1
|
Gambardella I, Nappi F, Worku B, Tranbaugh RF, Ibrahim AM, Balaram SK, Bernat JL. Taking the pulse of brain death: A meta-analysis of the natural history of brain death with somatic support. Eur J Neurol 2024; 31:e16243. [PMID: 38375732 DOI: 10.1111/ene.16243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/02/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND PURPOSE The conceptualization of brain death (BD) was pivotal in the shaping of judicial and medical practices. Nonetheless, media reports of alleged recovery from BD reinforced the criticism that this construct is a self-fulfilling prophecy (by treatment withdrawal or organ donation). We meta-analyzed the natural history of BD when somatic support (SS) is maintained. METHODS Publications on BD were eligible if the following were reported: aggregated data on its natural history with SS; and patient-level data that allowed censoring at the time of treatment withdrawal or organ donation. Endpoints were as follows: rate of somatic expiration after BD with SS; BD misdiagnosis, including "functionally brain-dead" patients (FBD; i.e. after the pronouncement of brain-death, ≥1 findings were incongruent with guidelines for its diagnosis, albeit the lethal prognosis was not altered); and length and predictors of somatic survival. RESULTS Forty-seven articles were selected (1610 patients, years: 1969-2021). In BD patients with SS, median age was 32.9 years (range = newborn-85 years). Somatic expiration followed BD in 99.9% (95% confidence interval = 89.8-100). Mean somatic survival was 8.0 days (range = 1.6 h-19.5 years). Only age at BD diagnosis was an independent predictor of somatic survival length (coefficient = -11.8, SE = 4, p < 0.01). Nine BD misdiagnoses were detected; eight were FBD, and one newborn fully recovered. No patient ever recovered from chronic BD (≥1 week somatic survival). CONCLUSIONS BD diagnosis is reliable. Diagnostic criteria should be fine-tuned to avoid the small incidence of misdiagnosis, which nonetheless does not alter the prognosis of FBD patients. Age at BD diagnosis is inversely proportional to somatic survival.
Collapse
Affiliation(s)
| | - Francesco Nappi
- Cardiac Surgery Center, Cardiologique du Nord de Saint-Denis, Paris, France
| | - Berhane Worku
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Robert F Tranbaugh
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Aminat M Ibrahim
- Department of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Sandhya K Balaram
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, New York, USA
| |
Collapse
|
2
|
Mustafa MS, Shafique MA, Fadlalla Ahmad TK, Hasan Ishag SM, Mhjoob AM, Haseeb A. Beyond the surface: unveiling the complexity of brain death and misdiagnoses in clinical practice. Ann Med Surg (Lond) 2024; 86:32-34. [PMID: 38222719 PMCID: PMC10783400 DOI: 10.1097/ms9.0000000000001595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 11/27/2023] [Indexed: 01/16/2024] Open
Affiliation(s)
- Muhammad Saqlain Mustafa
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| | - Muhammad Ashir Shafique
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| | | | | | | | - Abdul Haseeb
- Department of Medicine, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, Pakistan
| |
Collapse
|
3
|
Nair-Collins M, Joffe AR. Frequent Preservation of Neurologic Function in Brain Death and Brainstem Death Entails False-Positive Misdiagnosis and Cerebral Perfusion. AJOB Neurosci 2023; 14:255-268. [PMID: 34586014 DOI: 10.1080/21507740.2021.1973148] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Some patients who have been diagnosed as "dead by neurologic criteria" continue to exhibit certain brain functions, most commonly, neuroendocrine functions. This preservation of neurologic function after the diagnosis of "brain death" or "brainstem death" is an ongoing source of controversy and concern in the medical, bioethics, and legal literatures. Most obviously, if some brain function persists, then it is not the case that all functions of the entire brain have ceased and hence, declaring such a patient to be "dead" would be a false positive, in any nation with so-called "whole brain death" laws. Furthermore, and perhaps more concerning, the preservation of any brain function necessarily entails the preservation of some amount of brain perfusion, thereby raising the concern as to whether additional areas of neural tissue may remain viable, including areas in the brainstem. These and other considerations cast significant doubt on the reliability of diagnosing either "brain death" or "brainstem death."
