Incidence of brain death in the United States

Brain death: A review of the latest guidelines

ABSTRACT

The incidence of brain death/death by neurologic criteria (BD/DNC) among all hospital deaths in the US is approximately 2.06% or 15,000-20,000 cases annually. This article reviews the latest guidelines for adult and pediatric BD/DNC. Although there have not been many changes to the guidelines over the years, BD/DNC guideline updates maintain consistency in determining BD/DNC.

The Uniform Determination of Death Act is Not Changing. Will Physicians Continue to Misdiagnose Brain Death?

Efforts to revise the Uniform Determination of Death Act in order to align law with medical practice have failed. Medical practice must now align with the law. People who are not dead under the law that defines death should not be declared dead. There is no compelling reason to continue the practice of declaring legally living persons to be dead.

Role of Clinical and Multimodality Neuroimaging in the Evaluation of Brain Death/Death by Neurologic Criteria and Recent Highlights from 2023 Updated Guidelines

Purpose of Review: This review aims to provide a comprehensive overview of the diagnosis of brain death/death by neurologic criteria (BD/DNC) by emphasizing the clinical criteria established by the American Academy of Neurology (AAN) in light of their updated guidelines released in 2023. In this review, we will focus on the current implementation of ancillary tests including the catheter cerebral angiogram, nuclear scintigraphy, and transcranial Doppler, which provide support in diagnoses when clinical examination and apnea tests are inconclusive. Finally, we will also provide examples to discuss the implementation of certain imaging studies in the context of diagnosing BD/DNC. Recent Findings: Recent developments in the field of neurology have emphasized the importance of clinical criteria for diagnosing BD/DNC, with the AAN providing clear updated guidelines that include coma, apnea, and the absence of brainstem reflexes. Current ancillary tests, including the catheter cerebral angiogram, nuclear scintigraphy, and transcranial Doppler play a crucial role in confirming BD/DNC when the clinical assessment is limited. The role of commonly used imaging studies including computed tomography and magnetic resonance angiographies of the brain as well as CT/MR perfusion studies will also be discussed in the context of these new guidelines. Summary: BD/DNC represents the permanent cessation of brain functions, including the brainstem. This review article provides the historical context, clinical criteria, and pathophysiology that goes into making this diagnosis. Additionally, it explores the various ancillary tests and selected imaging studies that are currently used to diagnose BD/DNC under the newly updated AAN guidelines. Understanding the evolution of how to effectively use these diagnostic tools is crucial for healthcare professionals who encounter these BD/DNC cases in their practice.

An Update on Brain Death/Death by Neurologic Criteria since the World Brain Death Project

The World Brain Death Project (WBDP) is a 2020 international consensus statement that provides historical background and recommendations on brain death/death by neurologic criteria (BD/DNC) determination. It addresses 13 topics including: (1) worldwide variance in BD/DNC, (2) the science of BD/DNC, (3) the concept of BD/DNC, (4) minimum clinical criteria for BD/DNC determination, (5) beyond minimum clinical BD/DNC determination, (6) pediatric and neonatal BD/DNC determination, (7) BD/DNC determination in patients on ECMO, (8) BD/DNC determination after treatment with targeted temperature management, (9) BD/DNC documentation, (10) qualification for and education on BD/DNC determination, (11) somatic support after BD/DNC for organ donation and other special circumstances, (12) religion and BD/DNC: managing requests to forego a BD/DNC evaluation or continue somatic support after BD/DNC, and (13) BD/DNC and the law. This review summarizes the WBDP content on each of these topics and highlights relevant work published from 2020 to 2023, including both the 192 citing publications and other publications on BD/DNC. Finally, it reviews questions for future research related to BD/DNC and emphasizes the need for national efforts to ensure the minimum standards for BD/DNC determination described in the WBDP are included in national BD/DNC guidelines and due consideration is given to the recommendations about social and legal aspects of BD/DNC determination.

Organ donation after extracorporeal cardiopulmonary resuscitation: a nationwide retrospective cohort study

BACKGROUND

Limited data are available on organ donation practices and recipient outcomes, particularly when comparing donors who experienced cardiac arrest and received extracorporeal cardiopulmonary resuscitation (ECPR) followed by veno-arterial extracorporeal membrane oxygenation (ECMO) decannulation, versus those who experienced cardiac arrest without receiving ECPR. This study aims to explore organ donation practices and outcomes post-ECPR to enhance our understanding of the donation potential after cardiac arrest.

