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Lewis A. An Update on Brain Death/Death by Neurologic Criteria since the World Brain Death Project. Semin Neurol 2024; 44:236-262. [PMID: 38621707 DOI: 10.1055/s-0044-1786020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
The World Brain Death Project (WBDP) is a 2020 international consensus statement that provides historical background and recommendations on brain death/death by neurologic criteria (BD/DNC) determination. It addresses 13 topics including: (1) worldwide variance in BD/DNC, (2) the science of BD/DNC, (3) the concept of BD/DNC, (4) minimum clinical criteria for BD/DNC determination, (5) beyond minimum clinical BD/DNC determination, (6) pediatric and neonatal BD/DNC determination, (7) BD/DNC determination in patients on ECMO, (8) BD/DNC determination after treatment with targeted temperature management, (9) BD/DNC documentation, (10) qualification for and education on BD/DNC determination, (11) somatic support after BD/DNC for organ donation and other special circumstances, (12) religion and BD/DNC: managing requests to forego a BD/DNC evaluation or continue somatic support after BD/DNC, and (13) BD/DNC and the law. This review summarizes the WBDP content on each of these topics and highlights relevant work published from 2020 to 2023, including both the 192 citing publications and other publications on BD/DNC. Finally, it reviews questions for future research related to BD/DNC and emphasizes the need for national efforts to ensure the minimum standards for BD/DNC determination described in the WBDP are included in national BD/DNC guidelines and due consideration is given to the recommendations about social and legal aspects of BD/DNC determination.
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Affiliation(s)
- Ariane Lewis
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, NYU Langone Medical Center, New York
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Al Fauzi A, Apriawan T, Ranuh IGMAR, Christi AY, Bajamal AH, Turchan A, Agus Subagio E, Suroto NS, Santoso B, Dachlan EG, Utomo B, Kasper EM. Traumatic brain injury in pregnancy: A systematic review of epidemiology, management, and outcome. J Clin Neurosci 2023; 107:106-117. [PMID: 36527810 DOI: 10.1016/j.jocn.2022.12.007] [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: 10/11/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) during pregnancy is an extremely rare condition in our neurosurgical emergency practices. Studies on the epidemiology and management of TBI in pregnancy are limited to case reports or serial case reports. There is no specific guidelines of management of TBI in pregnancy yet. METHODS The authors performed a structured search of all published articles on TBI in pregnancy from 1990 to 2020. We restricted search for papers in English and Bahasa. RESULTS The literature search yielded 22 articles with total 43 patients. We distinguished C-section based on its timing according to the neurosurgical treatment into primary (simultaneous or prior to neurosurgery) and secondary group (delayed C-section). The mean GOS value in primary C-section is better compared to secondary C-section in severe TBI group (3.57 ± 1.47 vs 3.0 ± 1.27, respectively) consistently in the moderate TBI group (4.33 ± 1.11 vs 3.62 ± 1.47, respectively). The fetal death rate in primary C-section is lower compared to secondary C-section in severe TBI group (14.2 % vs 33.3 %, respectively), contrary, in moderate TBI group (16.7 % vs 12.5 %, respectively). CONCLUSIONS Care of pregnant patients with TBI often requires multidisciplinary approach to optimize treatment strategy on a case-by-case basis in light of prior experience across different center. We propose management guideline for head injury in pregnancy.
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Affiliation(s)
- Asra Al Fauzi
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.
| | - Tedy Apriawan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - I G M Aswin R Ranuh
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Ayu Yoniko Christi
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Abdul Hafid Bajamal
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Agus Turchan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Eko Agus Subagio
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Nur Setiawan Suroto
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Budi Santoso
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Erry Gumilar Dachlan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Budi Utomo
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Ekkehard M Kasper
- Department of Neurosurgery, St. Elizabeth's Medical Center, Boston, Massachusetts, USA
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Santos LAD, Pereira CU, Paula MCGD, Kalkmann GF, Rabelo NN. Traumatic Brain Injury in Pregnancy. ARQUIVOS BRASILEIROS DE NEUROCIRURGIA: BRAZILIAN NEUROSURGERY 2022. [DOI: 10.1055/s-0041-1733862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Abstract
Objective The present paper aims to provide a review on the main complications involving traumatic brain injury (TBI) during pregnancy and on the vegetative state after TBI.
Methods A systematic review was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria checklist.
Results Seven studies were included, of which four were case reports, one was a follow-up, one was a comparative study, and one was a literature review.
