Barriers to the Use of Neurologic Criteria to Declare Death in Africa

International variability in the diagnosis and management of disorders of consciousness

This manuscript explores the international variability in the diagnosis and management of disorders of consciousness (DoC). The identification, evaluation, intervention, exploration, prognostication and limitation of therapy for patients with DoC is reviewed through an international lens. The myriad factors that impact the diagnosis and management of DoC including 1) financial, 2) legal and regulatory, 3) cultural, 4) religious and 5) psychosocial considerations are discussed. As data comparing patients with DoC internationally are limited, findings from the general critical care or neurocritical care literature are described when information specific to patients with DoC is unavailable. There is a need for improvements in clinical care, education, advocacy and research related to patients with DoC worldwide. It is imperative to standardize methodology to evaluate consciousness and prognosticate outcome. Further, education is needed to 1) generate awareness of the impact of the aforementioned considerations on patients with DoC and 2) develop techniques to optimize communication about DoC with families. It is necessary to promote equity in access to expertise and resources for patients with DoC to enhance the care of patients with DoC worldwide. Improving understanding and management of patients with DoC requires harmonization of existing datasets, development of registries where none exist and establishment of international clinical trial networks that include patients in all phases along the spectrum of care. The work of international organizations like the Curing Coma Campaign can hopefully minimize international variability in the diagnosis and management of DoC and optimize care.

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.

Cuba's contribution in the diagnosis of brain death/death by neurologic criteria

I read with interest the paper by Lewis et al. to identify the countries in the Latin America/Caribbean Group of the United Nations (GRULAC) that have protocols for brain death/death by neurologic criteria (BD/DNC). Curiously, the authors don't mention Cuba, which has been one of the most active countries in the area, since the early '90s. The first kidney transplant in Cuba was performed on 24 February 1970, using a cadaveric donor. In September 1992, the First Symposium on Brain Death was held in Havana, with the attendance of the main and world-known authors at that time, like Cristopher Pallis, Earl Walker, among others. These conferences uninterruptedly continued over the years, and the last Symposium was held in December 2018. In the First Symposium, the Cuban Commission for Death Determination presented for the first time the Guidelines for the Determination of BD/DNC in Cuba. Since that time, Machado proposed a concept of death, based on the basic pathophysiological mechanism of consciousness generation. This author also proposed as ancillary tests in BD/DNC diagnosis the use of a test battery composed of multimodality evoked potentials (MEP) and electroretinography (ERG). Later, a Cuban Law for the determination of death was issued. The Cuban Commission The Commission stated that there is only one kind of death, based on the irreversible loss of brain functions based on the whole brain criteria. Furthermore, the Cuban law did not even mention the term 'transplants'. It is clear the human beings die regardless bodies would be useful or not for transplantation.