brain death: the neurologist’s perspective stephen t. mernoff, md clinical assistant professor of...

Brain Death: The Brain Death: The Neurologist’s PerspectiveNeurologist’s Perspective

Stephen T. Mernoff, MDStephen T. Mernoff, MDClinical Assistant Professor of Neurology, Brown Medical Clinical Assistant Professor of Neurology, Brown Medical

SchoolSchool

Medical Director, Neurorehabilitation Program, Rehabilitation Medical Director, Neurorehabilitation Program, Rehabilitation Hospital of Rhode IslandHospital of Rhode Island

Staff Neurologist, Roger Williams Medical CenterStaff Neurologist, Roger Williams Medical Center

Law Law & &

OrderOrder

I thought this would be easyI thought this would be easy

► i.e. a 15 minute discussion outlining i.e. a 15 minute discussion outlining the standard, uniformly accepted and the standard, uniformly accepted and applied criteria for brain death and the applied criteria for brain death and the method for its determinationmethod for its determination

But…But…

►Not uniformly defined between institutionsNot uniformly defined between institutions►Not one universally accepted standardNot one universally accepted standard►Not one universally and consistently Not one universally and consistently

applied algorithm for determinationapplied algorithm for determination►““If one subject in health law and bioethics If one subject in health law and bioethics

can be said to be at once well settled and can be said to be at once well settled and persistently unresolved, it is how to persistently unresolved, it is how to determine that death has occurred.” determine that death has occurred.” Rosenbaum, S. Ethical conflicts. Anesthesiology 1999;91:3-4Rosenbaum, S. Ethical conflicts. Anesthesiology 1999;91:3-4

VersaliusVersalius

►Madrid, 1564Madrid, 1564►AnatomistAnatomist►At autopsy: thorax openedAt autopsy: thorax openedheart heart

beating!beating!►Forced to leave SpainForced to leave Spain

This event and others This event and others need for formal need for formal pronouncement of deathpronouncement of death

Death: traditional Death: traditional cardiopulmonary definitioncardiopulmonary definition

►AsystoleAsystole

ANDAND►ApneaApnea

Mollaret P and Goulon M. Le Mollaret P and Goulon M. Le coma dcoma déépasspassé [“a state beyond é [“a state beyond

coma”]coma”]. . Rev Neurol 1959;101:3-15Rev Neurol 1959;101:3-15

►Concept of Brain Death introduced: Concept of Brain Death introduced: authors believed there was a definable authors believed there was a definable condition from which recovery was condition from which recovery was impossibleimpossible

►Criteria suggestedCriteria suggested►Not recognized widelyNot recognized widely

““Harvard Criteria”Harvard Criteria”Report of the Ad Hoc Committee of the Harvard Medical School Report of the Ad Hoc Committee of the Harvard Medical School

to Examine the Definition of Brain Death. A definition of to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340irreversible coma. JAMA 1968;205:337-340

► Driving forces: advances in careDriving forces: advances in care mechanical ventilation and ICU’smechanical ventilation and ICU’s Organ transplantation:Organ transplantation: cadaver (non-heart- cadaver (non-heart-

beating) donors beating) donors but some surgeons harvesting but some surgeons harvesting from patients with neurologic catastrophes:from patients with neurologic catastrophes: patients died patients died afterafter transplantation transplantation

► Many surgeons uncomfortable with this but “live donors” Many surgeons uncomfortable with this but “live donors” improved transplant outcomesimproved transplant outcomes

When has irreversible loss of full brain function When has irreversible loss of full brain function occurred?occurred?

--premise: not idea that brain, therefore person, is --premise: not idea that brain, therefore person, is dead;dead;

rather: coma irreversible and care futilerather: coma irreversible and care futile

Harvard CriteriaHarvard CriteriaReport of the Ad Hoc Committee of the Harvard Medical School to Report of the Ad Hoc Committee of the Harvard Medical School to

Examine the Definition of Brain Death. A definition of irreversible coma. Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-340JAMA 1968;205:337-340

► Purpose: “…to define irreversible coma as a Purpose: “…to define irreversible coma as a new criterion for death.”new criterion for death.”