Discussion Presence of neurological deficits such as hemiparesis, neonatal seizures, cerebral palsy, hemorrhage or hydrocephalus was observed in children of mothers who suffered trauma during pregnancy. The prolongation of a pregnancy in these victims, even in brain death, is within the reach of current medicine. Ethical issues must be considered when deciding to prolong a pregnancy of a woman in brain death.
Conclusion For the evaluation of pregnant women with TBI, there is a protocol that can be followed in the emergency care service. The cases reported in the literature suggest that there is no clear limit to restrict support to a pregnant patient in a vegetative state. Further studies should be done to elucidate this matter.
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Kidson KM, Lapinsky S, Grewal J. A Detailed Review of Critical Care Considerations for the Pregnant Cardiac Patient. Can J Cardiol 2021; 37:1979-2000. [PMID: 34534620 DOI: 10.1016/j.cjca.2021.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 01/19/2023] Open
Abstract
Maternal cardiovascular disease is a leading cause of maternal death worldwide and recently, maternal mortality has increased secondary to cardiovascular causes. Maternal admissions to critical care encompass 1%-2% of all critical care admissions, and although not common, the management of the critically ill pregnant patient is complex. Caring for the critically ill pregnant cardiac patient requires integration of pregnancy-associated physiologic changes, understanding pathophysiologic disease states unique to pregnancy, and a multidisciplinary approach to timing around delivery as well as antenatal and postpartum care. Herein we describe cardiorespiratory changes that occur during pregnancy and the differential diagnosis for cardiorespiratory failure in pregnancy. Cardiorespiratory diseases that are either associated or exacerbated by pregnancy are highlighted with emphasis on perturbations secondary to pregnancy and appropriate management strategies. Finally, we describe general management of the pregnant cardiac patient admitted to critical care.
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Affiliation(s)
- Kristen M Kidson
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, Vancouver, British Columbia, Canada; Department of Critical Care Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Stephen Lapinsky
- Mount Sinai Hospital and the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Jasmine Grewal
- Division of Cardiology, University of British Columbia, Pacific Adult Congenital Heart Disease Program, St Paul's Hospital, Vancouver, British Columbia, Canada.
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Boran ÖF, Yazar FM, Bakacak M, Soylu D, Yazar N, Öksüz H. Assessment of Somatic Support Process for Pregnant Brain Death Patients Occurring in a Transition Country Between Asia and Europe from Medical, Ethical, Legal and Religious Aspects. JOURNAL OF RELIGION AND HEALTH 2020; 59:2935-2950. [PMID: 31776818 DOI: 10.1007/s10943-019-00952-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In spite of the fact that brain death during pregnancy is not a common occurrence, it is an important ethical problem for all cultures and religions can have a significant influence on the donation decision after brain death. Therefore, this study aimed to present the case of a pregnant patient developing brain death which occurred in our intensive care unit and to compare the medical, ethical and legal problems relating to pregnant cases developing brain death with 24 cases in the literature. A 21-year-old 19-week pregnant case with gestational diabetes was monitored in the anesthesia intensive care unit and developed brain death due to intracranial mass and intraventricular hemorrhage. Though brain death is a situation well understood by organ transplant professionals, brain death developing in pregnant patients still involves many medical, ethical and legal problems.
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Affiliation(s)
- Ömer Faruk Boran
- Department of Anesthesiology and Reanimation, Sütçü Imam University School of Medicine, Kahramanmaraş, Turkey.
| | - Fatih Mehmet Yazar
- Department of General Surgery, Sütçü Imam University School of Medicine, Kahramanmaraş, Turkey
| | | | - Dilek Soylu
- Sütçü Imam University School of Medicine, Kahramanmaraş, Turkey
| | | | - Hafize Öksüz
- Department of Anesthesiology and Reanimation, Sütçü Imam University School of Medicine, Kahramanmaraş, Turkey
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Abstract
Trauma is the leading cause of nonobstetric maternal mortality and affects up to 8% of all pregnancies. Pregnant patients with traumatic brain injury (TBI) are an especially vulnerable population, and their management is complex, with multiple special considerations that must be taken into account. These include but are not limited to alterations in maternal physiology that occur with pregnancy, potential teratogenicity of pharmacologic therapies and diagnostic studies using ionizing radiation, need for fetal monitoring, Rh immunization status, placental abruption, and preterm labor. Despite these challenges, evidence regarding management of the pregnant patient with a TBI is lacking, limited to only case reports/series and retrospective analyses. Despite this uncertainty, expert opinion on management of these patients seems to be that, overall, the standard therapies for management of TBI are safe and effective in pregnancy, with a few notable exceptions described in this chapter. Significant work is needed to continue to develop best-practice and evidence-based guidelines for the management of TBI pregnancy.
