmorr-
chea ?
hage.
3. BODY TEMPERATURE? Kidneys were removed from 11 patients and eyes
Is the rectal temperature below 35°C? from 4. Kidneys were not removed from 11 patients for
the following reasons: 4 patients had poor renal func-
4. DRUGS? tion ; in 3 cases the police were conducting inquiries into
Have any drugs which may affect ventilation of the lungs or the circumstances in which the injuries had been recei-
the level of consciousness been administered during the pre- ved ; 1 patient was only 3 years old; the relatives of 2 pa-
ceding 12 h? tients refused permission; and 1 patients relatives were
5. Is coma due to a metabolic or endocrine cause? not asked.
Any press inquiries about the patient are dealt with by the hos- val was only 10 min. Maintenance of an adequate circu-
pital administrator. Lately, two to three weeks after the pa- lation was becoming increasingly difficult because of tor-
tients death, the units social worker has written to the next rential haemorrhage from his head injuries, and it was
of kin to offer help or an opportunity to "talk things over". necessary to confirm the diagnosis of brain death as
quickly as possible if the kidneys were to be obtained in
RESULTS a reasonable condition. Although it is tempting to do
In the two years from July, 1977, 22 patients suffered only one examination in such circumstances, it is prob-
brain death (see table). In 10 patierits the core tempera- ably wise to do two examinations even though the inter-
ture was below 35 ° C at the second examination. In 1 val between them may be very short.
patient it was below 35°C at the first examination. The conference recommends that the body tempera-
Head injury was the cause of brain death in 16 pa- ture should not be below 33°C before the tests for brain
tients.12 of these had had a road-traffic accident, 2 had death are carried out. This was not so at the time of the
fallen from considerable heights, and 2 had been shot. second examination in 10 cases in this series. However,
1 patient had overwhelming fat embolism after a road- the diagnosis of primary hypothermia had been excluded
traffic accident. 2 patients had a subarachnoid haemorr- by the presence of a normal central body temperature on
admission. An adequate arterial carbon-dioxide tension
DATA ON 22 CASES OF BRAIN DEATH at the time of the apnoea test was confirmed by arterial
blood-gas analysis. These patients demonstrate how dif-
ficult it is to maintain central body temperature in the
presence of brain death although all patients were
nursed in an ambient temperature of21°C and covered
with a heat-reflecting blanket. Our brain-death form
requires modification to take account of this difficulty.
Probably all patients who may have suffered brain
643
death should be nursed on a heated water mattress. have asignificant influence on the publics view of a
1 patient, a 10-year-old boy, had a central body local hospital. Health administrators should strive for
temperature of less than 35 °C at the time of the first good relations with local press and broadcasting agen-
examination. He had been perfectly well before his cies. When an inquiry is received from the media about
intracranial haemorrhage. a patient in whom the diagnosis of brain death has been
8 patients were unsuitable as kidney donors.4.5 Only made the sector administrator should provide a state-
2 of 13 next of kin asked refused permission for the ment which has been approved by the appropriate con-
removal of the kidneys. sultant. He should provide such a statement only when
If there is a local active policy of corneal grafting it he has received an assurance from the media that it will
is also important to ask permission to remove the eyes be published without any alterations.
as well. This can be done at the same time as asking for
We thank Dr C. Gardner-Thorpe for his help in putting the criteria
permission to remove the kidneys. for the diagnosis of brain death into tabular form, the physicians and
The most difficult problem is handling the relatives, surgeons of the Royal Devon and Exeter Hospitals for their coopera-
whether or not permission to remove the kidneys is tion in administering this protocol, and Mrs Andrea Foster for her
sought. The almost invariable suddenness of the catas- help in analysing case records and for typing the manuscript.
trophe plunges the relatives into bewilderment and dis- Requests for reprints should be addressed to J. S.
tress, and they need competent and compassionate hand-
ling. A clumsy approach will not only add greatly to their REFERENCES
distress but may also result in a refusal to allow the kid- 1. Conference of Medical and their Faculties
Royal Colleges (UK). Diagnosis
neys to be removed. It is important that.relatives under- of death. Br Med J 1976, i: 1187-88.
