Variability among hospital policies for determining brain death in adults*

Procedures of brain death diagnosis and organ explantation in a tertiary medical centre - a retrospective eight-year cohort study

AIM OF THE STUDY

To assess the frequency and variables associated with the need for ancillary tests to confirm suspected brain death in adult patients, and to assess the time from brain death to organ explantation in donors. We further sought to identify modifiable factors influencing the time between brain death and start of surgery.

METHODS

Medical records and the Swiss organ allocation system registry were screened for all consecutive adult patients diagnosed with brain death at an intensive care unit of a Swiss tertiary medical centre from 2013 to 2020. The frequency and variables associated with the performance of ancillary tests (i.e., transcranial doppler, digital subtraction angiography, and computed tomography angiography) to confirm brain death were primary outcomes; the time from death to organ explantation as well as modifying factors were defined as secondary outcomes.

RESULTS

Among 91 patients with a diagnosis of brain death, 15 were not explanted and did not undergo further ancillary tests. Of the remaining 76 patients, who became organ donors after brain death, ancillary tests were performed in 24%, most frequently in patients with hypoxic-ischaemic encephalopathy. The leading presumed causes of death (not mutually exclusive) were haemorrhagic strokes (49%), hypoxic-ischaemic encephalopathies (33%) and severe traumatic brain injuries (22%). Surgery for organ explantation was started within a median of 16 hours (interquartile range [IQR] 13-18) after death with delay increasing over time (nonparametric test for trend p = 0.05), mainly due to organ allocation procedures. Patients with brain death confirmed during night shifts were explanted earlier (during night shifts 14.3 hours, IQR 11.8-16.8 vs 16.3 hours, IQR 13.5-18.5 during day shifts; p = 0.05).

CONCLUSIONS

Ancillary tests to confirm brain death are frequently performed, mainly in resuscitated patients. The delay to surgery for organ explantation after confirmed brain death was longer during day shifts, increased over time and was mainly determined by organ allocation procedures.

Exclusive color-coded duplex sonography of extracranial vessels reliably confirms brain death: A prospective study

Background

Transcranial color-coded duplex sonography (TCCD) can be used as an ancillary test for determining irreversible loss of brain function (ILBF) when demonstration of cerebral circulatory arrest (CCA) is required. However, visualization of the intracranial vessels by TCCD is often difficult, or even impossible, in this patient cohort due to elevated intracranial pressure, an insufficient transtemporal bone window, or warped anatomical conditions. Since extracranial color-coded duplex sonography (ECCD) can be performed without restriction in the aforementioned situations, we investigated the feasibility of omitting TCCD altogether, such that the ILBF examination would be simplified, without compromising on its reliability.

Methods

A total of 122 patients were prospectively examined by two experienced neurointensivists for the presence of ILBF from 01/2019-12/2021. Inclusion criteria were (i) the presence of a severe cerebral lesion on cranial CT or MRI, and (ii) brainstem areflexia. Upon standardized clinical examination, 9 patients were excluded due to incomplete brainstem areflexia, and a further 22 due to the presence of factors with a potentially confounding influence on apnea testing, EEG or sonography. A total of 91 patients were enrolled and underwent needle-EEG recording for >30 min (= gold standard), as well as ECCD and TCCD. The sonographer was blinded to the EEG result.

Results

All patients whose ECCD result was consistent with ILBF had this diagnosis confirmed by EEG (n = 77; specificity: 1). Both ECCD and EEG were not consistent with ILBF in a further 12 patients. In the remaining two patients, ECCD detected reperfusion due to long-lasting cerebral hypoxia; however, ILBF was ultimately confirmed by EEG (sensitivity: 0.975). This yielded a positive predictive value (PPV) of one and a negative predictive value of 0.857 for the validity of ECCD in ILBF confirmation. TCCD was not possible/inconclusive in 31 patients (34%).

Conclusions

The use of ECCD for the confirmation of ILBF is associated with high levels of specificity and a high positive predictive value when compared to needle-electrode EEG. This makes ECCD a potential alternative to the ancillary tests currently used in this setting, but confirmation in a multi-center trial is warranted.

Trial registration

https://www.drks.de, DRKS00017803.

Variability in Pediatric Brain Death Determination Protocols in the United States

OBJECTIVE

To determine the variability in pediatric death by neurologic criteria (DNC) protocols between US pediatric institutions and compared to the 2011 DNC guidelines.

METHODS

In this cross-sectional study of DNC protocols obtained from pediatric institutions in the United States via regional organ procurement organizations, protocols were evaluated across 5 domains: general DNC procedures, prerequisites, neurologic examination, apnea testing, and ancillary testing. Descriptive statistics compared protocols to each other and the 2011 guidelines.