► ““There are two reasons why there is need There are two reasons why there is need for a definition:for a definition: 1) improvements in resuscitative and supportive 1) improvements in resuscitative and supportive

measures…sometimes…only partial success…measures…sometimes…only partial success…result is an individual whose heart continues to result is an individual whose heart continues to beat but whose brain is irreversibly damaged. beat but whose brain is irreversibly damaged. The burdern is great on patients who suffer The burdern is great on patients who suffer permanent loss of intellect, on their families, on permanent loss of intellect, on their families, on the hositals, and those in need of hospital beds the hositals, and those in need of hospital beds already occupied by those comatose patients.”already occupied by those comatose patients.”



► Note: presented in narrative rather than Note: presented in narrative rather than algorithmic form; stricter than ever before, but algorithmic form; stricter than ever before, but not strict enough (e.g. EEG duration criteria)not strict enough (e.g. EEG duration criteria)

► Purpose: “…to define irreversible coma as a Purpose: “…to define irreversible coma as a new criterion for death.”new criterion for death.”

► ““There are two reasons why there is need for There are two reasons why there is need for a definition:a definition: 2) Obsolete criteria for the definition of death can 2) Obsolete criteria for the definition of death can

lead to controversy in obtaining organs for lead to controversy in obtaining organs for transplantation.”transplantation.”



► ““An organ, brain or other, that no longer functions An organ, brain or other, that no longer functions and has no possibility of functioning again is for all and has no possibility of functioning again is for all practical purposes dead.”practical purposes dead.”

► A. determine presence of “a A. determine presence of “a permanentlypermanently nonfunctioning brain.”nonfunctioning brain.” 1. 1. UnreceptivityUnreceptivity and and UnresponsitivityUnresponsitivity: “total unawareness : “total unawareness

to externally applied stimuli…even the most intensely to externally applied stimuli…even the most intensely painful stimuli evoke no vocal or other response, not even painful stimuli evoke no vocal or other response, not even a groan, withdrawal of a limb, or quickening of respiration.”a groan, withdrawal of a limb, or quickening of respiration.”

2.2. No Movements or Breathing: No Movements or Breathing: no spontaneous no spontaneous movements or spontaneous respiration (turn off respirator movements or spontaneous respiration (turn off respirator for 3 minutes; prior to trial breathing room air for for 3 minutes; prior to trial breathing room air for ≥≥10 10 minutes and pCOminutes and pCO2 2 normal) or response to pain, touch, normal) or response to pain, touch, sound or light for an hour.sound or light for an hour.



► A. determine presence of “a A. determine presence of “a permanentlypermanently nonfunctioning brain.”nonfunctioning brain.” 3. No reflexes: pupils fixed, dilated and absence 3. No reflexes: pupils fixed, dilated and absence

of:of:► Pupillary response to bright lightPupillary response to bright light► ocular movement to head turning and ice water ocular movement to head turning and ice water

irrigation of earsirrigation of ears► blinkingblinking► postural activity (decerebrate or other)postural activity (decerebrate or other)► Swallowing, yawning, vocalizationSwallowing, yawning, vocalization► Corneal reflexesCorneal reflexes► Pharyngeal reflexesPharyngeal reflexes► Deep tendon reflexesDeep tendon reflexes► Respnse to plantar or noxious stimuliRespnse to plantar or noxious stimuli



► B. confirmatory dataB. confirmatory data 4. isoelectric EEG (specifies technique; have EKG and 4. isoelectric EEG (specifies technique; have EKG and

noncephalic leads to r/o confounders “At least 10 full minutes noncephalic leads to r/o confounders “At least 10 full minutes of recording are desirable, but twice that would be better.” of recording are desirable, but twice that would be better.” [!])[!])

► EEG: “when available it should be utilized”EEG: “when available it should be utilized” If EEG unavailable, “the absence of cerebral function has to If EEG unavailable, “the absence of cerebral function has to

be determined by purely clinical signs…or by absence of be determined by purely clinical signs…or by absence of circulation as judged by standstill of blood in the retinal circulation as judged by standstill of blood in the retinal vessels, or by absence of cardiac activity.”vessels, or by absence of cardiac activity.”