METHODS

We conducted a nationwide retrospective cohort study using data from the Japan Organ Transplant Network database, covering all deceased organ donors between July 17, 2010, and August 31, 2022. We included donors who experienced at least one episode of cardiac arrest. During the study period, patients undergoing ECMO treatment were not eligible for a legal diagnosis of brain death. We compared the timeframes associated with each donor's management and the long-term graft outcomes of recipients between ECPR and non-ECPR groups.

RESULTS

Among 370 brain death donors with an episode of cardiac arrest, 26 (7.0%) received ECPR and 344 (93.0%) did not; the majority were due to out-of-hospital cardiac arrests. The median duration of veno-arterial ECMO support after ECPR was 3 days. Patients in the ECPR group had significantly longer intervals from admission to organ procurement compared to those not receiving ECPR (13 vs. 9 days, P = 0.005). Lung graft survival rates were significantly lower in the ECPR group (log-rank test P = 0.009), with no significant differences in other organ graft survival rates. Of 160 circulatory death donors with an episode of cardiac arrest, 27 (16.9%) received ECPR and 133 (83.1%) did not. Time intervals from admission to organ procurement following circulatory death and graft survival showed no significant differences between ECPR and non-ECPR groups. The number of organs donated was similar between the ECPR and non-ECPR groups, regardless of brain or circulatory death.

CONCLUSIONS

This nationwide study reveals that lung graft survival was lower in recipients from ECPR-treated donors, highlighting the need for targeted research and protocol adjustments in post-ECPR organ donation.

A Biophilosophical Approach to the Determination of Brain Death

Technical and clinical developments have raised challenging questions about the concept and practice of brain death, culminating in recent calls for revision of the Uniform Determination of Death Act (UDDA), which established a whole brain standard for neurologic death. Proposed changes range from abandoning the concept of brain death altogether to suggesting that current clinical practice simply should be codified as the legal standard for determining death by neurologic criteria (even while acknowledging that significant functions of the whole brain might persist). We propose a middle ground, clarifying why whole brain death is a conceptually sound standard for declaring death, and offering procedural suggestions for increasing certainty that this standard has been met. Our approach recognizes that whole brain death is a functional, not merely anatomic, determination, and incorporates an understanding of the difficulties inherent in making empirical judgments in medicine. We conclude that whole brain death is the most defensible standard for determining neurologic death-philosophically, biologically, and socially-and ought to be maintained.

Retrospective Analysis of Patients Diagnosed with Brain Death in Our Hospital in the Last 15 Years

Objectives

Retrospective analysis of cases diagnosed with brain death in our hospital in the last 15 years.

Methods

The files and computer records of the cases diagnosed with brain death in the intensive care units of our hospital between January 2008 and January 2023 were evaluated retrospectively. The demographic data of the cases, the primary disease leading to brain death, the complementary tests used in the diagnosis of brain death, the day on which brain death was diagnosed in the intensive care unit, and the donor status were examined.

Results

A total of 228 cases diagnosed as brain death were detected. Seven patients with missing data were excluded from the study. 61.99% of the cases were male, 38.01% were female, 14.02% were under 18 years old, 68.34% were between 18 and 65 years old, 17.64% were over 65 years old. Brain death was diagnosed in 69.69% of the patients admitted to the intensive care unit in the first 7 days, 22.17% in 7-14 days, and 8.14% after 14 days. The primary disease causing brain death was found to be 47% hemorrhagic cerebral injury, 21% traumatic hemorrhagic injury, 18% ischemic cerebral injury, and 14% hypoxic cerebral injury. No ancillary testing was used in 38% of the cases. Carotid doppler ultrasound was used in 36%, computed tomography angiography was used in 22%, and transcranialdoppler was used in 4%. Families agreed to be organ transplant donors in 28.95% of the cases. 71.05% family members refused to be organ transplant donors.

Conclusion

The number of organ donations and the diagnosis of brain death has decreased rapidly with the covid-19 pandemic. In order to increase organ donation, we think that the necessary education should be given at an early age to increase organ donation awareness and social awareness.