RESULTS

A total of 130 protocols were analyzed with 118 dated after publication of the 2011 guidelines. Of those 118 protocols, identification of a mechanism of irreversible brain injury was required in 97%, while 67% required an observation period after acute brain injury before DNC evaluation. Most protocols required guideline-based prerequisites such as exclusion of hypotension (94%), hypothermia (97%), and metabolic derangements (92%). On neurologic examination, 91% required a lack of responsiveness, 93% no response to noxious stimuli, and 99% loss of brainstem reflexes. A total of 84% of protocols required the guideline-recommended 2 apnea tests. CO2 targets were consistent with guidelines in 64%. Contrary to guidelines, 15% required ancillary testing for all patients and 15% permitted ancillary studies that are not validated in pediatrics.

CONCLUSION

Variability exists between pediatric institutional DNC protocols in all domains of DNC determination, especially with respect to apnea and ancillary testing. Better alignment of DNC protocols with national guidelines may improve the consistency and accuracy of DNC determination.

Misinterpretations of Guidelines Leading to Incorrect Diagnosis of Brain Death: A Case Report and Discussion

Guidelines describe the process necessary for the diagnosis of brain death. We present a case of a 3-month-old former 36-week-gestation infant after a prolonged out-of-hospital cardiac arrest of 37 minutes who was clinically diagnosed as brain dead at 120 hours after the event. Unusual findings included a normal slightly sunken anterior fontanelle, normal cerebral blood flow perfusion scan at 73 hours after the event, only localized parieto-temporal edema on the latest computed tomographic (CT) scan of the brain at 48 hours after the event, and discussion of whether nonconvulsive seizures could have confounded the examination for brain death. In light of these unusual findings, we discuss and highlight what may be common misinterpretations of brain death guidelines that led to the mistaken diagnosis of death (as opposed to severe neurologic injury) in this child.

Opinions on the Legitimacy of Death Declaration by Neurological Criteria from the Perspective of 3 Abrahamic Faiths

Traditional criteria to identify death may not fit all circumstances. This manuscript explores religious jurisprudence to ascertain whether death declaration by neurological criteria (DDNC) is accepted as a valid method by 3 Abrahamic religious traditions ie. Islam, Judaism, and Catholicism. Among Islamic sources (order of primacy), neither the Qur'an, Sunnah as reported in Hadith, Ijma' (scholarly consensus), nor Qiyas (precedent-based analogy) clearly describe death determination criteria. Through Ijtihad (lowest level of Shari 'ah), 5 of 6 identified non-binding fatwa support DDNC. Faith-based medical organizations are divided. Eleven of 13 surveyed Muslim-majority countries have laws supporting DDNC. Concern exists that premature death declaration could violate the Shari'ah concept of Hifz-An-nafs (saving life). As such, DDNC remains debated in Islamic circles. Among the 3 main sources of Jewish law (Halacha), the Torah (oral and written) does not clearly define death declaration criteria. Although Talmudic interpretations of Misnah Oholot 1:6 and Gamara Hullin 21a suggest a possible justification for death determination using neurologic criteria in some conditions, the bulk of mitzvot d'rabbanan (Rabbinic Law) rejects DDNC and adheres to cardiorespiratory criteria. Lastly, Catholic Church Cannon Law and the Holy Scripture recorded in Bible does not define death determination criteria. Following the Council of Vienne, Saint Thomas's loss of integration view has predominated. In 2000, Pope John Paul II expressed tentative and qualifid support for DDNC, however the topic remains controversial. Despite dissenting opinions in each faith, DDNC is currently accepted as valid by many Muslims and Catholics, while rejected by Judaism.

What to exclude when brain death is suspected

BACKGROUND

With advances in critical care and organ donation, diagnosis of brain death is gaining importance. We aimed to assess potential brain death confounders from the literature, elucidating clinical presentation and diagnostic approaches in these cases.

METHODS

PubMed and Embase were screened using 37 predefined search terms to identify suitable articles reporting cases, case series, or cohort studies in adults.

RESULTS

Out of 4769 articles, 40 case reports or case series describing 45 patients with 19 critical conditions were identified. Mortality was 11% and full recovery 33%. Intoxications (42%; mainly anti-seizure drugs and baclofen) and polyneuritis (37%) were most frequent. Brainstem reflex tests were reported in 96%, apnoea test in 16% and ancillary tests in all but one patient. Full recovery mainly occurred with intoxications. Quality of evidence regarding frequency of confounders is very low and risk of bias high.

CONCLUSIONS

Brain death confounders are infrequently reported and formal studies are lacking. Mainly younger patients with polyneuritis and intoxications are described. As outcome, especially in the latter, is often favourable, high awareness and strict adherence to guidelines is crucial. The importance of identifying pathologies compatible with extensive and irreversible brain damage before proceeding to diagnostic tests should be emphasized.