► A and B all need to be A and B all need to be repeated 24 hours later repeated 24 hours later with no with no ΔΔ AND in the AND in the absence of hypothermiaabsence of hypothermia (<90˚F [32.2˚C]) (<90˚F [32.2˚C]) or CNS depressants,or CNS depressants, such as such as barbiturates, and barbiturates, and determined only by a physiciandetermined only by a physician



► If criteria are met, “Death is to be If criteria are met, “Death is to be declared and declared and thenthen the respirator turned the respirator turned off. The decision to do this and the off. The decision to do this and the responsibility for it are to be taked by responsibility for it are to be taked by the physician-in-charge, in consultation the physician-in-charge, in consultation with one or more physicians who have with one or more physicians who have been directly involved in the case. It is been directly involved in the case. It is unsound and undesirable to force the unsound and undesirable to force the family to make the decision.”family to make the decision.”



►ControversyControversy Physicians concerned: desire to remove Physicians concerned: desire to remove

burden of decision off the transplant surgeonburden of decision off the transplant surgeon Public concern: press concerned that Brigham Public concern: press concerned that Brigham

doctors were “playing god by removing doctors were “playing god by removing organs.” organs.” Murray JE. Surgery of the soul: reflectins on a curious career. Canton, MA: Murray JE. Surgery of the soul: reflectins on a curious career. Canton, MA: Science History Publications, 2001.Science History Publications, 2001.

Subsequent literature concerned that criteria Subsequent literature concerned that criteria biased by participation of transplant biased by participation of transplant surgeons on the committee whose programs surgeons on the committee whose programs could advance with brain death definedcould advance with brain death defined

►Wijdicks Wijdicks NEUROLOGY 2003;61:970-976NEUROLOGY 2003;61:970-976 finds little basis for this finds little basis for this in his review of the committee’s documentsin his review of the committee’s documents

Guidelines for the Determination Guidelines for the Determination of Death of Death JAMA 11/13/1981;246(19),2184-2186JAMA 11/13/1981;246(19),2184-2186

► Report of the Medical Consultants on the Report of the Medical Consultants on the Diagnosis of Death to the President’s Diagnosis of Death to the President’s Commission for the Study of Ethical Problems Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral in Medicine and Biomedical and Behavioral ResearchResearch

► Developed as an aid to implementation of the Developed as an aid to implementation of the proposed “Uniform Determination of Death Act” proposed “Uniform Determination of Death Act” (endorsed by: ABA, AMA, Nat’l Confernece of (endorsed by: ABA, AMA, Nat’l Confernece of Commissioners on Uniform State Laws, Commissioners on Uniform State Laws, President’s Commission for the Study of Ethical President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Problems in Medicine and Biomedical and Behavioral Research, AAN, AESBehavioral Research, AAN, AES

Guidelines for the Determination Guidelines for the Determination of Death of Death JAMA 11/13/1981;246(19),2184-2186JAMA 11/13/1981;246(19),2184-2186

►““Uniform Determination of Death Act”Uniform Determination of Death Act” ““An individual who has sustained either An individual who has sustained either

(1) irreversible cessation of circulatory (1) irreversible cessation of circulatory and respiratory functions, or (2) and respiratory functions, or (2) irreversible cessation of all functions of irreversible cessation of all functions of the entire brain, including the brain stem, the entire brain, including the brain stem, is dead. A determination of death must be is dead. A determination of death must be made in accordance with accepted made in accordance with accepted medical standards.”medical standards.”

Guidelines for the Determination Guidelines for the Determination of Death of Death JAMA 11/13/1981;246(19),2184-2186JAMA 11/13/1981;246(19),2184-2186: :

CriteriaCriteria► Note: presented in somewhat narrative and Note: presented in somewhat narrative and

somewhat algorithmic form; improvement somewhat algorithmic form; improvement from Harvard criteria but still room for from Harvard criteria but still room for interpretation of what to do and when.interpretation of what to do and when.

► ““An individual presenting the findings in An individual presenting the findings in eithereither section A (Cardiopulmonary) section A (Cardiopulmonary) oror section B (neurological) is dead….a section B (neurological) is dead….a diagnosis of death requires that diagnosis of death requires that bothboth cessation of functions cessation of functions andand irreversibility…be irreversibility…be demonstrated.”demonstrated.”


CriteriaCriteria► ““A. An individual with irreversible cessation of A. An individual with irreversible cessation of

circulatory and respiratory functions is dead.circulatory and respiratory functions is dead. 1. 1. CessationCessation is recognized by an appropriate is recognized by an appropriate

clinical examination….at least absence of clinical examination….at least absence of responsiveness, heartbeat, and respiratory responsiveness, heartbeat, and respiratory effort….may require the use of…ECG.”effort….may require the use of…ECG.”