Evaluation of Donor Lungs for Transplantation: The Efficacy of Screening Bronchoscopy for Detecting Donor Aspiration and Its Relationship to the Resulting Allograft Function in Corresponding Recipients

BACKGROUND

Potential organ donors often have suffered anoxic and/or traumatic brain injury during which they may have experienced aspiration of gastric material (AGM). Evaluation of such donors typically includes a screening bronchoscopic examination during which determinations of aspiration are made. The efficacy of this visual screening and its relationship to post-transplant allograft function are unknown.

METHODS

Before procurement, bronchoscopy was performed on donors in which both bronchoalveolar lavage fluid (BALF) was collected and a visual inspection made. As a marker of AGM, BALF specimens were analyzed for the presence of bile salts. Data collected on the corresponding recipients included primary graft dysfunction (PGD) score, post-transplant spirometry, acute rejection scores (ARS), and overall survival.

RESULTS

Of 31 donors evaluated, bronchoscopies revealed only 2 with visual evidence of AGM, whereas BALF analysis for bile salts indicated AGM in 14. As such, screening bronchoscopy had a sensitivity of only 7.1%. Visual detection of AGM via bronchoscopy was not associated with any resulting grade of PGD (χ2 = 2.96, P = .23); however, AGM defined by detection of bile salts was associated (χ2 = 7.56, P = .02). Over the first post-transplant year, the corresponding recipients experienced a similar improvement in allograft function (χ2 = 1.63, P = .69), ARS (P = .69), and survival (P = .24).

CONCLUSION

Visual inspection during a single bronchoscopic examination of lung donors underestimates the prevalence of AGM. The detection of bile salts in donor BALF is associated with early allograft dysfunction in the corresponding recipients but not with later allograft proficiency, acute rejection responses, or 1-year post-transplant survival.

Abortion, Brain Death, and Coercion

A "universalist" policy on brain death holds that brain death is death, and neurologic criteria for death determination are rightly applied to all, without exemptions or opt outs. This essay argues that advocates of a universalist brain death policy defend the same sort of coercive control of end-of-life decision-making as "pro-life" advocates seek to achieve for reproductive decision-making, and both are grounded in an illiberal political philosophy. Those who recognize the serious flaws of this kind of public policy with respect to abortion must apply the same logic to brain death.

Standards and Ethics Issues in the Determination of Death: A Position Paper From the American College of Physicians

The determination of a patient's death is of considerable medical and ethical significance. Death is a biological concept with social implications. Acting with honesty, transparency, respect, and integrity is critical to trust in the patient-physician relationship, and the profession, in life and in death. Over time, cases about the determination of death have raised questions that need to be addressed. This American College of Physicians position paper addresses current controversies and supports a clarification to the Uniform Determination of Death Act; maintaining the 2 current independent standards of determining death, cardiorespiratory and neurologic; retaining the whole brain death standard; aligning medical testing with the standards; keeping issues about the determination of death separate from organ transplantation; reaffirming the importance and role of the dead donor rule; and engaging in educational efforts for health professionals, patients, and the public on these issues. Physicians should advocate for policies and practices on the determination of death that are consistent with the profession's fundamental and timeless commitment to individual patients and the public.

Making a dead woman pregnant? A critique of the thought experiment of Anna Smajdor

In a thought-provoking article - or how she herself named it, 'a thought experiment' - the philosopher-medical ethicist Anna Smajdor analyzed in this journal the idea of whole-body gestational donation (WBGD) in brain-dead female patients, as an alternative means of gestation for prospective women who cannot or prefer not to become pregnant themselves. We have serious legal, economical, medical and ethical concerns about this proposal. First, consent for eight months of ICU treatment can never be assumed to be derived from consent for post-mortem organ donation; these two are of an incomparable and entirely different medical and ethical order. Moreover, the brain-dead woman is very likely to be medically unfit for high-tech surrogacy and the brain-dead state poses a high risk for deficient embryo/fetal development. Second, from a scarcity perspective, occupying an ICU bed for eight months appears to be unjust. The costs for eight months of ICU treatment are far too high compared to the costs of surrogacy for a living, selected, and healthy woman. Neither insurance companies nor prospective parents will want to pay these exceptionally high costs for a dead woman if a living surrogate mother can be hired for a considerably lower amount. Third, there is an increased risk for harm of the child to be in WBGD. And finally, WBGD risks violating the brain-dead woman's dignity and harming the interests of her loved ones. In short, there is simply no need for brain-dead women as surrogates.