Brain ultrasonography: methodology, basic and advanced principles and clinical applications. A narrative review

Brain ultrasonography can be used to evaluate cerebral anatomy and pathology, as well as cerebral circulation through analysis of blood flow velocities. Transcranial colour-coded duplex sonography is a generally safe, repeatable, non-invasive, bedside technique that has a strong potential in neurocritical care patients in many clinical scenarios, including traumatic brain injury, aneurysmal subarachnoid haemorrhage, hydrocephalus, and the diagnosis of cerebral circulatory arrest. Furthermore, the clinical applications of this technique may extend to different settings, including the general intensive care unit and the emergency department. Its increasing use reflects a growing interest in non-invasive cerebral and systemic assessment. The aim of this manuscript is to provide an overview of the basic and advanced principles underlying brain ultrasonography, and to review the different techniques and different clinical applications of this approach in the monitoring and treatment of critically ill patients.

Brain death and postmortem organ donation: report of a questionnaire from the CENTER-TBI study

Background

We aimed to investigate the extent of the agreement on practices around brain death and postmortem organ donation.

Methods

Investigators from 67 Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study centers completed several questionnaires (response rate: 99%).

Results

Regarding practices around brain death, we found agreement on the clinical evaluation (prerequisites and neurological assessment) for brain death determination (BDD) in 100% of the centers. However, ancillary tests were required for BDD in 64% of the centers. BDD for nondonor patients was deemed mandatory in 18% of the centers before withdrawing life-sustaining measures (LSM). Also, practices around postmortem organ donation varied. Organ donation after circulatory arrest was forbidden in 45% of the centers. When withdrawal of LSM was contemplated, in 67% of centers the patients with a ventricular drain in situ had this removed, either sometimes or all of the time.

Conclusions

This study showed both agreement and some regional differences regarding practices around brain death and postmortem organ donation. We hope our results help quantify and understand potential differences, and provide impetus for current dialogs toward further harmonization of practices around brain death and postmortem organ donation.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2241-4) contains supplementary material, which is available to authorized users.

Investigation of Public Perception of Brain Death Using the Internet

BACKGROUND

Brain death is a difficult concept for the public to comprehend, resulting in a reliance on alternative resources for clarity. This study aims to understand the public's perception of brain death via analysis of information on the Internet, determine the accuracy of that information, and understand how its perception affects the physician-patient relationship.

METHODS

We conducted a prospective cross-sectional study to evaluate information available to the public about brain death. The top 10 Google websites were analyzed for language complexity and accuracy in describing brain death. The top 10 YouTube videos were examined for content and the comments qualitatively analyzed for themes.

RESULTS

Inaccuracies describing brain death inconsistent with national guidelines were prevalent amongst 4 of 10 Google websites, 6 of 10 YouTube videos, and 80% of YouTube comments. On average, Google websites were written at a 12th grade level and 90% mentioned organ donation. Videos were frequently emotional (78%); 33% included negative comments toward physicians, of which 50% mentioned organ donation. All videos included clarification comments questioning the differences between brain death, death, coma, and persistent vegetative states.

CONCLUSIONS

The study revealed a significant amount of inaccurate information about brain death, affecting the public's understanding of the concept of brain death and resulting in negative emotions specifically toward physicians, and the link between brain death and organ donation. The medical community can improve understanding through consistent, simplified language, dissociating brain death from organ donation, and recognizing the emotions tied to discussions of brain death.

An institutional study of awareness of brain-death declaration among resident doctors for cadaver organ donation

Background and Aims:

Brain death is defined as irreversible and complete cessation of all brain function including that of the brainstem. The aim of this study was to assess the level of knowledge and awareness about brain-death declaration among resident doctors.

Methods:

This was an observational questionnaire-based study conducted in single institute in which 112 junior residents and 46 senior resident doctors in various medical specialities were included by universal sampling method. A prevalidated questionnaire consisting of questions related to knowledge, attitude and performance of brain-death declaration were distributed among residents as per the inclusion criteria to fill in the time limit of 30 min. Statistical tools used were mean and standard deviation, proportion and Chi-square test.

Results:

A total 87 resident doctors consisting of 71.26% males and 28.73% females responded to the questionnaire. About 91.95% correctly defined it as complete cessation of brain activity including brainstem reflexes. Most of the resident doctors (80.45%) knew about the documentation of absence of brainstem reflexes at 6 h intervals and 64.36% were aware about positive apnoea test. When asked about whether there is legal sanction for disconnecting life support in India, 56.32% said no, and 43.67% said yes. Only 12.64% of resident doctors were aware about a panel of 4 physicians are mandatory to declare brain death in India.

Conclusion:

Awareness and attitude towards the identification of brain death and possible deceased donor organ transplantation were lacking amongst resident doctors.

Observations on the Ethical and Social Aspects of Disorders of Consciousness

The care of chronically unconscious patients raises vexing medical, ethical, and social questions concerning diagnosis, prognosis, communication with family members, and decision making, including the withdrawal of life support. We provide updates on major controversies surrounding disorders of consciousness. Issues such as withdrawal of artificial nutrition and hydration – which had been considered “settled” by many in the medical, legal and ethical communities – have resurfaced under the pressure of social groups and religious authorities. Some assumptions about the level of awareness and the prognosis of vegetative state and minimal conscious patients are questioned by advances in clinical care because of insights produced by neuroscience research techniques, particularly functional neuroimaging. Both the clinical and neuroscience dimensions of disorders of consciousness raise complex issues such as resource allocation and high levels of diagnostic inaccuracies (at least, for the vegetative state). We conclude by highlighting areas needing further research and collaboration.