2. 2. IrreversibilityIrreversibility is recognized by persistent is recognized by persistent cessation of functions during an appropriate period cessation of functions during an appropriate period of observation and/or trial of therapy.” of observation and/or trial of therapy.” [duration of [duration of observation period dependent on whether is expected vs. observation period dependent on whether is expected vs. unexpected, whether resuscitation attempted, or moment of unexpected, whether resuscitation attempted, or moment of possible death is witnessed or not]possible death is witnessed or not]


CriteriaCriteria►““B. An individual with irreversible B. An individual with irreversible

cessation of all functions of the entire cessation of all functions of the entire brain, including the brain stem, is brain, including the brain stem, is dead….”dead….” ““1. Cessation1. Cessation is recognized when evaluation is recognized when evaluation

discloses findings of a discloses findings of a andand b: b:► a. Cerebral functions are absent, and…”a. Cerebral functions are absent, and…”

Deep coma (unreceptivity and unresponsivity)Deep coma (unreceptivity and unresponsivity) ““Medical circumstances may require the use of confirmatory Medical circumstances may require the use of confirmatory

studies such as an EEG or blood-flow study.” [??Those studies such as an EEG or blood-flow study.” [??Those circumstances not specified!]circumstances not specified!]

► b. “Brainstem functions are absent” determined by testing b. “Brainstem functions are absent” determined by testing pupillary light, corneal, oculocephalic, oculovestibular, pupillary light, corneal, oculocephalic, oculovestibular, oropharyngeal, and respiratory (apnea) reflexes; oropharyngeal, and respiratory (apnea) reflexes;




discloses findings of a discloses findings of a andand b: b:► b. “Brainstem functions are absent” determined by b. “Brainstem functions are absent” determined by

testing pupillary light, corneal, oculocephalic, testing pupillary light, corneal, oculocephalic, oculovestibular, oropharyngeal, and respiratory (apnea) oculovestibular, oropharyngeal, and respiratory (apnea) reflexes; “When these reflexes cannot be adequately reflexes; “When these reflexes cannot be adequately assessed, confirmatory tests are recommended.”assessed, confirmatory tests are recommended.”

► Apnea testing specified: OApnea testing specified: O22 ventilation x 10 minutes then ventilation x 10 minutes then w/d ventilator with passive flow of Ow/d ventilator with passive flow of O2,2,, confirm pCO, confirm pCO22≥≥60 60 by ABG; “spontaneous breathing efforts indicate that part by ABG; “spontaneous breathing efforts indicate that part of the brain stem is functioning.”of the brain stem is functioning.”




discloses findings of a discloses findings of a andand b: b:► ““Peripheral nervous system activity and spinal cord Peripheral nervous system activity and spinal cord

reflexes may persist after death. True decerebrate or reflexes may persist after death. True decerebrate or decorticate posturing or seizures are inconsistent with decorticate posturing or seizures are inconsistent with the diagnosis of death.”the diagnosis of death.”


CriteriaCriteria► ““B. An individual with irreversible cessation B. An individual with irreversible cessation

of all functions of the entire brain, including of all functions of the entire brain, including the brain stem, is dead….”the brain stem, is dead….” ““2. Irreversibility2. Irreversibility is recognized when evaluation discloses is recognized when evaluation discloses

findings of a findings of a andand b b andand c” c” oror by absence of blood flow to by absence of blood flow to the brain the brain ≥≥10 minutes, shown by angiography :10 minutes, shown by angiography :

► a. The cause of coma is established and is sufficient to a. The cause of coma is established and is sufficient to account for the loss of brain functions, and…account for the loss of brain functions, and…

► b. the possibility of recovery of any brain functions is b. the possibility of recovery of any brain functions is excluded, and…” (i.e. rule out sedation, hypothermia excluded, and…” (i.e. rule out sedation, hypothermia <32.2˚C <32.2˚C core tempcore temp, neuromuscular blockade, and shock) , neuromuscular blockade, and shock)

► ““c. the cessation of all brain functions persists for an c. the cessation of all brain functions persists for an appropriate period of observation and/or trial or therapy” (6 appropriate period of observation and/or trial or therapy” (6 hours; 12 hours if no confirmatory tests; 24 hours if anoxic hours; 12 hours if no confirmatory tests; 24 hours if anoxic injury)injury)

Practice parameters for Practice parameters for determining brain death in determining brain death in adults adults (summary statement)(summary statement) NEUROLOGY NEUROLOGY

1995;45:1012-10141995;45:1012-1014► Report of the Quality Standards Subcommittee of Report of the Quality Standards Subcommittee of the American Academy of Neurologythe American Academy of Neurology

► Brain Death Definition: “the irreversible loss of Brain Death Definition: “the irreversible loss of functin of the brain, including the brainstem.”functin of the brain, including the brainstem.”