Extracorporeal cardiopulmonary resuscitation dissemination and integration with organ preservation in the USA: ethical and logistical considerations

Use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary resuscitation, termed eCPR, offers the prospect of improving survival with good neurological function after cardiac arrest. After death, ECMO can also be used for enhanced preservation of abdominal and thoracic organs, designated normothermic regional perfusion (NRP), before organ recovery for transplantation. To optimize resuscitation and transplantation outcomes, healthcare networks in Portugal and Italy have developed cardiac arrest protocols that integrate use of eCPR with NRP. Similar dissemination of eCPR and its integration with NRP in the USA raise novel ethical issues due to a non-nationalized health system and an opt-in framework for organ donation, as well as other legal and cultural factors. Nonetheless, eCPR investigations are ongoing, and both eCPR and NRP are selectively employed in clinical practice. This paper delineates the most pressing relevant ethical considerations and proposes recommendations for implementation of protocols that aim to promote public trust and reduce conflicts of interest. Transparent policies should rely on protocols that separate lifesaving from organ preservation considerations; robust, centralized eCPR data to inform equitable and evidence-based allocations; uniform practices concerning clinical decision-making and resource utilization; and partnership with community stakeholders, allowing patients to make decisions about emergency care that align with their values. Proactively addressing these ethical and logistical challenges could enable eCPR dissemination and integration with NRP protocols in the USA, with the potential to maximize lives saved through both improved resuscitation with good neurological outcomes and increased organ donation opportunities when resuscitation is unsuccessful or not in accordance with individuals' wishes.

Neuropathologic findings in a young woman 4 years following declaration of brain death: case analysis and literature review

Brain death (death by neurologic criteria) is declared in 2% of all in-hospital deaths in the United States. Published neuropathology studies of individuals maintained on cardiorespiratory support are generally decades old, and notably include only 3 cases with long intervals between brain and "somatic" death (68 days, 101 days, 20 years). Here, we share our observations in a young woman supported for nearly 4½ years following declaration of brain death after oropharyngeal surgery. While limited by tissue availability and condition, we found evidence of at least partial perfusion of the superficial cerebral and cerebellar cortices by external carotid and vertebral arteries (via meningeal and posterior pharyngeal branches), characterized by focal cellular reaction and organization. Dural venous sinuses had thrombosis and recanalization, as well as iron deposition. In nonperfused brain areas, tissue "mummification," akin to that seen in certain postmortem conditions, including macerated stillbirths and saponification (adipocere formation), was identified, and are reviewed herein. Unfortunately, correlation with years-earlier clinical and radiographic observations was not possible. Nevertheless, we feel that our careful neuropathologic inspection of this case expands the understanding of the spectrum of human brain tissue alterations possible in a very rarely seen set of conditions.

Increasing Solid Organ Donation: A Role for Emergency Physicians

BACKGROUND

More than 100,000 Americans with failing organs await transplantation, mostly from dead donors. Yet only a fraction of patients declared dead by neurological criteria (DNC) become organ donors.

DISCUSSION

Emergency physicians (EPs) can improve solid organ donation in the following ways: providing perimortem critical care support to potential organ donors, promptly notifying organ procurement organizations (OPOs), asking neurocritical care specialists to evaluate selected emergency department patients for death based on established neurologic criteria, participating in research to advance these developments, implementing automatic OPO notification technologies, and educating the professional and lay communities about organ donation and transplantation, including exploration of opt-out (presumed consent) organ recovery policies.

CONCLUSION

With future improvements in organ preservation and DNC assessment, EPs may become even more involved in the donation process. EPs should support and engage in efforts to promote organ donation and transplantation.

Brain death/death by neurologic criteria determination: an update

PURPOSE OF REVIEW

Brain death, also known as death by neurologic criteria (DNC), is a well-established concept. In this article, we present a short history of the concept and give an overview of recent changes and a practical update on diagnosis and definitions of brain death/DNC. Unresolved issues will be discussed.

RECENT FINDINGS

There is variability in brain death/DNC determination worldwide. In recent years, successful attempts have been made to harmonize these criteria and, consequently, to improve public trust in the process and diagnosis. An international multidisciplinary collaboration has been created and it has published minimum criteria, provided guidance for professionals and encouragement to revise or develop guidelines on brain death/DNC worldwide.