Radionuclide Evaluation of Brain Death in the Post-McMath Era

The pronouncement of death is a determination of paramount social, legal, and ethical import. The novel construct of "brain death" was introduced 50 years ago, yet there persist gaps in understanding regarding this diagnosis on the part of medical caregivers and families. The tragic, much-publicized case of Jahi McMath typifies potential problems that can be encountered with this diagnosis and serves as an effective point of departure for discussion. This article recapitulates the historical development of brain death and the evolution of scintigraphic examinations as ancillary or confirmatory studies, emphasizing updated clinical and imaging practice guidelines and the current role of scintigraphy. The limitations of clinical and radionuclide studies are then reviewed. Finally, the article examines whether radionuclide examinations might be able to play an expanded role in the determination of brain death by improving accuracy and facilitating effective communication with family members.

A Comparison of Brain Death Criteria between China and the United States

BACKGROUND

Criteria for determining brain death (BD) vary between China and the United States. We reported the results of an investigation designed to compare procedures to determine BD in two countries.

METHODS

The latest criteria in the United states were published in 2010. The latest criteria in China were published in 2009. We used these two types of BD criteria to evaluate patients who were considered to be BD. The time, cost, and accuracy of the diagnosis were compared.

RESULTS

From January 1, 2012 to October 8, 2013, there were 37 patients which were applied for BD evaluation in the Neurological Intensive Care Unit of Beijing Tiantan Hospital. The cause of coma were known as subarachnoid hemorrhage (18 patients, 48.6%), intracerebral hemorrhage (8 patients, 21.6%), cerebral ischemia (9 patients, 24.3%), brain stem tumor (1 patient, 2.7%), and intracranial infection (1 patient, 2.7%). The clinical examinations were done for all of the patients except 1 patient who had low blood pressure. Three patients had brainstem reflexes that were excluded from BD. Twenty-five patients had apnea tests, and 20 tests were completed that were all positive. Confirmatory tests were completed differently: Transcranial Doppler (30 patients, positive rate 86.7%), electroencephalogram (25 patients, positive rate 100%), and somatosensory evoked potential (16 patients, positive rate 100%). Thirty-three patients were diagnosed BD by criteria of the United States. Only 9 patients were diagnosed BD by Chinese criteria. The use of time and money in the USA criteria was obviously fewer than those in Chinese criteria (P = 0.000).

CONCLUSION

Compared with BD criteria of the United States, Chinese criteria were stricter, lower positive rate, more cost in money and time, and more reliable by families and doctors.

Opinions on the Legitimacy of Brain Death Among Sunni and Shi'a Scholars

The concept of brain death poses a great challenge to clinicians who may be required to bridge the interface of culture, religion, law, and medicine. This review discusses and applies Islamic jurisprudence to the question of whether brain death is accepted as true death under Islamic law. Among the five sources of Islamic law, the Qur'an and Sunnah do not directly address brain death. Scholarly consensus (Ijmā') does not exist, and Qiya does not apply. When applying Ijtihad, the identified collection of non-binding fatwā offer conflicting results. Debate continues as to the validity of brain-death criteria within Islamic circles.

Intensive care practices in brain death diagnosis and organ donation

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).

Brain death and Islam: the interface of religion, culture, history, law, and modern medicine

How one defines death may vary. It is important for clinicians to recognize those aspects of a patient's religious beliefs that may directly influence medical care and how such practices may interface with local laws governing the determination of death. Debate continues about the validity and certainty of brain death criteria within Islamic traditions. A search of PubMed, Scopus, EMBASE, Web of Science, PsycNet, Sociological Abstracts, DIALOGUE ProQuest, Lexus Nexus, Google, and applicable religious texts was conducted to address the question of whether brain death is accepted as true death among Islamic scholars and clinicians and to discuss how divergent opinions may affect clinical care. The results of the literature review inform this discussion. Brain death has been acknowledged as representing true death by many Muslim scholars and medical organizations, including the Islamic Fiqh Academies of the Organization of the Islamic Conference and the Muslim World League, the Islamic Medical Association of North America, and other faith-based medical organizations as well as legal rulings by multiple Islamic nations. However, consensus in the Muslim world is not unanimous, and a sizable minority accepts death by cardiopulmonary criteria only.