Collapse
Affiliation(s)
| | - Ari R Joffe
- University of Alberta and Stollery Children's Hospital
| |
Collapse
|
4
|
Nair-Collins M. Spinal reflexes and brain death. Clin Neurophysiol Pract 2022; 7:143-145. [PMID: 35676911 PMCID: PMC9167867 DOI: 10.1016/j.cnp.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/02/2022] [Accepted: 05/04/2022] [Indexed: 11/27/2022] Open
|
5
|
Healthcare Professionals’ Understandings of the Definition and Determination of Death: A Scoping Review. Transplant Direct 2022; 8:e1309. [PMID: 35372677 PMCID: PMC8963853 DOI: 10.1097/txd.0000000000001309] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 12/03/2022] Open
Abstract
Background. During the 1950s, advances in critical care, and organ transplantation altered the relationship between organ failure and death. There has since been a shift away from traditional cardiocirculatory based to brain-based criteria of death, with resulting academic controversy, despite the practice being largely accepted worldwide. Our objective is to develop a comprehensive description of the current understandings of healthcare professionals regarding the meaning, definition, and determination of death. Methods. Online databases were used to identify papers published from 2003 to 2020. Additional sources were searched for conference proceedings and theses. Two reviewers screened papers using predefined inclusion and exclusion criteria. Complementary searches and review of reference lists complemented the final study selection. A data extraction instrument was developed to iteratively chart the results of the review. A qualitative approach was conducted to thematically analyze the data. Results. Seven thousand four hundred twenty-eight references were identified. In total, 75 papers met the inclusion criteria. Fourteen additional papers were added from complementary searches. Most were narratives (35%), quantitative investigations (21%), and reviews (18%). Identified themes included: (1) the historical evolution of brain death (BD), (2) persistent controversies about BD and death determination, (3) wide variability in healthcare professionals’ knowledge and attitudes, (4) critical need for BD determination revision. Conclusions. We concluded that although BD is widely accepted, there exists variation in healthcare providers’ understanding of its conceptual basis. Death determination remains a divisive issue among scholars. This review identified a need for increased opportunities for formal training on BD among healthcare providers.
Collapse
|
6
|
Joffe AR, Khaira G, de Caen AR. The intractable problems with brain death and possible solutions. Philos Ethics Humanit Med 2021; 16:11. [PMID: 34625089 PMCID: PMC8500820 DOI: 10.1186/s13010-021-00107-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 09/14/2021] [Indexed: 05/21/2023] Open
Abstract
Brain death has been accepted worldwide medically and legally as the biological state of death of the organism. Nevertheless, the literature has described persistent problems with this acceptance ever since brain death was described. Many of these problems are not widely known or properly understood by much of the medical community. Here we aim to clarify these issues, based on the two intractable problems in the brain death debates. First, the metaphysical problem: there is no reason that withstands critical scrutiny to believe that BD is the state of biological death of the human organism. Second, the epistemic problem: there is no way currently to diagnose the state of BD, the irreversible loss of all brain functions, using clinical tests and ancillary tests, given potential confounders to testing. We discuss these problems and their main objections and conclude that these problems are intractable in that there has been no acceptable solution offered other than bare assertions of an 'operational definition' of death. We present possible ways to move forward that accept both the metaphysical problem - that BD is not biological death of the human organism - and the epistemic problem - that as currently diagnosed, BD is a devastating neurological state where recovery of sentience is very unlikely, but not a confirmed state of irreversible loss of all [critical] brain functions. We argue that the best solution is to abandon the dead donor rule, thus allowing vital organ donation from patients currently diagnosed as BD, assuming appropriate changes are made to the consent process and to laws about killing.
