Summary:
The discussion explores reflex movements observed in near brain death, focusing on spinal reflexes in brain-dead patients, their clinical significance, and the ethical, cultural, and emotional dimensions of handling such cases. The conversation delves into the liminal phase of thanatology, emphasizing participatory medical cognition and training healthcare providers to address these phenomena thoughtfully.
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Key Words
- Brain death
- Spinal reflexes
- Lazarus sign
- Thanatology
- Liminality
- Passage of rites
- Medical cognition
- Participatory medicine
- Ethical approval
- Caregiver communication
UDHC keyword glossary:https://
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Conversational transcripts:
[14/09, 11:50]hu1: Yesterday's afternoon session demonstrating a hitherto unknown near death sign in a patient who also had the Narketpally sign 👇
[14/09, 11:54]hu1: Another near death sign driven by the oculocephalic reflex, first reported by @Participatory Medicine Elective Student Author while on his elective at another medical college in India👇
[14/09, 12:40]hu1: The near death involuntary signs 👇
[14/09, 12:45) hu2 : Thank you for sharing
So much work remains post singularity. Folks are busy freaking out
...
Brain death - Organ transplantation is a critical ethical question.
Is an EEG done on them? Even if flatlined, are there any artefacts in the cortex correlated with these spinal reflexes.
[14/09, 12:47] hu1: Wish we had wearable EEGs
[14/09, 12:48] hu2: Even with that avoiding electrode skin contact break would be difficult
[14/09, 12:50]hu2: See if your dept is willing to procure from a Delhi based manufacturer
8 channels only, but have good signal quality
[14/09, 12:51]hu2: 8 channels will not suffice.
Actually 64 or even 128 channels would give a wonderful picture under continuous monitoring
[14/09, 13:32] hu1 : We have only 27000 as patient capital in the department https://medicinedepartment.
[14/09, 13:59]hu2: BITS Hyderabad or others can sponsor for your patients.
IIT Hyderabad has a strong medical devices practice
[14/09, 15:38]huai1: Of course. Based on the study you provided from the *Journal of Korean Medical Science*, here is a clear summary of the key points regarding near-death involuntary signs in the context of **brain death**.
### Summary of the Study on Reflex Movements in Brain Death
This prospective study investigated how often and what types of involuntary reflex movements occur in patients who have been declared brain dead.
#### **Key Findings:**
1. **Frequency:** Out of 26 brain-dead adult patients, **5 (19.2%) exhibited involuntary reflex movements**. This shows that while not the majority, these movements are **not rare**.
2. **Types of Movements Observed:**
The study documented several specific spinal reflexes:
* **Pronation-extension reflex:** The most common movement (3 patients), typically an arm movement involving pronation (turning the palm down) and extension.
* **Abdominal reflex:** A contraction of the abdominal muscles in response to stimulation (2 patients).
* **Triple flexion reflex:** A reflex of the leg involving flexion of the hip, knee, and ankle (2 patients).
* **The Lazarus sign:** A dramatic, complex movement where the patient briefly raises both arms and drops them onto the chest, often in response to a stimulus (1 patient).
* **Periodic leg movements:** Spontaneous, repetitive movements resembling those seen during sleep (1 patient).
3. **Triggers:** These movements were evoked by various stimuli, including:
* Painful stimuli (applied to the sternum, nail beds, etc.)
* Tactile stimulation (touching the palm or sole)
* Neck flexion
* The apnea test (a test to check for the absence of breathing, which can cause a rise in blood CO2)
#### **Why This Is Important (Clinical Significance):**
* **These are SPINAL reflexes, not BRAIN reflexes.** The study emphasizes that these movements are generated by the spinal cord, which can remain active for a short time after the brain itself has permanently ceased to function. They are **not** a sign of life or recovery of brain function.
* **Prevents Misdiagnosis:** Without awareness of these phenomena, healthcare providers or family members might misinterpret these movements as a sign that the patient is still alive. This could lead to:
* **Delays in diagnosing brain death.**
* **Confusion and emotional distress for families.**
* **Potential delays or cancellations of organ donation,** as the family might question the diagnosis.
#### **Proposed Mechanisms:**
The study discusses several theories for why these movements happen after brain death:
* **Disinhibition:** The brain normally suppresses these spinal reflexes. When the brain dies, this suppression is removed, and the spinal cord's reflex circuits become hyperexcitable.