Brainstem death: A comprehensive review in Indian perspective

With the advent of cardiopulmonary resuscitation techniques, the cardiopulmonary definition of death lost its significance in favor of brain death. Brain death is a permanent cessation of all functions of the brain in which though individual organs may function but lack of integrating function of the brain, lack of respiratory drive, consciousness, and cognition confirms to the definition that death is an irreversible cessation of functioning of the organism as a whole. In spite of medical and legal acceptance globally, the concept of brain death and brain-stem death is still unclear to many. Brain death is not promptly declared due to lack of awareness and doubts about the legal procedure of certification. Many brain dead patients are kept on life supporting systems needlessly. In this comprehensive review, an attempt has been made to highlight the history and concept of brain death and brain-stem death; the anatomical and physiological basis of brain-stem death, and criteria to diagnose brain-stem death in India.

The implementation of a protocol promoting the safe practice of brain death determination

PURPOSE

The purpose of the study is to describe the implementation of measures introduced in Israel in 2009 to promote the safe practice of brain death determination (BDD).

MATERIALS AND METHODS

The measures require (1) physicians to undergo a mandatory training course, (2) the mandatory performance of an ancillary test, and (3) retrospective examination of all BDD forms by an independent committee. Any deviations from practice parameters were noted. Surveys were also undertaken to assess (i) the attitude of local physicians to the measures and (ii) whether similar measures are in place in Europe and whether they were considered necessary.

RESULTS

After implementation, the measures resulted in the absence of deviations from practice parameters over time. A majority of local physician (n = 64) felt the measures added a sense of security to BDD (73%) and ensured its proper performance (85%). The European survey (n = 20 countries) revealed (1) specialized BDD training is required in 60%, provided in 50%, while felt necessary by 80%; (2) independent supervision of BDD is performed in only one other country; and (3) BDD is performed country-wide using the same criteria in 80% while felt necessary by 95%.

CONCLUSION

The measures were successfully implemented, reduced diversity in patient testing, and positively accepted by local physicians. Wider application of the measures may be appropriate as suggested by the results of a European survey and the variability of BDD reported in the literature.

Is the presence of medical trainees associated with increased mortality with weekend admission?

BACKGROUND

Several studies have demonstrated increased inhospital mortality following weekend admission. We hypothesized that the presence of resident trainees reduces the weekend mortality trends.

METHODS

We identified all patients with a non-elective hospital admission from 1/1/2003 through 12/31/2008. We abstracted vital status on discharge and calculated the Charlson comorbidity score for all inpatients. We compared odds of inpatient mortality following non-elective admission on a weekend day as compared to a weekday, while considering diagnosis, patient characteristics, comorbidity, hospital factors, and care at hospitals with resident trainees.

RESULTS

Data were available for 48,253,968 patient discharges during the six-year study period. The relative risk of mortality was 15% higher following weekend admission as compared to weekday admission. After adjusting for diagnosis, age, sex, race, income level, payer, comorbidity, and weekend admission the overall odds of mortality was higher for patients in hospitals with fewer nurses and staff physicians. Mortality following a weekend admission for patients admitted to a hospital with resident trainees was significantly higher (17%) than hospitals with no resident trainees (p < 0.001).

CONCLUSIONS

Low staffing levels of nurses and physicians significantly impact mortality on weekends following non-elective admission. Conversely, patients admitted to hospitals with more resident trainees had significantly higher mortality following a weekend admission.

Brain Death Determination

In the United States, each year 1% to 2% of deaths are brain deaths. Considerable variation in the practice of determining brain death still remains, despite the publication of practice parameters in 1995 and an evidence-based guideline update in 2010. This review is intended to give bedside clinicians an overview of definition, the causes and pitfalls of misdiagnosing brain death, and a focus on the specifics of the brain death determination process.

The degree of certainty in brain death: probability in clinical and Islamic legal discourse

The University of Michigan conference "Where Religion, Policy, and Bioethics Meet: An Interdisciplinary Conference on Islamic Bioethics and End-of-Life Care" in April 2011 addressed the issue of brain death as the prototype for a discourse that would reflect the emergence of Islamic bioethics as a formal field of study. In considering the issue of brain death, various Muslim legal experts have raised concerns over the lack of certainty in the scientific criteria as applied to the definition and diagnosis of brain death by the medical community. In contrast, the medical community at large has not required absolute certainty in its process, but has sought to eliminate doubt through cumulative diagnostic modalities and supportive scientific evidence. This has recently become a principal model, with increased interest in data analysis and evidence-based medicine with the intent to analyze and ultimately improve outcomes. Islamic law has also long employed a systematic methodology with the goal of eliminating doubt from rulings regarding the question of certainty. While ample criticism of the scientific criteria of brain death (Harvard criteria) by traditional legal sources now exists, an analysis of the legal process in assessing brain death, geared toward informing the clinician's perspective on the issue, is lacking. In this article, we explore the role of certainty in the diagnostic modalities used to establish diagnoses of brain death in current medical practice. We further examine the Islamic jurisprudential approach vis-à-vis the concept of certainty (yaqīn). Finally, we contrast the two at times divergent philosophies and consider what each perspective may contribute to the global discourse on brain death, understanding that the interdependence that exists between the theological, juridical, ethical, and medical/scientific fields necessitates an open discussion and active collaboration between all parties. We hope that this article serves to continue the discourse that was successfully begun by this initial interdisciplinary endeavor at the University of Michigan.