► Justification: “…need for standardization of the Justification: “…need for standardization of the neurologic examination criteria for the diagnosis of neurologic examination criteria for the diagnosis of brain death.”brain death.”

► Process: based on review of literature 1976-1994; Process: based on review of literature 1976-1994; are are GUIDELINESGUIDELINES (class II evidence or strong (class II evidence or strong consensus of class III evidence)consensus of class III evidence)

► Format: algorithm with precise definitions and Format: algorithm with precise definitions and precisely specified exam methodsprecisely specified exam methods

Practice parameters for determining brain death in Practice parameters for determining brain death in

adults:adults: (summary statement) NEUROLOGY(summary statement) NEUROLOGY 1995;45:1012- 1995;45:1012-

1014: 1014:

I. I. Diagnostic CriteriaDiagnostic Criteria

►A. “PrerequisitesA. “Prerequisites 1.Clinical or neuroimaging evidence of an 1.Clinical or neuroimaging evidence of an

acute CNS catastrophe that is compatible acute CNS catastrophe that is compatible with the clinical diagnosis of brain deathwith the clinical diagnosis of brain death

2. Exclusion of complicating medical 2. Exclusion of complicating medical conditions” (electrolyte, acid-base, conditions” (electrolyte, acid-base, endocrine)endocrine)

““3.No drug intoxication or poisoning3.No drug intoxication or poisoning 4. Core temperature 4. Core temperature ≥≥3232˚̊C(90C(90˚̊F)”F)”



1014: 1014:


►B. Coma, lack of brainstem reflexes, B. Coma, lack of brainstem reflexes, and apneaand apnea 1.Coma or unresponsiveness… (defined 1.Coma or unresponsiveness… (defined

specifically)specifically) 2. Absence of brainstem reflexes (defined 2. Absence of brainstem reflexes (defined

specifically):specifically):►PupilsPupils►Ocular movementOcular movement►Facial sensation and facial motor responseFacial sensation and facial motor response►Pharyngeal and tracheal reflexesPharyngeal and tracheal reflexes



1014: 1014:


►B. Coma, lack of brainstem reflexes, B. Coma, lack of brainstem reflexes, and apneaand apnea 3. Apnea: 3. Apnea: very specificvery specific description of description of

apnea testing protocol e.g. core temp apnea testing protocol e.g. core temp ≥ ≥ 36.5˚C; BP, volume, baseline PO36.5˚C; BP, volume, baseline PO22 and and PCOPCO22



1014: 1014:

II. II. Pitfalls in the diagnosis of brain deathPitfalls in the diagnosis of brain death

►A. Severe facial traumaA. Severe facial trauma►B. Preexisting pupillary abonormalitiesB. Preexisting pupillary abonormalities►C. Toxic levels of any: sedatives, C. Toxic levels of any: sedatives,

aminoglycosides, TCA’s, aminoglycosides, TCA’s, anticholinergics, AED’s, anticholinergics, AED’s, chemotherapeutic agents, or NM chemotherapeutic agents, or NM blocking agentsblocking agents

►D. Chronic COD. Chronic CO22 retention retention



1014: 1014:

III. III. Clinical observations compatible with the diagnosis Clinical observations compatible with the diagnosis of brain deathof brain death

►A. Spontaneous movementsA. Spontaneous movements►B. Respiratory-like movementsB. Respiratory-like movements►C. Sweating, blushing, tachycardiaC. Sweating, blushing, tachycardia►D. Normal BP without pressorsD. Normal BP without pressors►E. Absence of diabetes insipidusE. Absence of diabetes insipidus►F. DTR’s, superficial abdominal F. DTR’s, superficial abdominal

reflexes, triple flexion responsereflexes, triple flexion response►G. Babinski reflexG. Babinski reflex