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Affiliation(s)
- Matthew R Leach
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Christopher G Zammit
- Department of Critical Care Medicine and Neuroscience Institute, TriHealth, Cincinnati, OH, United States.
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Mutlu V, Utku T. Knowledge and Attitude Toward Brain Death and Organ Donation Among Anesthesiology and Reanimation Professionals. Transplant Proc 2019; 51:2163-2166. [PMID: 31474286 DOI: 10.1016/j.transproceed.2019.01.168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 01/21/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE We aimed to establish the basic data for the improvement of the weak points by determining the knowledge and attitude of professionals in anesthesiology and reanimation or/and intensive care, who are 50% responsible for the diagnosis of brain death. METHODS After the approval of the ethics committee, questionnaires were sent to participants. The data were collected electronically. The questionnaire consists of 89 questions. RESULTS A total of 564 (22.56%) completed questionnaires were returned. The sex distribution of the respondents was 207 (36.7%) female and 357 (63.3%) male; the mean age was 37 (SD, 7) years. Among participants, 87.2% reported needing ancillary testing for the diagnosis of brain death. Nevertheless, the rate of those who never needed ancillary testing was high among the participants who were specialized and working in hospitals covered by Erzurum RCC (31.2% and 26.7%, respectively) (P < .05). A total of 55.3% of respondents reported considering brain death and 41.9% reported considering circulatory arrest at the time of death. Participants' religious beliefs are not against to organ donation (93.4%). However, the percentage of respondents who thought that families refuse organ donation because of their religion was 84.1%. Suggestions for increasing organ transplants from deceased donors include education (54.1%), religious support (21.4%), use of media resources (25%), government support and legislative changes (10.1% and 7.6%, respectively), and education of health workers (9.4%). CONCLUSION The most important way to solve this problem is to give adequate education to main stakeholders. This is the most effective method to improve the public's behavior.
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Affiliation(s)
- Vildaniye Mutlu
- Department of Anaesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul, Turkey.
| | - Tuğhan Utku
- Department of Anaesthesiology and Reanimation, Yeditepe Medical Faculty, Istanbul, Turkey
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Gopčević A, Rode B, Vučić M, Horvat A, Širanović M, Gavranović Ž, Košec V, Košec A. Ethical and medical management of a pregnant woman with brain stem death resulting in delivery of a healthy child and organ donation. Int J Obstet Anesth 2017; 32:82-86. [DOI: 10.1016/j.ijoa.2017.06.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 06/11/2017] [Accepted: 06/18/2017] [Indexed: 11/28/2022]
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Neurologic complications in critically ill pregnant patients. HANDBOOK OF CLINICAL NEUROLOGY 2017. [PMID: 28190440 DOI: 10.1016/b978-0-444-63599-0.00035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Neurologic complications in a critically ill pregnant woman are uncommon but some of the complications (such as eclampsia) are unique to pregnancy and the puerperal period. Other neurologic complications (such as seizures in the setting of epilepsy) may worsen during pregnancy. Clinical signs and symptoms such as seizure, headache, weakness, focal neurologic deficits, and decreased level of consciousness require careful consideration of potential causes to ensure prompt treatment measures are instituted to prevent ongoing neurologic injury. Clinicians should be familiar with syndromes such as pre-eclampsia, eclampsia, stroke, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Necessary imaging studies can usually be performed safely in pregnancy. Scoring systems for predicting maternal mortality are inadequate, as are recommendations for neurorehabilitation. Tensions can arise when there is conflict between the interests of the mother and the interests of the fetus, but in general maternal health is prioritized. The complexity of care requires a multidisciplinary and multiprofessional approach to achieve best outcome in an often unexpected situation.
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Medical, legal, and ethical challenges associated with pregnancy and catastrophic brain injury. Int J Gynaecol Obstet 2015; 129:276-80. [DOI: 10.1016/j.ijgo.2014.12.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 12/09/2014] [Accepted: 02/13/2015] [Indexed: 11/22/2022]
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Iltis AS. Organ Donation, Brain Death and the Family: Valid Informed Consent. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2015; 43:369-382. [PMID: 26242960 DOI: 10.1111/jlme.12254] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
I argue that valid informed consent is ethically required for organ donation from individuals declared dead using neurological criteria. Current policies in the U.S. do not require this and, not surprisingly, current practices inhibit the possibility of informed consent. Relevant information is withheld, opportunities to ensure understanding and appreciation are extremely limited, and the ability to make and communicate a free and voluntary decision is hindered by incomplete disclosure and other practices. Current practices should be revised to facilitate valid informed consent for organ donation.