Brain death in Canadian PICUs: demographics, timing, and irreversibility

OBJECTIVES

To determine any discordance between first and second brain death examinations and investigate the quality of brain death determination in Canadian PICUs.

DESIGN

Multicenter retrospective chart review.

SETTING

Four Canadian PICUs.

PATIENTS

All deaths from 1999 to 2003 were screened. Patients included were 36 wks corrected gestation to 17 yrs old and had at least one brain death examination documented in the chart.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Medical records were reviewed to determine demographics, results of the brain death examinations, ancillary tests, and time intervals between injury event, fixed dilated pupils, first brain death examination, second brain death examination, and terminal event. Discordance between brain death examinations was defined as the medical conclusion documented in the chart as brain death followed by no brain death. Prespecified subgroups were age <1 yr vs. ≥ 1 yr and organ donor vs. nonorgan donor. Mann-Whitney-Wilcoxon and unpaired t tests compared time intervals between subgroups; p value ≤ 0.05 was considered significant. Of those screened, 135 of 907 (15%) met the study eligibility criteria and 110 of 135 (81%) had at least two brain death examinations. The prevalence of discordance between brain death examinations was 1 of 110 (0.91%) (95% confidence interval <0.01%-5.5%). In those who had two apnea tests, the prevalence of discordance between brain death examinations was 1 of 63 (1.6%) (95% confidence interval <0.01%-9.3%). Twenty-five (19%) patients had only one brain death examination, and one of these became an organ donor without ancillary testing. Twenty-four (18%) patients did not have an apnea test. Of the 48 (36%) who had only one apnea test, 16 became organ donors without any ancillary test. Patients <1 yr old had a longer time interval between the first and second brain death examinations than those >1 yr old.

CONCLUSIONS

Some brain death diagnoses were not based on two examinations, and some did not include an apnea test. In patients who had two brain death examinations, discordant results were uncommon.

Scintigraphic confirmation of brain death

The concept of brain death has gained importance in the past few decades to prevent futile attempts to sustain ventilation and blood circulation when the brain has lost all function and to procure beneficial tissues or life-saving organs for transplantation. However, differences remain among professional societies and various study group recommendations, as well as among individual legal statutes, in how brain death is defined and the methodology for which the diagnosis is attained. Furthermore, reports have appeared both in the medical literature and the lay press concerning quality assurance measures in brain death documentation. Scintigraphy is a commonly used technique in the evaluation of brain death and can be performed with the use of either nonspecific tracers, such as Tc99m diethylene triamine pentaacetic acid, or brain-specific tracers, such as Tc99m hexamethylpropyleneamineoxime (HMPAO). Planar imaging, with or without radionuclide angiography, continues to be the mainstay for the scintigraphic confirmation of brain death. Flow with multiprojection static planar imaging with the use of Tc99m HMPAO can be used to evaluate the cerebral hemispheres, basal ganglia, thalamus, and cerebellum. Single-photon emission computed tomography (SPECT) can provide cross-sectional information but can be difficult to perform in the context of brain death. The current use of SPECT primarily is supplemental to help differentiate overlying scalp from intracerebral activity. The reliability of SPECT to exclude flow and metabolism in the brainstem remains to be scientifically validated.

Survey of determination of death after cardiac arrest by intensive care physicians

OBJECTIVE

The controversy regarding death determination in the context of organ donation after cardiocirculatory death requires investigation. We sought to describe the manner in which Canadian adult and pediatric intensive care physicians report death determination after cardiac arrest.

DESIGN

Pilot-tested paper survey.

SETTING

Mail out between June and November 2009.

SUBJECTS

Canadian adult and pediatric intensive care physicians.

INTERVENTION

Paper-based survey.

MAIN RESULTS

Forty-nine percent of 501 Canadian intensive care physicians responded. Eighty-five percent practiced in tertiary care, university-affiliated centers, and 26% were from pediatric centers. Physicians had a median of 10 yrs (range 0-35) experience. Physicians reported that they performed determination of death after cardiac arrest a median of seven (range 0-60) times per year. Of 11 tests or procedures used, the absence of heart sounds by auscultation, palpable pulse, and breath sounds were the most common, although there was high variability in practice. No diagnostic test/procedure was uniformly performed or omitted. Sixty-five percent of respondents believed autoresuscitation exists and 37% of physicians reported to have seen a possible case during their career. Forty-eight percent had formal training for determining death after cardiac arrest and 22% used guidelines. The majority of respondents agreed that standardized methods for determination of death after cardiac arrest are required in general (69%) and specifically for donation after cardiocirculatory death (91%).

