Brain death

• MINNEAPOLIS, Oct. 11, 2023 /PRNewswire/ -- New guidance has been issued for clinicians on the determination of brain death, also known as death by neurologic criteria.
• This guideline updates the 2010 AAN adult practice guidelines and the 2011 AAP/CNS/SCCM pediatric practice guidelines on the determination of brain death.
• Because of a lack of high-quality evidence on the subject, the experts used an evidence-informed consensus process to develop the guideline.
• The consensus practice guideline outlines the standardized procedure for trained clinicians to evaluate people for brain death.

After several years of controversy, and both praise and blame for his willingness to perform high-risk surgeries, neurosurgeon Charlie Teo has been subject to practice restrictions by a special committee of the Medical Council of New South Wales. So how does the process of restricting doctors’ medical practice work? And what did this mean for Teo?

How are health practitioners regulated in Australia?

• Health practitioner regulators in Australia aren’t generally empowered to make punitive decisions about health professionals’ conduct.
• Instead, Australia’s health practitioner regulations (the so-called “national law”) require decision-makers to exercise their powers to protect patients.
• As the Australian Health Practitioners Regulation Agency (AHPRA) acknowledges, requirements to protect the public may sometimes result in “a determination that is harsher on the practitioner than if punishment were the sole purpose”.

What happened in the Teo case?

• In late 2022, proceedings commenced against Teo via two complaints by the New South Wales Health Care Complaints Commission (HCCC).
• Tragically, neither patient regained consciousness after the operations and both patients died – one just ten days after.
• The HCCC alleged Teo had engaged in two categories of this wrongdoing: conduct below the standard reasonably expected of a doctor of his training and experience, and unethical conduct.

What were the findings and consequences for Teo?

• Though the committee is not legally bound to apply the rules of evidence applied in criminal courts, it decided, broadly for procedural fairness reasons, to receive and consider all of Teo’s unchallenged evidence.
• In a decision of more than 100 pages, the committee found Teo guilty of unsatisfactory professional conduct.
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What about patient autonomy or clinical freedom?

• Here, the committee had to balance the practitioner’s right to practise medicine against the paramount consideration of patient health and safety and against the patient’s right to exercise autonomy.
• a surgeon does not have a licence to undertake any conceivable procedure even with the agreement or acquiescence of the patient.

Is medical regulation strict in Australia and NSW?

• Many reviews and academic studies find the national law to be fair and appropriate, or not strict enough.
• However, some scholars and representative groups including the Australian Medical Association (AMA) find some aspects are too strict and unsympathetic to practitioners.
• But a potted history of NSW medical history showcases how successive medical scandals have tended to drive strong regulatory reform.

What next for Teo?

Teo may appeal the orders of the committee to the NSW Civil and Administrative Tribunal or seek a review of the conditions. But as the conditions are not subject to an end date, it appears they will otherwise continue indefinitely.

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• The UDDA, established in 1981, defines brain death as"the irreversible cessation of all functions of the entirebrain, including the brain stem."
• AAN guidelines permit the diagnosis of brain death to be established by bedside examination alone, without requiring an electroencephalogram (EEG) or cerebral blood flow studies.
• These inconsistencies result in increasing public distrust of the determination of brain death, which permits the harvesting of vital organs.
• The Journal of American Physicians and Surgeons is published by the Association of American Physicians and Surgeons (AAPS) , a national organization representing physicians in all specialties since 1943.

• The landmark approval stands to significantly expand the pool of eligible donor hearts in the United States and follows FDA PMA approval of the OCS Heart System for use with organs from donors after brain death (DBD) received in September 2021.
• The OCS Heart System is now approved withthe extended clinical indication forex vivo reanimation, functional monitoring, and beating-heart preservation of donation-after-circulatory-death (DCD) hearts.This indication is based on the results of the OCS DCD Heart Trial and the associated Continued Access Protocol (CAP).
• "The FDA's approval of the OCS for DCD donor hearts is the natural progression from the prior approval of the device for extended criteria brain dead donors, supported by the excellent results from the U.S. DCD trial," said Dr. Jacob Schroder, surgical director of heart transplantation at Duke University Medical Center and the principal investigator for the OCS DCD Heart Trial.
• With OCS we will be able to expand access to this life saving therapy to more end-stage heart failure patients."