SUMMARY

There are two sets of criteria for declaration of death. First, if there is neither cardiac output nor respiratory effort, then cardiopulmonary criteria are used. Second, if both the cerebrum and brainstem have completely and permanently lost all functions, and there is a persistent coma, absent brainstem reflexes and no spontaneous respiratory effort, death can be declared on the basis of brain death/DNC. Although attempts to formulate uniform criteria are ongoing, consensus has been reached on the minimum criteria. Some inconsistencies and questions remain.

Family Interview Evaluation for Organ Donation: Communication of Death and Information About Organ Donation

BACKGROUND

The aim of this study was to identify variables related to organ donation that can contribute to the development of best practices in planning and conducting family interviews by health professionals.

METHODS

This descriptive and prospective study of quantitative approach was conducted at 2 southern Brazil health institutions referenced in organ donation. Data collection occurred between 2018 and 2019 by health professionals who conduct family interviews using validated instruments that assessed the stages of the interview. Analysis was performed by means of the proportions of the studied variables associated with the donation authorization categories per the χ² test. The significance level adopted was 0.05.

RESULTS

The variables that presented the highest level of significance in the correlation with the prevalence of family authorization for organ donation included the following: communication with the family about the results of each test in the brain death diagnostic protocol; identification of whether the family understood the information about the death; presence of a member of the transplantation commission who had training to communicate information about organ donation; presence of a family member who had power to authorize the donation; and the interval between the communication of death and information about organ donation.

CONCLUSIONS

The study presents important gaps that can be filled by health teams and hospitals in order to improve the welcoming and respect for families, as well as the organ donation rates. It is important to understand that each family is unique when facing mourning, and to distance the communication of death from the discussion about organ donation is an act of respect and empathy.

Organ Donation Decision in Families With Brain-Dead Patients: An Evolutionary Concept Analysis

BACKGROUND AND AIM

Organ donation decision is a complicated process for bereaved families; however, its attributes and associated factors are not clear. Accordingly, the purpose of this study was to analyze the concept of organ donation decision in families with brain-dead patients.

METHODS

Concept analysis was performed using Rodgers' evolutionary method. For this purpose, PubMed, OVID, Scopus, and ProQuest databases were searched in English from 1985 to 2019. In total, 54 articles were analyzed using the thematic analysis to identify the attributes, antecedents, and consequences of the concept. The validity of the data was provided by examining the analysis process by 2 independent researchers.

FINDINGS/CONCLUSIONS

Organ donation decision in these families is a complicated and conflicting process of vicarious decision-making that begins with an organ donation request: a difficult, painful, and critical experience that requires extensive interpersonal interactions and is ultimately influenced by various factors, leading to the acceptance or refusal. The antecedents include deceased-related factors, family-related factors, the quality of organ donation request, and the quality of health care professionals' interactions. The consequences include the positive outcomes (grief solace, gift of life, and promoting human values) and negative outcomes (ambiguity, doubt and regret, and psychological inconsistency). The results of this concept analysis led to a better understanding of the complexity of an organ donation decision in these families. In this way, in addition to knowledge development, it assists the health care staff to support families in making the organ donation decision.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Although case managers rarely participate in organ donation, they definitely need to understand the concepts related to organ donation decision while advocating for the patients or families. The results of this concept analysis can broaden the case managers' and other health care professionals' knowledge about families' organ donation decision and help them take more effective interventions for management of this process. Case managers and the health care team can use the information of this article for informing families about brain death, negotiating with families for organ donation, preparing information, and caring and facilitating the families in making the clear and unconflicted decision.

Brain death and the internet: evaluating the readability and quality of online health information

BACKGROUND

Brain death has been accepted medically and legally as biological death. Nevertheless, it is a difficult concept for the public to understand, resulting in a reliance on online resources for clarity. When the information is inaccurate, misleading, or elusive, the internet could have adverse effects on the public's decision-making. Here we aimed to assess the quality and readability of information regarding brain death on the internet.

METHODS

The five most popular search engines were queried using the keyword 'brain death' and the top 30 websites of each search engine were evaluated. Authorship was classified as medical or public. Gunning Fog Index (GFI) and Flesch Reading Ease Score (FRES) were calculated to analyze readability. The LIDA was used to assess quality.

RESULTS

The overall LIDA score was 60,3%, with a mean score of 60,8%, 60,7%, and 59,3% for accessibility, usability, and reliability, respectively, indicating a moderate level. The accessibility of medical websites (p=0.037) and the reliability of public websites (p=0.031) were found to be significantly weaker. The average FRES was 41,6±14,6 rated as difficult, and the mean GFI was 15,7±3,4, indicating mean readability at "difficult, grade >10".