1014: 1014:

IV. IV. Confirmatory laboratory tests (Options)Confirmatory laboratory tests (Options)

►““Brain death is a clinical diagnosis. A Brain death is a clinical diagnosis. A repeat clinical evaluation 6 hours later repeat clinical evaluation 6 hours later is recommended, but this interval is is recommended, but this interval is arbitrary. A confirmatory test is not arbitrary. A confirmatory test is not mandatory but is desirable in patients mandatory but is desirable in patients in whom specific components of in whom specific components of clinical testing cannot be reliably clinical testing cannot be reliably performed or evaluated….most performed or evaluated….most sensitive test [is listed] first:sensitive test [is listed] first:



1014: 1014:

IV. IV. Confirmatory laboratory tests (Options)(specific Confirmatory laboratory tests (Options)(specific criteria described for all)criteria described for all)

►A. Conventional Angiography A. Conventional Angiography ►B. EEG: no electrical activity over B. EEG: no electrical activity over ≥≥30’30’►C. Transcranial Doppler U/SC. Transcranial Doppler U/S►D. Technetium-99m HMPA brain scanD. Technetium-99m HMPA brain scan►E. Somatosensory evoked potentialsE. Somatosensory evoked potentials



1014: 1014:

V. V. Medical record documentation (Medical record documentation (StandardStandard))► A. Etiology and irreversibility of condition A. Etiology and irreversibility of condition ► B. Absence of brainstem reflexesB. Absence of brainstem reflexes► C. Absence of motor response to painC. Absence of motor response to pain► D. Absence of respiration with PCOD. Absence of respiration with PCO22≥≥60 mm 60 mm

HgHg► E. Justification for confimatory test and result E. Justification for confimatory test and result

of confirmatory testof confirmatory test► F. Repeat neurologic examination F. Repeat neurologic examination Option: Option: the the

interval is arbitrary, but a 6-hour period is interval is arbitrary, but a 6-hour period is reasonablereasonable

Canadian criteria Canadian criteria Guidelines for the Guidelines for the

diagnosis of brain death. Canadian Neurocritical Care Group. Can diagnosis of brain death. Canadian Neurocritical Care Group. Can J Neurol Sci 1999;26:64-6J Neurol Sci 1999;26:64-6

► I haven’t obtained this reference yet I haven’t obtained this reference yet but secondary report:but secondary report: Doesn’t require testing of oculocephalic Doesn’t require testing of oculocephalic

reflexreflex Permits core temperature as low as Permits core temperature as low as

32.232.2˚C during the apnea test˚C during the apnea test Interval between exams as short as 2 Interval between exams as short as 2

hours; as long as 24 hours for anoxic-hours; as long as 24 hours for anoxic-ischemic insultischemic insult

““State Law”State Law”

► Practice parameters for determining brain Practice parameters for determining brain death in adults death in adults (summary statement)(summary statement) NEUROLOGY 1995;45:1012-1014NEUROLOGY 1995;45:1012-1014

““Regardless of the conclusions of this statement , Regardless of the conclusions of this statement , the Quality Standards Subcommittee of the AAN the Quality Standards Subcommittee of the AAN recognizes the need to comply with state law.”recognizes the need to comply with state law.”

Does RI have an applicable statute?Does RI have an applicable statute? RIDOH has no specific policy or guidelines for RIDOH has no specific policy or guidelines for

Brain Death determination; leaves it to Brain Death determination; leaves it to institutions to develop their owninstitutions to develop their own

►should Ethics Network look into standardization across should Ethics Network look into standardization across the state?the state?

Brain Death Protocols in some RI Brain Death Protocols in some RI hospitalshospitals

►Hospital #1: no protocolHospital #1: no protocol►Hospital #2: based on President’s Hospital #2: based on President’s

Commission but criteria somewhat Commission but criteria somewhat vague and only semi-algorithmicvague and only semi-algorithmic

►Hospital #3: based on 1995 Practice Hospital #3: based on 1995 Practice Parameters; precise criteria and Parameters; precise criteria and precise algorithm providedprecise algorithm provided

►Other hospitals around the state?Other hospitals around the state?