Collapse
Affiliation(s)
- Ari R Joffe
- University of Alberta and Stollery Children's Hospital, Division of Pediatric Critical Care, Edmonton, Alberta, Canada.
- University of Alberta, John Dossetor Health Ethics Center, 4-546 Edmonton Clinic Health Academy, 11405 112 Street, Edmonton, Alberta, T6G 1C9, Canada.
| | - Gurpreet Khaira
- University of Alberta and Stollery Children's Hospital, Division of Pediatric Critical Care, Edmonton, Alberta, Canada
| | - Allan R de Caen
- University of Alberta and Stollery Children's Hospital, Division of Pediatric Critical Care, Edmonton, Alberta, Canada
| |
Collapse
|
7
|
Fainberg N, Mataya L, Kirschen M, Morrison W. Pediatric brain death certification: a narrative review. Transl Pediatr 2021; 10:2738-2748. [PMID: 34765497 PMCID: PMC8578760 DOI: 10.21037/tp-20-350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/05/2021] [Indexed: 11/30/2022] Open
Abstract
In the five decades since its inception, brain death has become an accepted medical and legal concept throughout most of the world. There was initial reluctance to apply brain death criteria to children as they are believed more likely to regain neurologic function following injury. In spite of early trepidation, criteria for pediatric brain death certification were first proposed in 1987 by a multidisciplinary committee comprised of experts in the medical and legal communities. Protocols have since been developed to standardize brain death determination, but there remains substantial variability in practice throughout the world. In addition, brain death remains a topic of considerable ethical, philosophical, and legal controversy, and is often misrepresented in the media. In the present article, we discuss the history of brain death and the guidelines for its determination. We provide an overview of past and present challenges to its concept and diagnosis from biophilosophical, ethical and legal perspectives, and highlight differences between adult and pediatric brain death determination. We conclude by anticipating future directions for brain death as related to the emergence of new technologies. It is our position that providers should endorse the criteria for brain death diagnosis in children as proposed by the Society of Critical Care Medicine (SCCM), American Academy of Pediatrics (AAP), and Child Neurology Society (CNS), in order to prevent controversy and subjectivity surrounding what constitutes life versus death.
Collapse
Affiliation(s)
- Nina Fainberg
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leslie Mataya
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew Kirschen
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
| | - Wynne Morrison
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
| |
Collapse
|
8
|
Shewmon DA. Statement in Support of Revising the Uniform Determination of Death Act and in Opposition to a Proposed Revision. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2021; 48:jhab014. [PMID: 33987668 DOI: 10.1093/jmp/jhab014] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Discrepancies between the Uniform Determination of Death Act (UDDA) and the adult and pediatric diagnostic guidelines for brain death (BD) (the "Guidelines") have motivated proposals to revise the UDDA. A revision proposed by Lewis, Bonnie and Pope (the RUDDA), has received particular attention, the three novelties of which would be: (1) to specify the Guidelines as the legally recognized "medical standard," (2) to exclude hypothalamic function from the category of "brain function," and (3) to authorize physicians to conduct an apnea test without consent and even over a proxy's objection. One hundred seven experts in medicine, bioethics, philosophy, and law, spanning a wide variety of perspectives, have come together in agreement that while the UDDA needs revision, the RUDDA is not the way to do it. Specifically, (1) the Guidelines have a non-negligible risk of false-positive error, (2) hypothalamic function is more relevant to the organism as a whole than any brainstem reflex, and (3) the apnea test carries a risk of precipitating BD in a non-BD patient, provides no benefit to the patient, does not reliably accomplish its intended purpose, and is not even absolutely necessary for diagnosing BD according to the internal logic of the Guidelines; it should at the very least require informed consent, as do many procedures that are much more beneficial and less risky. Finally, objections to a neurologic criterion of death are not based only on religious belief or ignorance. People have a right to not have a concept of death that experts vigorously debate imposed upon them against their judgment and conscience; any revision of the UDDA should therefore contain an opt-out clause for those who accept only a circulatory-respiratory criterion.