CONCLUSIONS

Intensive care physicians in Canada report: 1) variability in the practice of determining death after cardiac arrest; 2) the existence of autoresuscitation; and 3) a need for standardization of practice. The results of this survey support the need to develop more robust education, guidelines, and standards for the determination of death after cardiac arrest, in general, as well as within the context of donation after cardiocirculatory death.

Neurologic determination of death

Death determined by neurologic criteria or brain death is better understood as brain arrest or the final clinical expression of complete and irreversible neurologic failure. Despite widespread national, international, and legal acceptance of the concept, substantial variation exists in the standards and their application, and there remains a need to clarify and standardize terminology (eg, ancillary and supplementary testing, brain death, or neurologic determination of death). The aim of this article is to review the specific criteria and requirements of brain death, paying special attention to areas of controversy and practice inconsistency.

Do admissions and discharges to long-term care facilities influence hospital burden of Clostridium difficile infection?

BACKGROUND

Substantial geographical clustering of Clostridium difficile infection (CDI) outbreaks in hospitals in the USA have previously been demonstrated.

AIM

To test the hypothesis that hospital burden of CDI is associated with admission from and discharge to long-term care facilities (LTCFs).

METHODS

Hospital discharge data from 19 states in the USA were used to identify all patients discharged with a diagnosis of CDI from 1 January 2002 to 31 December 2004. For every hospital, the proportion of discharges with a diagnosis of CDI was calculated, and those above the 90th percentile were classified as 'high CDI' hospitals. We tested the association between this measure of hospital burden of CDI and the rates of admission from and discharges to LTCFs. We adjusted for other hospital level characteristics, case-complexity and local population characteristics.

FINDINGS

We identified 38,372,951 discharges during the three-year study period. Of all discharges, 274,311 (0.71%) had a primary or secondary diagnosis of CDI. Hospitals had a mean CDI burden of 7.8 cases per 1000 discharges. High CDI hospitals (N = 610; 10.0%) had a mean CDI burden of 34.8 cases per 1000 discharges. Compared to other hospitals, high CDI hospitals were more likely to have a high proportion of admissions from or discharges to LTCFs. This association persisted after adjustments for other hospital characteristics, case-complexity, and area population characteristics.

CONCLUSION

A high rate of admission from or discharge to LTCFs is associated with an increased hospital burden of CDI.

Challenges in organ transplantation

Organ transplantation has progressed tremendously with improvements in surgical methods, organ preservation, and pharmaco-immunologic therapies and has become a critical pathway in the management of severe organ failure worldwide. The major sources of organs are deceased donors after brain death; however, a substantial number of organs come from live donations, and a significant number can also be obtained from non-heart-beating donors. Yet, despite progress in medical, pharmacologic, and surgical techniques, the shortage of organs is a worldwide problem that needs to be addressed internationally at the highest possible levels. This particular field involves medical ethics, religion, and society behavior and beliefs. Some of the critical ethical issues that require aggressive interference are organ trafficking, payments for organs, and the delicate balance in live donations between the benefit to the recipient and the possible harm to the donor and others. A major issue in organ transplantation is the definition of death and particularly brain death. Another major critical factor is the internal tendency of a specific society to donate organs. In the review below, we will discuss the various challenges that face organ donation worldwide, and particularly in Israel, and some proposed mechanisms to overcome this difficulty.

A critique of the apneic oxygenation test for the diagnosis of "brain death"

OBJECTIVE

To determine the reliability and safety of the apneic oxygenation test to diagnose brain death for the purpose of organ donation.

DATE SOURCES

Published scientific literature in Medline database, organ donation guidelines and neurophysiological principles described in medical textbooks.

STUDY SELECTION

Articles on brain death, apnea testing, and radionuclide scintigraphy.

DATA EXTRACTION AND SYNTHESIS

Hypercarbia with a target Paco2 of 60 mm Hg (8.0 kPa) must be reached before apnea is deemed consistent with brain death in some clinical guidelines, whereas a level of 50 mm Hg (6.7 kPa) is required in another. However, the sensitivity and specificity of the test are doubtful because some patients have commenced spontaneous respiration >60 mm Hg (8.0 kPa) and high levels of Paco2 may cause CO2 narcosis. Furthermore, the test may be harmful if the brain stem is responsive because hypercarbia may also cause intracranial hypertension and contribute to brain damage. Although guidelines for organ donation recommend the test as an essential component of brain death diagnosis, it is often not performed or performed inadequately. Wide variation in conduct of the test has prompted calls for standardization.

CONCLUSIONS

: The apneic oxygenation test is unreliable in the diagnosis of brain death. It is scientifically flawed and hypothesized to cause brain death. In lieu of this test, a reliable test of brain perfusion should be mandatory, whereas the apneic oxygenation test, if performed at all, should be restricted to demonstration of apnea after brain perfusion has been shown to be absent.