CONCLUSIONS

Online health information on brain death exceeds the National Institutes of Health recommended reading levels. Our results emphasize the need to establish quality guidelines to improve the comprehensiveness of health website content. Brain death is still a contentious topic; therefore, reliable, and easy-to-read online educational materials can help public understand the concept of brain death and potentially improve the transplant rate.

Brain Death/Death by Neurologic Criteria Determination

PURPOSE OF REVIEW

This article describes the prerequisites for brain death/death by neurologic criteria (BD/DNC), clinical evaluation for BD/DNC (including apnea testing), use of ancillary testing, and challenges associated with BD/DNC determination in adult and pediatric patients.

RECENT FINDINGS

Although death determination should be consistent among physicians and across hospitals, states, and countries to ensure that someone who is declared dead in one place would not be considered alive elsewhere, variability exists in the prerequisites, clinical evaluation, apnea testing, and use of ancillary testing to evaluate for BD/DNC. Confusion also exists about performance of an evaluation for BD/DNC in challenging clinical scenarios, such as for a patient who is on extracorporeal membrane oxygenation or a patient who was treated with therapeutic hypothermia. This prompted the creation of the World Brain Death Project, which published an international consensus statement on BD/DNC that has been endorsed by five world federations and 27 medical societies from across the globe.

SUMMARY

The World Brain Death Project consensus statement is intended to provide guidance for professional societies and countries to revise or develop their own protocols on BD/DNC, taking into consideration local laws, culture, and resource availability; however, it does not replace local medical standards. To that end, pending publication of an updated guideline on determination of BD/DNC across the lifespan, the currently accepted medical standards for BD/DNC in the United States are the 2010 American Academy of Neurology standard for determination of BD/DNC in adults and the 2011 Society of Critical Care Medicine/American Academy of Pediatrics/Child Neurology Society standard for determination of BD/DNC in infants and children.

Organ Procurement From Poisoned Patients: A 14-Year Survey in 2 Academic Centers

OBJECTIVES

Organ transplant from poisoned donors is an issue that has received much attention, especially over the past decade. Unfortunately, there are still opponents to this issue who emphasize that toxins and drugs affect the body's organs and do not consider organs from poisoned donors appropriate for transplantation.

MATERIALS AND METHODS

Cases of brain death due to poisoning were collected from 2 academic centers in Tehran, Iran during a period from 2006 to 2020. Donor information and recipient condition at 1 month and 12 months after transplant and the subsequent transplant success rates were investigated.

RESULTS

From 102 poisoned donors, most were 30 to 40 years old (33.4%) and most were men (55.9%). The most common causes of poisoning among donors were opioids (28.4%). Six candidate donors had been referred with cardiorespiratory arrest; these patients had organs that were in suitable condition, and transplant was successful. Acute kidney injury was seen in 30 donors, with emergency dialysis performed in 23 cases. For 51% of donors, cardiopulmonary resuscitation was performed. The most donated organs were the liver (81.4%), left kidney (81.4%), and right kidney (80.4%). Survival rate of recipients at 1 month and 12 months was 92.5% and 91.4%, respectively. Graft rejection rate at 1 month and 12 months after transplant was 0.7% and 2.21%, respectively.

CONCLUSIONS

Organ donation from poisoning-related brain deaths is one of the best sources of organ supply for people in need. If the organ is in optimal condition before transplant, there are no exclusions for use of the graft.

New perspectives on brain death

Brain death, or death by neurological criteria (BD/DNC), has been accepted conceptually, medically and legally for decades. Nevertheless, some areas remain controversial or understudied, pointing to a need for focused research to advance the field. Multiple recent contributions have increased our understanding of BD/DNC, solidified our practice and provided guidance where previously lacking. There have also been important developments on a global scale, including in low-to-middle income countries such as in South America. Although variability in protocols and practice still exists, new efforts are underway to reduce inconsistencies and better train practitioners in accurate and sound BD/DNC determination. Various legal challenges have required formal responses from national societies, and the American Academy of Neurology has filled this void with much needed guidance. Questions remain regarding concepts such as 'whole brain' versus 'brainstem' death, and the intersection of BD/DNC and rubrics of medical futility. These concepts are the subject of this review.