Collapse
Affiliation(s)
- D Alan Shewmon
- University of California Los Angeles, Los Angeles, California, USA
| |
Collapse
|
9
|
Apnea Testing in the Setting of Pediatric Brain Death: Continuous Positive Airway Pressure May Be the Safer Option. Pediatr Crit Care Med 2020; 21:1107-1108. [PMID: 33278226 DOI: 10.1097/pcc.0000000000002528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Nair-Collins M, Miller FG. Current Practice Diagnosing Brain Death Is Not Consistent With Legal Statutes Requiring the Absence of All Brain Function. J Intensive Care Med 2020; 37:153-156. [DOI: 10.1177/0885066620939037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The legal standard for the determination of death by neurologic criteria in the United States is laid out in the Uniform Determination of Death Act (UDDA), which requires the irreversible cessation of all functions of the entire brain. Most other nations endorse a “whole-brain” standard as well. However, current practice in the determination of death by neurologic criteria is not consistent with this legal standard, because some patients who are diagnosed as brain-dead, in fact retain some brain function, or retain the capacity for the return of some brain function. In response, the American Academy of Neurology published updated guidelines, which assert that hypothalamic function is consistent with the neurological standard enshrined in the UDDA. Others have suggested that it is an open question whether the hypothalamus and pituitary are part of “the entire brain,” as delineated in the UDDA. While we agree that determination of death practices are worthy of continued dialogue and refinement in practice that dialogue must adhere to reasonable standards of logic and scientific accuracy.
Collapse
Affiliation(s)
- Michael Nair-Collins
- Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Franklin G. Miller
- Medical Ethics in Medicine, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
11
|
Rady MY. Integration of Routine Parental Request of Organ Donation in End-of-Life Care of Children with Neurologic Disorders in the UK: Unresolved Medical, Legal, Cultural, and Religious Challenges. Neurocrit Care 2020; 33:630-635. [PMID: 32445107 DOI: 10.1007/s12028-020-00997-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The UK adopted the opt-out system (deemed or presumed consent) in end-of-life organ donation enforceable in May 2020. Presumed consent applies to adults but not children. Transplant advocates have recommended that all children on end-of-life care should be referred for potential organ donation to increase the supply of transplantable organs in the UK. To buttress this objective, a UK survey of parents of deceased children mostly with neurologic disorders secondary to severe brain injuries recommended the integration of routine parental discussion of donation regardless of donation eligibility in end-of-life care. Donation discussions emphasize the utility and suitability of organs in dying children for transplantation to maximize consent rate. To ensure that this recommendation does not harm children and parents, contemporary medical, legal, cultural, and religious challenges to end-of-life organ donation should be disclosed in parental discussion of donation and resolved appropriately. To that effect, it is urged that: (1) practice guidelines for the diagnosis and treatment of neurologic disorders secondary to severe brain injuries in children are updated and aligned with recent advances in neuroscience to eliminate potential errors from premature treatment discontinuation and/or incorrect diagnosis of death by brain(stem) criteria, (2) transparent and non-biased disclosure of all empiric information when discussing donation to ensure informed parental decision-making, and (3) a societal dialogue is conducted on the legal, cultural, and religious consequences of integration of routine donation discussion and referral in end-of-life care of children in the UK.