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Affiliation(s)
- Ana S Iltis
- Director of the Center for Bioethics, Health and Society and a Professor of Philosophy at Wake Forest University. She holds a Ph.D. in Philosophy from Rice University
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Whitney N, Raslan AM, Ragel BT. Decompressive craniectomy in a neurologically devastated pregnant woman to maintain fetal viability. J Neurosurg 2012; 116:487-90. [DOI: 10.3171/2011.11.jns11707] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Severe traumatic brain injury (TBI) in pregnant women can result in devastating outcomes for both the mother and the fetus. Historically, there has been concern regarding the issues involved when the fetus is not yet viable outside the womb. Currently, the ability to treat severe TBI with aggressive management of intracranial pressure (ICP) has led to the possibility of sustaining maternal life until the fetus is of a viable age and can be delivered. The authors present the case of a young woman 21 weeks pregnant with a severe TBI (Glasgow Coma Scale Score 3) in whom safe medical ICP management became ineffective. A decompressive craniectomy was performed to obviate the need for aggressive medical management of elevated ICP using fetal-toxic medications, and thus providing the fetus the best chance of continued in utero development until a viable gestational age was reached.
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Esmaeilzadeh M, Dictus C, Kayvanpour E, Sedaghat-Hamedani F, Eichbaum M, Hofer S, Engelmann G, Fonouni H, Golriz M, Schmidt J, Unterberg A, Mehrabi A, Ahmadi R. One life ends, another begins: Management of a brain-dead pregnant mother-A systematic review-. BMC Med 2010; 8:74. [PMID: 21087498 PMCID: PMC3002294 DOI: 10.1186/1741-7015-8-74] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 11/18/2010] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND An accident or a catastrophic disease may occasionally lead to brain death (BD) during pregnancy. Management of brain-dead pregnant patients needs to follow special strategies to support the mother in a way that she can deliver a viable and healthy child and, whenever possible, also be an organ donor. This review discusses the management of brain-dead mothers and gives an overview of recommendations concerning the organ supporting therapy. METHODS To obtain information on brain-dead pregnant women, we performed a systematic review of Medline, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). The collected data included the age of the mother, the cause of brain death, maternal medical complications, gestational age at BD, duration of extended life support, gestational age at delivery, indication of delivery, neonatal outcome, organ donation of the mothers and patient and graft outcome. RESULTS In our search of the literature, we found 30 cases reported between 1982 and 2010. A nontraumatic brain injury was the cause of BD in 26 of 30 mothers. The maternal mean age at the time of BD was 26.5 years. The mean gestational age at the time of BD and the mean gestational age at delivery were 22 and 29.5 weeks, respectively. Twelve viable infants were born and survived the neonatal period. CONCLUSION The management of a brain-dead pregnant woman requires a multidisciplinary team which should follow available standards, guidelines and recommendations both for a nontraumatic therapy of the fetus and for an organ-preserving treatment of the potential donor.
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Affiliation(s)
- Majid Esmaeilzadeh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Christine Dictus
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Elham Kayvanpour
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Farbod Sedaghat-Hamedani
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Michael Eichbaum
- Departments of Obstetrics and Gynecology, University of Heidelberg, Heidelberg, Germany
| | - Stefan Hofer
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Guido Engelmann
- Department of Pediatrics, University of Heidelberg, Heidelberg, Germany
| | - Hamidreza Fonouni
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Jan Schmidt
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Rezvan Ahmadi
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
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Abstract
This paper suggests that there are insurmountable problems for brain death as a criterion of death. The following are argued: (1) brain death does not meet an accepted concept of death, and is not the loss of integration of the organism as a whole; (2) brain death does not meet the criterion of brain death itself; brain death is not the irreversible loss of all critical functions of the entire brain; and (3) brain death may, however rarely, be reversible. I conclude that brain death, while a devastating neurological state with a dismal prognosis, is not death.
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Affiliation(s)
- Ari R Joffe
- University of Alberta, and Stollery Children's Hospital, Edmonton, AB, Canada.
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