* **Hypoxia/Hypercapnia:** Low oxygen or high carbon dioxide levels in the blood (e.g., during the apnea test) can stimulate spinal neurons.
* **Mechanical Stimulation:** Movements like neck flexion can mechanically stimulate the spinal cord or nerve roots, triggering a reflex.
### **Conclusion for "Near-Death Involuntary Signs"**
In the specific context of **brain death**, the "involuntary signs" mentioned are **spinal reflex movements**. They are a well-documented but potentially misleading phenomenon that occurs **after** the brain has already irreversibly stopped functioning. Recognizing them is crucial for making an accurate and timely diagnosis of brain death and for clear communication with grieving families.
[14/09, 16:03]hu3: How is this handled with caregivers? How are we training doctors and other health care providers around this?
This is a liminal phase, passage of time. How do we handle it?
[14/09, 16:05]hu3: Very interesting study..
I think context of India and our limitations in terms of space time etc. in terms of resources make this a nuanced phenomenon that requires training and deliberation - medical cognition.
[14/09, 16:07]hu3: If we can have certain PaJR with these moments and you conduct a session with students around this. They then deliberate and write a reflective diary of these sessions..
Since we are using PaJR
We can contribute towards our ongoing research in different context - liminal phase,
Passage of rites..
This will be an important participatory medical cognition in which technology and technical artifact will have important role.
[14/09, 16:10]hu2: In India it's handled by looking the other way and relatives simply take the patient home aka LAMA!
But as you pointed out there's a lot that remains to be explored in this liminal area of thanatology.
Here's a single person account from a religious perspective https://www.degruyterbrill.
[14/09, 16:13]hu2: I will read this.. this seems interesting.. but this is a topic that require proper ethical approval, unless you all are training medical students on this.
I see the angle of religion also, may be caste..
I see emotional implications of such training.
Thematic Analysis
1. Reflex Movements in Brain Death
- *Clinical Observations*: Reflex movements such as the Lazarus sign, triple flexion reflex, and abdominal reflex are identified as spinal, not brain-mediated, phenomena. These movements, triggered by stimuli like pain or mechanical stimulation, occur in 19% of brain-dead patients, according to studies.
- *Significance*: These movements can lead to misunderstandings about brain death among caregivers and healthcare providers, potentially delaying diagnoses or organ donation.
2. Ethical and Emotional Implications
- *Caregiver Communication*: Handling reflex movements requires sensitive communication to prevent distress among grieving families. Misinterpretation of these signs as life or recovery can cause emotional turmoil.
- *Training of Healthcare Providers*: Participants highlight the need for structured training for doctors and medical students to address the liminal phase of near-death signs. Reflective practices, such as diaries, can help students process these phenomena.
3. Participatory Medical Cognition
- *Integration of Technology*: Wearable EEGs or advanced monitoring systems are proposed to better understand these reflexes and their correlation with cortical activity.
- *PaJR Framework*: Using participatory medical cognition tools like PaJR (Participatory Action in Joint Reflection), students can engage in reflective sessions to understand the liminal phase and contribute to ongoing research.
4. Cultural and Religious Dimensions
- *Thanatology and Liminality*: Reflex movements in near brain death are linked to liminal phases of life and death, reflecting a nuanced intersection of medical science and cultural beliefs.
- *Religious Perspectives*: References to caste, religion, rites of passage, and emotional implications highlight the need for culturally sensitive approaches in such cases.
5. Resource Constraints
- *Indian Context*: Limited medical resources, space, and equipment (e.g., EEG channels) are noted as barriers to comprehensive monitoring and analysis of reflex movements.
- *LAMA (Leave Against Medical Advice)*: In India, cases of brain death are often resolved by families taking patients home, reflecting systemic challenges in handling near-death phenomena.
6. Ethical Research and Training
- *Approval and Sensitivity*: Participants stress the importance of ethical approval for training initiatives and research into reflex movements and their implications on caregivers.
- *Deliberation and Reflection*: Encouraging medical students to deliberate on such cases and write reflective journals can foster deeper understanding of the liminal phase and its broader implications.
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Key Insights
- Reflex movements in brain death are clinically significant but often misunderstood, requiring better communication and training for healthcare providers.
- Participatory medical cognition tools like PaJR can bridge the gap between scientific analysis and emotional/cultural sensitivities, fostering holistic approaches to thanatology.
- Ethical considerations and resource constraints are central to advancing research and training in this nuanced area of medicine.
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