Collapse
Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Blvd, Phoenix, AZ, 85054, USA.
| |
Collapse
|
12
|
|
13
|
Rady MY. RETRACTED: Routine parental request of organ donation in end-of-life care of children in the United Kingdom: Unresolved medical, legal, cultural and religious challenges. Med Leg J 2019; 88:NP1-NP4. [PMID: 31631740 PMCID: PMC7338689 DOI: 10.1177/0025817219875307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, USA
| |
Collapse
|
14
|
[Diagnosis of irreversible loss of brain function ("brain death")-what is new?]. DER NERVENARZT 2019; 90:1021-1030. [PMID: 31312849 DOI: 10.1007/s00115-019-0765-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The determination of the irreversible cessation of brain function (ICBF) is conducted in Germany according to the guideline of the German Medical Association, which is currently its fourth update issued in July 2015. This article provides an assessment of the current situation including an international comparison. International case reports with allegedly incorrect ICBF diagnosis are reviewed from the point of view of the German guideline. These case reports underpin the validity of the German guideline, especially its following provisions: (1) in patients with known or suspected adaptation to chronic hypercapnia, apnea cannot be diagnosed as usual; therefore in such a case the proof of cerebral circulatory arrest is mandatory; (2) if perfusion scintigraphy is used for proof of cerebral circulatory arrest, only validated lipophilic radiopharmaceuticals are allowed. This is compatible with new research data which indicate that cellular function can be reactivated for several hours after circulatory arrest but not the brain function. The recently updated recommendations of the German Society for Clinical Neurophysiology and Functional Imaging (DGKN) for ancillary testing include editorial adaptations (e.g., the more precise specification of the electrode positions for electroencephalography), standards of display screen with digital electroencephalography and age-related minimum values of mean arterial pressure for Doppler and duplex sonography in children. The novel requirements regarding the institutional organization of ICBF diagnostics in Germany issued in the "Second law on the amendment of transplantation law-improvement of the cooperation and the framework for organ donation" that became effective recently are presented and discussed critically in this review.
Collapse
|
15
|
|
16
|
|
17
|
Ozdemir S, Tan YZ, Ozturk FK, Battal F. Confirmation of Brain Death with Positron Emission Tomography. J Pediatr Intensive Care 2019; 9:51-53. [PMID: 31984158 DOI: 10.1055/s-0039-1696652] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022] Open
Abstract
After recent advances regarding organ transplantation, accurate and timely diagnosis of brain death has gained importance. In the diagnosis of brain death, in addition to clinical findings, various ancillary tests are very crucial. In this study, the scintigraphic imaging of the brain death of an 8-year-old girl with both Tc-99m diethylenetriaminepentaacetic and 18F-fluorodeoxyglucose (FDG) has been presented. This case study shows that 18F-FDG positron emission tomography-computed tomography imaging can be a useful technique in evaluating brain death in patients.
Collapse
Affiliation(s)
- Semra Ozdemir
- Department of Nuclear Medicine, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Yusuf Ziya Tan
- Department of Nuclear Medicine, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Fulya Koc Ozturk
- Department of Nuclear Medicine, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Fatih Battal
- Department of Pediatrics, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey
| |
Collapse
|
18
|
Kirschen MP, Francoeur C, Murphy M, Traynor D, Zhang B, Mensinger JL, Ichord R, Topjian A, Berg RA, Nishisaki A, Morrison W. Epidemiology of Brain Death in Pediatric Intensive Care Units in the United States. JAMA Pediatr 2019; 173:469-476. [PMID: 30882855 PMCID: PMC6503509 DOI: 10.1001/jamapediatrics.2019.0249] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Guidelines for declaration of brain death in children were revised in 2011 by the Society of Critical Care Medicine, American Academy of Pediatrics, and Child Neurology Society. Despite widespread medical, legal, and ethical acceptance, ongoing controversies exist with regard to the concept of brain death and the procedures for its determination. OBJECTIVES To determine the epidemiology and clinical characteristics of pediatric patients declared brain dead in the United States. DESIGN, SETTING, AND PARTICIPANTS This study involved the abstraction of all patient deaths from the Virtual Pediatric Systems national multicenter database between January 1, 2012, and June 30, 2017. All patients who died in pediatric intensive care units (PICUs) were included. MAIN OUTCOMES AND MEASURES Patient demographics, preillness