Brain Death: The Neurologist's Perspective

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

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 applied Not one universally and consistently applied

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

VersaliusVersalius

►Madrid, 1564Madrid, 1564►AnatomistAnatomist►At autopsy: thorax openedAt autopsy: thorax openedheart beating!heart 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 cardiopulmonary Death: traditional cardiopulmonary definitiondefinition

►AsystoleAsystoleANDAND

►ApneaApnea

Mollaret P and Goulon M. Le coma Mollaret P and Goulon M. Le coma ddéépasspassé [“a state beyond coma”]é [“a state beyond coma”]. . Rev Rev

Neurol 1959;101:3-15Neurol 1959;101:3-15

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

►Criteria suggestedCriteria suggested►Not recognized widelyNot recognized widely

““Harvard Criteria”Harvard Criteria”Report 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

► Driving forces: advances in careDriving forces: advances in care mechanical venti lat ion and ICU’smechanical venti lat ion and ICU’s Organ transplantation:Organ transplantation: cadaver (non-heart-beating) cadaver (non-heart-beating)

donors donors but some surgeons harvesting from patients with but some surgeons harvesting from patients with neurologic catastrophes:neurologic catastrophes: patients died patients died afterafter transplantationtransplantation

► 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 dead;--premise: not idea that brain, therefore person, is 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 Examine the Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-Definition of Brain Death. A definition of irreversible coma. JAMA 1968;205:337-

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

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

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


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

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

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

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


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

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

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

2.2. No Movements or Breathing: No Movements or Breathing: no spontaneous movements or no spontaneous movements or spontaneous respiration (turn off respirator for 3 minutes; prior to spontaneous respiration (turn off respirator for 3 minutes; prior to trial breathing room air for trial breathing room air for ≥≥10 minutes and pCO10 minutes and pCO2 2 normal) or normal) or response to pain, touch, sound or light for an hour.response to pain, touch, sound or light for an hour.


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

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


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

leads to r/o confounders “At least 10 full minutes of recording are leads to r/o confounders “At least 10 full minutes of recording are desirable, but twice that would be better.” [!])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 be If EEG unavailable, “the absence of cerebral function has to be

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

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


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


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

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

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

Subsequent literature concerned that criteria Subsequent literature concerned that criteria biased by participation of transplant surgeons biased by participation of transplant surgeons on the committee whose programs could on the committee whose programs could advance with brain death definedadvance 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 of Guidelines for the Determination of Death 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 Commission Diagnosis of Death to the President’s Commission for the Study of Ethical Problems in Medicine and for the Study of Ethical Problems in Medicine and Biomedical and Behavioral ResearchBiomedical and Behavioral Research

► 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 of Guidelines for the Determination of Death 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 (1) An individual who has sustained either (1)

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

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

► Note: presented in somewhat narrative and Note: presented in somewhat narrative and somewhat algorithmic form; improvement from somewhat algorithmic form; improvement from Harvard criteria but still room for interpretation of Harvard criteria but still room for interpretation of what to do and when.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 section B (neurological) is dead….a diagnosis of death (neurological) is dead….a diagnosis of death requires that requires that bothboth cessation of functions cessation of functions andand irreversibility…be demonstrated.”irreversibility…be demonstrated.”


► ““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 clinical is recognized by an appropriate clinical

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

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


► ““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….” ““1. Cessation1. Cessation is recognized when evaluation discloses is recognized when evaluation discloses

findings of a 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;



findings of a findings of a andand b: b:►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; “When these oropharyngeal, and respiratory (apnea) reflexes; “When these reflexes cannot be adequately assessed, confirmatory tests are reflexes cannot be adequately assessed, confirmatory tests are recommended.”recommended.”

