Incidence of Brainstem Dysfunction and Brain Death and End-of-Life Care Practices: A Two-Year Retrospective Review

INTRODUCTION

The brainstem forms the lower part of the brain, connecting the diencephalon to the spinal cord and cerebellum. It contains nuclei of the cranial nerves, the ascending reticular activating system and autonomic centres that mediate vital sensory and motor pathways. It regulates crucial functions such as breathing, circulation and the sleep–wake cycle and its dysfunction can lead to cardiovascular collapse, respiratory failure and ultimately brainstem death.^[1]

Brain death is defined as the irreversible loss of all brain and brainstem function, characterised clinically by coma, the absence of brainstem reflexes and apnoea.^[2] Once confirmed, the patient is legally and clinically dead. The diagnosis is usually established by repeated neurological examinations, including two assessments of brainstem reflexes and an apnoea test (Goila and Pawar, 2009).^[2]

End-of-life (EoL) care in the intensive care unit (ICU) often begins when brainstem dysfunction or death is established. It involves withholding or withdrawing life support after appropriate discussions between the healthcare team and the patient’s relatives.^[3,4] However, in many low- and middle-income countries, including Nigeria, such practices remain ethically and culturally sensitive, and are often viewed as unacceptable. The high incidence of irreversible brain injuries, combined with the economic burden,^[5] pressure on critical care facilities and emotional distress to families, underscores the need to understand the local practice and acceptability of EoL care (EoLC).

This study aimed to determine the incidence and causes of brainstem dysfunction or death among ICU patients in a tertiary hospital and to evaluate the timing, documentation and family decision-making processes regarding EoLC. Notably, all cases of brainstem dysfunction recorded in this study ultimately progressed to brain death.

MATERIALS AND METHODS

This was a retrospective cross-sectional study conducted in the ICU of the University College Hospital, Ibadan, Nigeria, over 2 years from March 2020 to February 2022.

All patients who died in the ICU during the study were reviewed. Cases with documented brainstem dysfunction or brainstem death were identified and included in the analysis.

RESULTS

A total of 232 deaths occurred in the ICU during the study period of 2 years, in which 24 (10%) developed brain stem dysfunction 10.3%. The patients with brain stem dysfunction were predominantly males (75%, 18 of 24). The most common cause of brain stem dysfunction in this study was severe head injury (54%, 13 of 24), followed by haemorrhagic stroke (21%, 5 of 24). Prognosis was discussed with relatives in 37.5% of patients.

Majority of the patients (58%, 14 of 24) died within 24–72 h of the diagnosis of brain stem dysfunction. About 40% had cardiac arrest before developing brain stem death. The tests done in establishing dysfunction in patients included gag reflex (100%, 24 of 24), pupillary reflex (100%, 24 of 24), occulocochlear reflex (8.2%, 2 of 24) and apnoea test (12.5%, 3 of 24). Prognostication was documented in 9 (37.5%) patients.

In these cases, discussions occurred after confirmation of brainstem dysfunction and were led by the ICU consultant. Meetings were typically held once, with follow-up discussions in cases where families requested clarification. No prognostication notes were identified in nursing or physician records for the remaining 15 patients.

37.5% of the patients had the prognosis discussed with their relatives, while there was no discussion with 62.5% of the patients. 9 (37.5%) had cardiac arrest before developing brainstem death, while 15 (62.5%) didn’t have cardiac arrest preceding brainstem death.

DISCUSSION

This study found that 10% of ICU deaths were preceded by brainstem dysfunction, which is notably higher than the 2% incidence reported in the United States by Seifi et al. (2020) [Figure 1]. The difference may reflect disparities in healthcare infrastructure and the overall health index between high-income and low-middle-income countries.^[6] Furthermore, Seifi et al. (2020) observed that the incidence of brain death was higher among Black patients than among Caucasians, which aligns with the current findings in a predominantly Black population.^[6]

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Figure 1: Incidence of brain stem death.

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Severe head injury and stroke were the leading causes of brainstem death, Figure 2 consistent with the findings of Seifi et al. (2020), who reported neurological pathologies as the predominant causes.^[6] Trauma remains a major cause of ICU admission in low-resource settings, driven by road traffic accidents and violence. This may also explain the male predominance (75%) observed, as men are more often involved in such high-risk activities. Similar male predominance in trauma cases was documented Figure 3 by Elachi et al. (2015) in Makurdi, Nigeria, whereas Ekenze et al. (2009) observed a smaller gender difference among children in southeastern Nigeria.^[7,8]

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Figure 2: 13 (54.2%) severe head injury, 5 (20.8%) haemorrhagic stroke, while others include 6 (25%), 1 organophosphate poisoning, 2 pediatrics had severe pneumonia, 2 intracranial tumour 1 C-spine injury.

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Figure 3: Gender distribution.

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In contrast to the current findings, Escudero et al. (2015) in Spain found stroke to be the most common cause of brainstem death, followed by trauma.^[9] This difference may be explained by socioeconomic and environmental factors such as traffic safety and healthcare access.

In this study, 58% of patients were declared clinically dead within 24–72 h after brainstem death, as shown in Figure 4, a finding consistent with the observations of Sandroni et al. (2016), who reported that asystole usually occurs within a few days if limited supportive care is continued.^[10]

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Figure 4: Time between brainstem death and clinical death.

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Only about one-third of relatives were engaged in prognosis discussions [Table 1]. This highlights an important ethical challenge in Nigerian ICUs, where cultural and religious beliefs often discourage open EoL discussions.^[11,12] Families frequently struggle to accept brain death because patients appear warm, with ongoing cardiac activity sustained by mechanical ventilation, as shown in Table 2. Allowing relatives to witness brainstem death testing and providing clear explanations have been shown to increase understanding and acceptance.^[13,14]

The diagnostic tests used in this study were mostly bedside reflex assessments, which differ from international standards, where the apnoea test and electroencephalography are routinely applied.^[15] Limited access to equipment and variations in practice guidelines may account for this. Brainstem death presents a complex challenge for families, clinicians and healthcare systems. For families, it represents an emotionally difficult transition from hope to acceptance of death. For healthcare providers, it demands a balance between preserving life and avoiding futile care. Establishing national guidelines, training clinicians in communication of poor prognosis and incorporating cultural sensitivity are essential to improve EoL practices in ICUs.^[3,16]

CONCLUSION

Brainstem dysfunction or death accounted for approximately one-tenth of ICU mortalities in this tertiary hospital, with severe head injury being the leading cause. Most of the patients progressed to clinical death within 72 h of diagnosis, yet structured prognostication and EoL discussions were inconsistently documented.

There is a pressing need for standardised national protocols for brainstem death determination and EoLC, improved documentation practices and training in culturally sensitive communication. Strengthening these frameworks may enhance family understanding, ethical decision-making and optimal utilisation of limited critical-care resources in low- and middle-income settings.