developmental status, severity of illness, cause of death, PICU medical and physical length of stay, and organ donation status, as well as comparison between patients who were declared brain dead vs those who sustained cardiovascular or cardiopulmonary death. RESULTS Of the 15 344 patients who died, 3170 (20.7%) were declared brain dead; 1861 of these patients (58.7%) were male, and 1401 (44.2%) were between 2 and 12 years of age. There was a linear association between PICU size and number of patients declared brain dead per year, with an increase of 4.27 patients (95% CI, 3.46-5.08) per 1000-patient increase in discharges (P < .001). The median (interquartile range) of patients declared brain dead per year ranged from 1 (0-3) in smaller PICUs (defined as those with <500 discharges per year) to 10 (7-15) for larger PICUs (those with 2000-4000 discharges per year). The most common causative mechanisms of brain death were hypoxic-ischemic injury owing to cardiac arrest (1672 of 3170 [52.7%]), shock and/or respiratory arrest without cardiac arrest (399 of 3170 [12.6%]), and traumatic brain injury (634 of 3170 [20.0%]). Most patients declared brain dead (681 of 807 [84.4%]) did not have preexisting neurological dysfunction. Patients who were organ donors (1568 of 3144 [49.9%]) remained in the PICU longer after declaration of brain death compared with those who were not donors (median [interquartile range], 29 [6-41] hours vs 4 [1-8] hours; P < .001). CONCLUSIONS AND RELEVANCE Brain death occurred in one-fifth of PICU deaths. Most children declared brain dead had no preexisting neurological dysfunction and had an acute hypoxic-ischemic or traumatic brain injury. Brain death determinations are infrequent, even in large PICUs, emphasizing the importance of ongoing education for medical professionals and standardization of protocols to ensure diagnostic accuracy and consistency.
Collapse
Affiliation(s)
- Matthew P. Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Department of Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Conall Francoeur
- Centre mère-enfant Soleil du Centre Hospitalier Universitaire de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Marie Murphy
- Department of Nursing, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Danielle Traynor
- Department of Nursing, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bingqing Zhang
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Janell L. Mensinger
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Rebecca Ichord
- Department of Neurology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Wynne Morrison
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| |
Collapse
|
19
|
The Death Debate: Penumbra Conundrum. Am J Hosp Palliat Care 2018; 35:1473-1476. [DOI: 10.1177/1049909118778288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Determination and declaration of death by neurologic criteria, brain death, is an established and legally accepted clinical practice with profound implications. Concerns regarding the accuracy of this diagnosis raise important clinical, ethical, and legal issues. A recent magazine article highlights these concerns by describing a poignant example of a patient meeting accepted clinical and ancillary testing criteria for brain death in the setting of post cardiac arrest hypoxic ischemic encephalopathy (CA-HIE). With continuation of ventilatory and nutritional support, this patient not only survived but over time demonstrated findings that were no longer consistent with brain death. Offered here is a review of the course of events described in the article, an overview of the variable clinical implications of CA-HIE and their relationship to the diagnosis of brain death, a proposed pathophysiologic correlation, and recommendations for palliative clinicians providing consultation with regard to goals of care and intervention options in cases of CA-HIE with severe neurologic injury.
Collapse
|
20
|
Sosa T, Berrens Z, Conway S, Stalets EL. Apnea Threshold in Pediatric Brain Death: A Case with Variable Results Across Serial Examinations. J Pediatr Intensive Care 2018; 8:108-112. [PMID: 31093465 DOI: 10.1055/s-0038-1675193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 09/08/2018] [Indexed: 10/27/2022] Open
Abstract
Consensus guidelines currently exist for the evaluation of pediatric patients with suspected brain death. The guidelines include the requirement for two consistent examinations separated by an observation period and a threshold of 60 mm Hg for PaCO 2 during apnea testing. We present a patient who met all prerequisites to perform brain death examination but had variability in examinations during apnea testing. We discuss our strategy in managing these unexpected findings, including the importance of open and ongoing communication with the family, and the implications for current guidelines for the determination of brain death in pediatric patients.