Extubation versus tracheostomy in withdrawal of treatment-ethical, clinical, and legal perspectives

The provision of life-sustaining ventilation, such as tracheostomy to critically ill patients, is commonly performed. However, the utilization of tracheostomy or extubation after a withdrawal of treatment decision is debated. There is a dearth of practical information available to aid clinical decision making because withdrawal of treatment is a challenging scenario for all concerned. This is further complicated by medicolegal and ethical considerations. Care of the "hopelessly ill" patient should be based on daily evaluation and comfort making it impossible to fit into general algorithms. Although respect for autonomy is important in healthcare, it is limited for patients in an unconscious state. Beneficence remains the basis for withdrawing treatment in futile cases and underpins the "doctrine of double effect." This article presents a relevant clinical case of hypoxic brain injury where a question of withdrawal of treatment arose and examines the ethical, clinical, and medicolegal considerations inherent in such cases, including beneficence, nonmaleficence, and the "sanctity of life doctrine." In addition, the considerations of prognosis for recovery, patient autonomy, patient quality of life, and patient family involvement, which are central to decision making, are addressed. The varying legal frameworks that exist internationally regarding treatment withdrawal are also described. Good ethics needs sound facts, and despite the lack of legal foundation in several countries, withdrawal of treatment remains practiced, and the principles described within this article aim to aid clinician decision making during such complex and multifaceted end-of-life decisions.

Variability in pediatric brain death determination and documentation in southern California

OBJECTIVES

Because the concept of brain death is difficult to define and to apply, we hypothesized that significant variability exists in pediatric brain death determination and documentation.

METHODS

Children (0-18 years of age) for whom death was determined with neurologic criteria between January 2000 and December 2004, in southern California, were included. Medical charts were reviewed for documented performance of 14 specific elements derived from the 1987 brain death guidelines and confirmatory testing.

RESULTS

A total of 51.2% of children (142 of 277 children) referred to OneLegacy became organ donors. Care locations varied, including PICUs (68%), adult ICUs (29%), and other (3%). One patient was <7 days, 6 were 7 days to 2 months, 22 were 2 months to 1 year, and 113 were >1 year of age. The number of brain death examinations performed was 0 (4 patients), 2 (122 patients), 3 (14 patients), or 4 (2 patients). Recommended intervals between examinations were followed for 18% of patients >1 year of age and for no younger patients. A mean of only 5.5 of 14 examination elements were completed by neurologists and pediatric intensivists and 5.8 by neurosurgeons. No apnea testing was recorded in 60% of cases, and inadequate PaCO(2) increase occurred in more than one half. Cerebral blood flow determination was performed as a confirmatory test 74% of the time (83 of 112 cases), compared with 26% (29 of 112 cases) for electroencephalography alone.

CONCLUSIONS

Children suffering brain death are cared for in various locations by a diverse group of specialists. Clinical practice varies greatly from established guidelines, and documentation is incomplete for most patients. Physicians rely on cerebral blood flow measurements more than electroencephalography for confirmatory testing. Codifying clinical and testing criteria into a checklist could lend uniformity and enhance the quality and rigor of this crucial determination.

Predictors of Clostridium difficile colitis infections in hospitals

Hospital-level predictors of high rates of 'Clostridium difficile-associated disease' (CDAD) were evaluated in over 2300 hospitals across California, Arizona, and Minnesota. American Hospital Association data were used to determine hospital characteristics associated with high rates of CDAD. Significant correlations were found between hospital rates of CDAD, common infections and other identified pathogens. Hospitals in urban areas had higher average rates of CDAD; yet, irrespective of geographic location, hospital rates of CDAD were associated with other infections. In addition, hospitals with 'high CDAD' rates had slower turnover of beds and were more likely to offer transplant services. These results reveal large differences in rates of CDAD across regions. Hospitals with high rates of CDAD have high rates of other common infections, suggesting a need for broad infection control policies.

Variability in hospital-based brain death guidelines in Canada

PURPOSE

Variability has been reported in the practices to determine death by neurological criteria for adults and children. The objective of this study was to determine if this variability exists in the Canadian context.

METHODS

A cross-sectional survey of the Canadian intensive care units (ICUs) involved in the care of potential organ donors, and Canadian organ procurement organizations (OPOs) was undertaken. We contacted the medical directors of these units and asked them to provide their guidelines for the neurological determination of death (NDD). A framework, which identifies key diagnostic criteria for NDD, was used to assess the content of all study documents.

RESULTS

With a response rate of 68%, we found that key diagnostic criteria for NDD were incorporated inconsistently in the guidelines from Canadian ICUs and OPOs. Areas of concern include omissions in: the testing of brainstem reflexes; components of the apnea test; indications for the use of supplementary testing; wait intervals prior to performing the first NDD examination; the definition of NDD; and potential confounding factors. In addition, inconsistencies were found pertaining to wait intervals required between examinations and the legal timing of death.

CONCLUSION

These findings reinforce the need to standardize the practice of the neurological determination of death in Canadian centres, which has the potential to reduce practice variation. Clear medical standards for NDD augment the quality, rigour and credibility of this determination.