From heart to brain: the new definitions of death

The transatlantic divide over brain death determination and the debate

In 1976, the Royal College of Physicians published neurological criteria of death. The memorandum stated that-after preconditions and exclusion criteria were met-the absence of brainstem function, including apnoea testing, would suffice. In the USA, many experts felt that brain death could be only determined by demonstrating death of the entire brain. In the history of further refinement of UK and USA brain death criteria, one particular period stands out that would bring about an apparent transatlantic divide. On 13 October 1980, the British Broadcasting Corporation aired a programme entitled 'Transplants: Are the Donors Really Dead?' Several United States experts not only disagreed with the United Kingdom criteria, but claimed that patients diagnosed with brain death using United Kingdom criteria could recover. The fallout of this television programme was substantial, as indicated by a media frenzy and a 6-month period of heated correspondence within The Lancet and The British Medical Journal. Members of the Parliament questioned the potential long-term effect on the public's trust in organ transplantation. Given the concerns raised, the British Broadcasting Corporation commissioned a second programme, which was broadcast on 19 February 1981 entitled 'A Question of Life or Death: The Brain Death Debate.' Two panels debated the issues on the accuracy of the electroencephalogram and its place, the absolute need for assessing preconditions before an examination, the problems with recognition of toxins and the feasibility of doing a new prospective study in the United Kingdom, which would follow patients' examination assessed with United Kingdom criteria until cardiac standstill. The positions of the United States and United Kingdom remained diametrically opposed to each other. This article revisits this landmark moment and places it in a wider historical context. In the USA, the focus was not on the brainstem, and the definition of brain death became rapidly infused with terms such as whole brain death (all intracranial structures above the foramen magnum), cerebral death (all supratentorial structures) or higher brain death (cortical structures) virtually synonymous with persistent vegetative state. This review also identifies the fortitude of neurosurgeon Bryan Jennett and neurologist Christopher Pallis by introducing new corroborative data on the diagnosis of brain death and clarifying the United Kingdom position. Both understood that brainstem death was the infratentorial consequence of a supratentorial catastrophe. With the 1995 American Academy of Neurology practice parameters, the differences between the UK and USA brain death determination would become much less apparent.

Prognosis of deeply comatose patients on ventilators

Although the concept of brain death has been widely accepted, the criteria required for making the diagnosis remain controversial. This prospective study was undertaken to examine the reliability of a set of clinical criteria adopted in Taiwan. One hundred and forty deeply comatose patients (101 men, 39 women; mean age 49.5 (SD 17.6) years) requiring ventilation were studied. Seventy three patients met the clinical criteria for brainstem death; all developed cardiac asystole (97% within seven days) despite continued full cardiorespiratory support. Brainstem death was diagnosed in only two of the 21 patients with hypoxic or ischaemic insults. This stresses the rarity of hypoxic or ischaemic encephalopathy as a cause of brainstem death. The results show that if strict attention is paid to preconditions and exclusions, brainstem death can be reliably diagnosed on clinical grounds alone.