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Greer DM, Shemie SD, Lewis A, Torrance S, Varelas P, Goldenberg FD, Bernat JL, Souter M, Topcuoglu MA, Alexandrov AW, Baldisseri M, Bleck T, Citerio G, Dawson R, Hoppe A, Jacobe S, Manara A, Nakagawa TA, Pope TM, Silvester W, Thomson D, Al Rahma H, Badenes R, Baker AJ, Cerny V, Chang C, Chang TR, Gnedovskaya E, Han MK, Honeybul S, Jimenez E, Kuroda Y, Liu G, Mallick UK, Marquevich V, Mejia-Mantilla J, Piradov M, Quayyum S, Shrestha GS, Su YY, Timmons SD, Teitelbaum J, Videtta W, Zirpe K, Sung G. Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project. JAMA 2020; 324:1078-1097. [PMID: 32761206 DOI: 10.1001/jama.2020.11586] [Citation(s) in RCA: 267] [Impact Index Per Article: 66.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. OBJECTIVE To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. PROCESS Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. EVIDENCE SYNTHESIS Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. RECOMMENDATIONS Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability. CONCLUSIONS AND RELEVANCE This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.
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Affiliation(s)
- David M Greer
- Boston University School of Medicine, Boston, Massachusetts
| | - Sam D Shemie
- McGill University, Montreal Children's Hospital, Montreal, Canada
- Canadian Blood Services, Ottawa, Canada
| | | | | | | | | | - James L Bernat
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | | | - Anne W Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis
| | - Marie Baldisseri
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas Bleck
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Arnold Hoppe
- Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Stephen Jacobe
- University of Sydney and Children's Hospital of Westmead, Westmead, Australia
| | | | | | | | | | | | | | - Rafael Badenes
- Hospital Clinic Universitari, University of Valencia, Valencia, Spain
| | - Andrew J Baker
- St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Canada
| | - Vladimir Cerny
- J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic
| | | | - Tiffany R Chang
- The University of Texas Health Science Center at Houston, Houston
| | | | - Moon-Ku Han
- Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | | | | | | | - Gang Liu
- Capital Medical University, Beijing, China
| | | | | | | | | | | | | | | | | | | | - Walter Videtta
- National Hospital, Alejandro Posadas, Buenos Aires, Argentina
| | | | - Gene Sung
- University of Southern California, Los Angeles
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Abstract
Prompted by concerns raised by the rise in litigations, which challenge the legal status of brain death (BD), Lewis and colleagues recently proposed a revision of the Uniform Determination of Death Act (UDDA). The revision consists of (i) narrowing down the definition of BD to the loss of specific brain functions, namely those functions that can be assessed on bedside neurological examination; (ii) requiring that the determination of BD must be in accordance with the specific guidelines designated in the revision; and (iii) eliminating the necessity for obtaining consent prior to performing the tests for BD determination. By analyzing Lewis and colleagues' revision, this article shows that this revision is fraught with difficulties. Therefore, this article also proposes two approaches for an ethical revision of the UDDA; the first is in accordance with scientific realism and Christian anthropology, while the second is grounded in trust and respect for persons. If the UDDA is to be revised, then it should be based on sound ethical principles in order to resolve the ongoing BD controversies and rebuild public trust. Summary This article critically examines the recent revision of the Uniform Determination of Death Act (UDDA) advanced by Lewis and colleagues. The revision only further reinforces the status quo of brain death without taking into account the root cause of the litigations and controversies about the declaration of death by neurological criteria. In view of this deficiency, this article offers two approaches to revising the UDDA, both of which are founded on sound moral principles.
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Affiliation(s)
- Doyen Nguyen
- St. Mary Seminary and Graduate School of Theology, Wickliffe, OH, USA
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Abstract
The case of Jahi McMath has reignited a discussion concerning how society should define death. Despite pronouncing McMath brain dead based on the American Academy of Neurology criteria, the court ordered continued mechanical ventilation to accommodate the family's religious beliefs. Recent case law suggests that the potential for a successful challenge to the neurologic criteria of death provisions of the Uniform Determination of Death Act are greater than ever in the majority of states that have passed religious freedom legislation. As well, because standard ethical claims regarding brain death are either patently untrue or subject to legitimate dispute, those whose beliefs do not comport with the brain death standard should be able to reject it.
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Affiliation(s)
- Greg Yanke
- School of Historical, Philosophical & Religious Studies, Arizona State University, Tempe, AZ, 85281, USA.
| | - Mohamed Y Rady
- Department of Critical Care, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA
| | - Joseph L Verheijde
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA
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