Collapse
Affiliation(s)
- Tina Sosa
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Zachary Berrens
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Susan Conway
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| |
Collapse
|
21
|
Verheijde JL, Rady MY, Potts M. Neuroscience and Brain Death Controversies: The Elephant in the Room. JOURNAL OF RELIGION AND HEALTH 2018; 57:1745-1763. [PMID: 29931477 PMCID: PMC6132575 DOI: 10.1007/s10943-018-0654-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The conception and the determination of brain death continue to raise scientific, legal, philosophical, and religious controversies. While both the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in 1981 and the President's Council on Bioethics in 2008 committed to a biological definition of death as the basis for the whole-brain death criteria, contemporary neuroscientific findings augment the concerns about the validity of this biological definition. Neuroscientific evidentiary findings, however, have not yet permeated discussions about brain death. These findings have critical relevance (scientifically, medically, legally, morally, and religiously) because they indicate that some core assumptions about brain death are demonstrably incorrect, while others lack sufficient evidential support. If behavioral unresponsiveness does not equate to unconsciousness, then the philosophical underpinning of the definition based on loss of capacity for consciousness as well as the criteria, and tests in brain death determination are incongruent with empirical evidence. Thus, the primary claim that brain death equates to biological death has then been de facto falsified. This conclusion has profound philosophical, religious, and legal implications that should compel respective authorities to (1) reassess the philosophical rationale for the definition of death, (2) initiate a critical reappraisal of the presumed alignment of brain death with the theological definition of death in Abrahamic faith traditions, and (3) enact new legislation ratifying religious exemption to death determination by neurologic criteria.
Collapse
Affiliation(s)
- Joseph L. Verheijde
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259 USA
| | - Mohamed Y. Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E Mayo Blvd, Phoenix, AZ 85054 USA
| | - Michael Potts
- Department of Philosophy and Religion, Methodist University, 5400 Ramsey Street, Fayetteville, NC 28311-1498 USA
| |
Collapse
|
22
|
Verheijde JL, Rady MY, Potts M. Reader response: An interdisciplinary response to contemporary concerns about brain death determination. Neurology 2018; 91:533-534. [DOI: 10.1212/wnl.0000000000006150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
23
|
|
24
|
Dalle Ave AL, Bernat JL. Inconsistencies Between the Criterion and Tests for Brain Death. J Intensive Care Med 2018; 35:772-780. [DOI: 10.1177/0885066618784268] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The whole-brain criterion of death provides that a person who has irreversibly lost all clinical functions of the brain is dead. Bedside brain death (BD) tests permit physicians to determine BD by showing that the whole-brain criterion of death has been fulfilled. In a nonsystematic literature review, we identified and analyzed case reports of a mismatch between the whole-brain criterion of death and bedside BD tests. We found examples of patients diagnosed as BD who showed (1) neurologic signs compatible with retained brain functions, (2) neurologic signs of uncertain origin, and (3) an inconsistency between standard BD tests and ancillary tests for BD. Two actions can resolve the mismatch between the whole-brain criterion of death and BD tests: (1) loosen the whole-brain criterion of death by requiring only the irreversible cessation of relevant brain functions and (2) tighten BD tests by requiring an ancillary test proving the cessation of intracranial blood flow. Because no one knows the precise brain functions whose loss is necessary to fulfill the whole-brain criterion of death, we advocate tightening BD tests by requiring the absence of intracranial blood flow.
Collapse
Affiliation(s)
- Anne L. Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland
- Institute for Biomedical Ethics, University Medical Center, Geneva, Switzerland
| | - James L. Bernat
- Neurology Department, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| |
Collapse
|