Brain Death around the worldBrain Death around the worldWijdicks EFM. Brain death worldwide: Accepted fact but no global Wijdicks EFM. Brain death worldwide: Accepted fact but no global

consensus in diagnostic criteria consensus in diagnostic criteria NEUROLOGY 2002;58:20-25NEUROLOGY 2002;58:20-25

► Guidelines of 80 countries reviewedGuidelines of 80 countries reviewed► Legal standards on organ transplantation present in Legal standards on organ transplantation present in

69% (55 of 80 countries)69% (55 of 80 countries)► Practice guidelines for brain death for adults in 88%Practice guidelines for brain death for adults in 88%

50% guidelines require >1 physician to declare50% guidelines require >1 physician to declare All guidelines specified exclusion of confounders, presence All guidelines specified exclusion of confounders, presence

of irreversible coma, absent motor response, and absent of irreversible coma, absent motor response, and absent brainstem reflexesbrainstem reflexes

Apnea testing required in 59%Apnea testing required in 59% differences in time of observation and required expertise of differences in time of observation and required expertise of

examining physiciansexamining physicians Confirmatory laboratory testing mandatory in 28 of 70 Confirmatory laboratory testing mandatory in 28 of 70

(40%) guidelines(40%) guidelines

Brain Death around the worldBrain Death around the worldWijdicks EFM. Brain death worldwide: Accepted fact but no global Wijdicks EFM. Brain death worldwide: Accepted fact but no global

consensus in diagnostic criteria consensus in diagnostic criteria NEUROLOGY 2002;58:20-25NEUROLOGY 2002;58:20-25

►Conclusion: “uniform agreement on Conclusion: “uniform agreement on the neurologic exam with exception of the neurologic exam with exception of the apnea test; but other major the apnea test; but other major differences found in the procedures for differences found in the procedures for diagnosing brain death in adults, and diagnosing brain death in adults, and standardization should be considered.”standardization should be considered.”

Misconceptions:Misconceptions:

► 1. There is one nationally or internationally 1. There is one nationally or internationally accepted standard for determination of accepted standard for determination of brain death. In fact there is variability and brain death. In fact there is variability and inconsistency over time and at single points inconsistency over time and at single points in time including the present:in time including the present: between published guidelines (differences between published guidelines (differences

between 1968 Harvard criteria, 1981 Presidents between 1968 Harvard criteria, 1981 Presidents Commission, 1995 Practice Parameters; 1999 Commission, 1995 Practice Parameters; 1999 Canadian criteria)Canadian criteria)

between jurisdictions (especially internationally)between jurisdictions (especially internationally) among patient populationsamong patient populations in the use of confirmatory testsin the use of confirmatory tests

Misconceptions: “Brain Death” ?Misconceptions: “Brain Death” ?sufficient for withdrawal of sufficient for withdrawal of

mechanical ventilationmechanical ventilation► Case: ICU patient; multi-organ failure, comatose Case: ICU patient; multi-organ failure, comatose

since cardiopulmonary arrest. Caregivers feel since cardiopulmonary arrest. Caregivers feel ongoing tx futile but family wants to continue. ongoing tx futile but family wants to continue. Neurology consult requested to determine if “Brain Neurology consult requested to determine if “Brain Death” applies to ?convince family to change to Death” applies to ?convince family to change to CMO. Implication also that if Brain Death CMO. Implication also that if Brain Death determined, ICU could d/c vent even if family determined, ICU could d/c vent even if family disagreed. disagreed. No potential for organ donation.No potential for organ donation. Hospital didn’t have Brain Death ProtocolHospital didn’t have Brain Death Protocol ?state law doesn’t define “brain death” (???)?state law doesn’t define “brain death” (???) Consultant: don’t need “brain death” for this; need good Consultant: don’t need “brain death” for this; need good

communication with family so they understand fully the communication with family so they understand fully the prognosis and valid option to withdraw interventions (even prognosis and valid option to withdraw interventions (even ventilation)ventilation)

?Misconceptions: “Brain ?Misconceptions: “Brain Death” ?necessary for Death” ?necessary for

withdrawal of mechanical withdrawal of mechanical ventilationventilation►““brain death” originally motivated by brain death” originally motivated by

potential for organ transplantation but potential for organ transplantation but concept often being invoked for concept often being invoked for decision-making even when there is no decision-making even when there is no potential for organ donationpotential for organ donation

misconceptionsmisconceptions

►All medical personnel, especially ICU All medical personnel, especially ICU staffs, have consistent and accurate staffs, have consistent and accurate understandings of brain death criteriaunderstandings of brain death criteria 64% physicians and 28% of non-physician 64% physicians and 28% of non-physician

staff correctly identified clinical criteria for staff correctly identified clinical criteria for brain death and/or correctly identified brain death and/or correctly identified patients as dead vs. alive in case scenariospatients as dead vs. alive in case scenarios