2. Conference of Medical Royal Colleges and their Faculties (UK). Diagnosis
stand the hopelessness of the prognosis.6 We find it help-
of death. Br Med J 1979; i: 332.
ful to use such phrases as "the person you knew and 3. BritishTransplant Society Report. The shortage of organs for clinical trans-
loved has already gone-it is just his shell that we are plantation. Br Med J 1975; i: 251-55.
4. Slapak M. Is my patient a potential donor for kidney transplantation? Br J
keeping alive". Hosp Med 1979: 21: 627-32.
It is essential that a doctor other than those looking 5. Luksza AR. Brain-dead kidney donor: selection, care and administration. Br
after the patient makes the formal request for the remo- Med J 1979; i: 1316-19.
6. Morton JB, Leonard DRA. Cadaver nephrectomy: an operation on the
val of organs. In this way there is seen to be complete donors family. Br Med J 1979; i: 239-41
separation between the immediate interests of those
looking after the potential donor and those who may be
looking after a potential recipient. Exeter has an active
renal-transplant programme, and permission for the Round the World
removal of organs is requested by a member of the trans-
plant firm. Where there is no such programme we
believe that the smooth running of a system such as ours From our Correspondents
elsewhere would be greatly enhanced if two or three peo-
Canada
ple were always available to ask relatives for permission
to remove organs. SCREENING FOR BREAST CANCER
As far as possible the same relatives should be seen by THE National Cancer Institute of Canada, the Department
the same doctor when the patients prognosis is dis- of Health and Welfare, and the Canadian Cancer Society are
cussed. In this way at least some understanding can be about to launch an inquiry into the effects of early diagnosis
built up over the relatively short time available. It also in breast cancer. It is hoped to attract 90 000 volunteers
between the ages of 40 and 59. The programme is expected to
helps to ensure that different information is not given to run for five years and eight different centres are to take part.
different relatives. (On one occasion, one set of relatives
The two main objectives are: to ascertain whether screening
was told that death had occurred when the diagnosis of
for breast cancer needs to include mammography; and to find
brain death was established and another set was told out whether screening in women under 50 is beneficial. All
that death had occurred when mechanical ventilation volunteers will undergo an initial physical examination. The
had been discontinued an hour later.) The presence of population selected will then be randomised and half will be
a member of the nursing staff at doctors interviews with offered mammography, while the other half will be taught to
relatives also helps to ensure that there is no conflict palpate their breasts. Those women in whom no abnormalities
are detected will then have an annual follow-up, half receiving
between "what the doctors said" and "what the nurse
a physical examination only, and the other half having a physi-
said".
cal examination plus mammography. The study is starting in
The medical staff have a responsibility to see that the
a glare of publicity. Findings from the Health Insurance Plan
nursing staff understand what brain death is, how it is in New York have indicated that women under 50 do not benefit
diagnosed, and how it is managed. Nurses are with the from mammography screening. There has also been concern
patient for long periods during which they are expected about the risks of radiation, and while the director of the
to maintain the highest standard of care, knowing that -Canadian study, Dr Anthony Miller, of the National Cancer
there is no chance that the patient will recover. They Institute of Canada, in an interview with the Toronto Globe
bear the brunt of the care of the relatives. They cope and Mail, stated categorically that the benefits of mammogra-
well when they are well informed and supported by the phy in the under-50 group exceed the dangers, his opinion has
been disputed by Dr Irwin Bross, of Roswell Park Hospital,
medical staff. Indeed, such nurses are essential for the
New York. Dr Bross has appreciable circumstantial evidence
humane and efficient management of patients with brain in favour of his views, and he cites the decision of the Cancer
death. Institute of the National Institutes of Health to suspend mam-
Switching off a life-support system is still news- mographic screening in women below 50. Dr Miller declares
worthy, and reporters are often persistent in their in- that he knows the benefits of mammography outweigh the risk,
quiries about accident victims. Newspaper reports can so it is being asked why he wants to press on with the trial.