Tuesday, March 26, 2013

Brain-death diagnosis based on stringent clinical criteria: MOH

Mar 26, 2013

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.

[In other words, we don't know WTF standards HK uses.]

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.
[So the fact that Ms Chin recovered from a "diagnosed" brain death would indicate that the diagnosis by the HK doctors were faulty.]

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

[And this is the news article that prompted the doctors' reply:]

Mar 24, 2013


'I have been blessed with a second chance'

Singapore lawyer declared brain dead wakes up amid calls to pull plug on her

By K.c. Vijayan

Lawyer Suzanne Chin is convinced that what happened to her four years ago is nothing short of a miracle.

The mother of two was living and working in Hong Kong when she suffered a heart attack, was hospitalised in a coma and declared brain dead.The head of the intensive care unit, two neurologists and a cardiologist told her husband to prepare for the worst. Soon, he was advised to take her off life support because, simply put, there was no hope.

Then, three days after she was admitted, she woke up from her coma. She recovered within a week and left the hospital. Today, she is living in Singapore, still working as a lawyer, still a wife and mum. She is well, and she is alive.Chief Justice Sundaresh Menon recalled her remarkable story in a speech earlier this month on euthanasia and assisted dying. When The Sunday Times contacted Ms Chin for her story, she agreed only to answer questions via e-mail....
[OK. First a politically incorrect joke about why a lawyer would be found to be brain dead... Never mind.

CJ Menon had raised this issue so that we can have a discussion about end of life issues, assisted death (or suicide) and euthanasia. Based on the online comments to Suzanne Chin's story (which were sharing of similar or related religious experiences) and comments to the letter from the doctors (Anti-HOTA), we don't seem to be ready to have a rational discussion.

Maybe we should just get back to that lawyer joke I wanted to tell... again, never mind.

My suspicion was that the HK doctors had screwed up, as the letter from the Singapore Doctors had implied. However, I searched for some information on this - hoping to see an official report from the HK doctors explaining this error or how to prevent this error. 

I found an updated guide on determining Brain Stem Death (BSD) from HK Society of Critical Care Medicine. Revised in Aug 2009. Just months after Suzanne Chin's miracle recovery from BSD. Possibly a response, though obliquely, to that incident.

I also found a post on facebook: 

There was Suzanne's "testimony" as well as her brother, Dr Alan Chin who is a medical doctor. This was the second opinion from another neurologist, and Dr Chin's observation and narrative:
"We requested for a second opinion from a neurologist who examined her that afternoon.

Her pupils were fixed and dilated. Vestibulo-ocular reflex was negative. She had a negative gag and cough reflex. There was no pain reflex in response to deep pressure over sternum, fingers, and eyebrow. She was flaccid, a-reflexic and there was no plantar response. His diagnosis was also that of brain stem death.

That evening, Suzanne looked dead. She was cold and clammy; facial discoloration had set in, especially under her eyes. There was also a smell of death over her."
I would have preferred a more objective source, and maybe someone can find one. But if we take Dr Chin's testimony at face value, it would seem that the HK doctor did everything right, and Ms Chin was by all indications, brain dead, and this truly was an unexplainable miracle. 

BUT if we consider that Dr Chin might have some interests in promoting belief in miracles, his testimony may not be considered impartial.  Certainly, there is some validation of their belief if her condition were as bleak as he reported. Again, it would good to have an independent enquiry from HK medical authorities to provide a more unbiased report. Certainly if the HK neurologists had made a mistake, it would be in their interest to support a "miraculous explanation" as it would absolved them of any wrong-doing.

So in my mind, this is still unresolved.] 

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