►Brain death Brain death ≡ loss of cortical function≡ loss of cortical function i.e. need loss of i.e. need loss of brainstembrainstem function as well function as well

PitfallsPitfalls

► Incorrect application of accepted criteriaIncorrect application of accepted criteria Van Norman GA, A matter of life and death. Anesthesiology 1999;91:275-Van Norman GA, A matter of life and death. Anesthesiology 1999;91:275-8787

e.g. 2 patients with devastating brain injuries e.g. 2 patients with devastating brain injuries certified as brain dead and referred for organ certified as brain dead and referred for organ donation donation despite the presence of despite the presence of spontaneous respirations and in one of them spontaneous respirations and in one of them movement during organ retrieval leading to movement during organ retrieval leading to use of muscle relaxants and general use of muscle relaxants and general anesthesiaanesthesia

e.g. brain death determined after patient e.g. brain death determined after patient received IV muscle relaxants and Mg low received IV muscle relaxants and Mg low (eventually patient discharged home alert (eventually patient discharged home alert and oriented)and oriented)

ControversiesControversies

►Philosophically, why need loss of Philosophically, why need loss of brainstem function as well? i.e. brainstem function as well? i.e. Harvard criteria based on Harvard criteria based on irreversibility irreversibility of comaof coma and and futility of care,futility of care, not “death not “death of the person.”of the person.”

Going forwardGoing forward

►Are current Brain Death criteria Are current Brain Death criteria satisfactory? Some are calling for satisfactory? Some are calling for additional study to see if they are as additional study to see if they are as reliable as “conventional wisdom” reliable as “conventional wisdom” suggests and many believe.suggests and many believe. Dead, or Dead Enough? Current algorithms Dead, or Dead Enough? Current algorithms

use certain measures; but those just measure use certain measures; but those just measure brain activity above a certain threshold brain activity above a certain threshold along along a continuuma continuum. Maybe some cells still . Maybe some cells still functioning? functioning? How to determine that threshold?How to determine that threshold?

Going ForwardGoing Forward Doig CJ and Burgess E, Brain Death: Doig CJ and Burgess E, Brain Death:

resolving inconsistencies in the ethical declaration of death. Can J resolving inconsistencies in the ethical declaration of death. Can J Anesth 2003;50(7):725-31Anesth 2003;50(7):725-31

►Are current Brain Death criteria Are current Brain Death criteria satisfactory? Some are calling for satisfactory? Some are calling for additional study to see if they are as additional study to see if they are as reliable as “conventional wisdom” reliable as “conventional wisdom” suggests and many believe.suggests and many believe. Tests of cortical and subcortical brain Tests of cortical and subcortical brain

function lack specificityfunction lack specificity Inconsistency of clinical criteriaInconsistency of clinical criteria

Going forwardGoing forward

► A need for more uniform criteria: note A need for more uniform criteria: note difficulty I had in obtaining “front-line” (i.e. difficulty I had in obtaining “front-line” (i.e. hospital) level information and variability hospital) level information and variability between hospitals within the state!between hospitals within the state! Within the stateWithin the state nationallynationally ?internationally?internationally

► Ethics network look into this, determine Ethics network look into this, determine what the various hospitals have and don’t what the various hospitals have and don’t have, andadvocate for more uniform criteria have, andadvocate for more uniform criteria within Rhode Island?within Rhode Island?

Rosenbaum, S. Ethical conflicts. Rosenbaum, S. Ethical conflicts. Anesthesiology 1999;91:3-4Anesthesiology 1999;91:3-4

►““If one subject in health law and If one subject in health law and bioethics can be said to be at once bioethics can be said to be at once well settled and persistently well settled and persistently unresolved, it is how to determine that unresolved, it is how to determine that death has occurred.”death has occurred.”

brain death: the neurologist’s perspective stephen t. mernoff, md clinical assistant professor of...

Documents

definition of brain

coma irreversible

concept of brain death

futile slide

determination slide

apnea slide

harvard medical school

harvard criteria report