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



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

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


► ““B. An individual with irreversible cessation of all B. An individual with irreversible cessation of all functions of the entire brain, including the brain functions of the entire brain, including the brain stem, is dead….”stem, is dead….” ““2. Irreversibility2. Irreversibility is recognized when evaluation discloses findings is recognized when evaluation discloses findings

of a of a andand b b andand c” c” oror by absence of blood flow to the brain by absence of blood flow to the brain ≥≥10 10 minutes, shown by angiography :minutes, shown by angiography :► a. The cause of coma is established and is sufficient to account for the a. The cause of coma is established and is sufficient to account for the

loss of brain functions, and…loss of brain functions, and…► b. the possibility of recovery of any brain functions is excluded, and…” b. the possibility of recovery of any brain functions is excluded, and…”

(i.e. rule out sedation, hypothermia (i.e. rule out sedation, hypothermia <32.2˚C core temp<32.2˚C core temp, neuromuscular , neuromuscular blockade, and shock) blockade, and shock)

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

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

NEUROLOGY 1995;45:1012-1014NEUROLOGY 1995;45:1012-1014► Report of the Quality Standards Subcommittee of the Report of the Quality Standards Subcommittee of the

American Academy of NeurologyAmerican Academy of Neurology► Brain Death Definition: “the irreversible loss of functin of Brain Death Definition: “the irreversible loss of functin of

the brain, including the brainstem.”the brain, including the brainstem.”► Justification: “…need for standardization of the neurologic Justification: “…need for standardization of the neurologic

examination criteria for the diagnosis of brain death.”examination criteria for the diagnosis of brain death.”► Process: based on review of literature 1976-1994; are Process: based on review of literature 1976-1994; are

GUIDELINESGUIDELINES (class II evidence or strong consensus of (class II evidence or strong consensus of class III evidence)class III evidence)

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

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

I. I. Diagnostic CriteriaDiagnostic Criteria

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

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

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

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



►B. Coma, lack of brainstem reflexes, and B. Coma, lack of brainstem reflexes, and apneaapnea 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



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

testing protocol e.g. core temp testing protocol e.g. core temp ≥ 36.5˚C; BP, ≥ 36.5˚C; BP, volume, baseline POvolume, baseline PO22 and PCO and PCO22


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

►D. Chronic COD. Chronic CO22 retention retention


III. III. Clinical observations compatible with the diagnosis of brain Clinical observations compatible with the diagnosis of brain deathdeath

►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 reflexes, F. DTR’s, superficial abdominal reflexes,

triple flexion responsetriple flexion response►G. Babinski reflexG. Babinski reflex


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

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


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


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 Hg60 mm Hg► E. Justification for confimatory test and result of E. Justification for confimatory test and result of

confirmatory testconfirmatory 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 diagnosis of Guidelines for the diagnosis of brain death. Canadian Neurocritical Care Group. Can J Neurol Sci brain death. Canadian Neurocritical Care Group. Can J Neurol Sci

1999;26:64-61999;26:64-6

► I haven’t obtained this reference yet but I haven’t obtained this reference yet but secondary report:secondary report: Doesn’t require testing of oculocephalic reflexDoesn’t require testing of oculocephalic reflex Permits core temperature as low as 32.2Permits core temperature as low as 32.2˚C ˚C

during the apnea testduring the apnea test Interval between exams as short as 2 hours; as Interval between exams as short as 2 hours; as

long as 24 hours for anoxic-ischemic insultlong as 24 hours for anoxic-ischemic insult

““State Law”State Law”► Practice parameters for determining brain death in Practice parameters for determining brain death in

adults adults (summary statement)(summary statement) NEUROLOGY 1995;45:1012-1014NEUROLOGY 1995;45:1012-1014

““Regardless of the conclusions of this statement , the Regardless of the conclusions of this statement , the Quality Standards Subcommittee of the AAN recognizes Quality Standards Subcommittee of the AAN recognizes the need to comply with state law.”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 Brain RIDOH has no specific policy or guidelines for Brain

Death determination; leaves it to institutions to develop Death determination; leaves it to institutions to develop their owntheir own►should Ethics Network look into standardization across the should Ethics Network look into standardization across the

state?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 vague Commission but criteria somewhat vague and only semi-algorithmicand only semi-algorithmic

►Hospital #3: based on 1995 Practice Hospital #3: based on 1995 Practice Parameters; precise criteria and precise Parameters; precise criteria and precise algorithm providedalgorithm 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 consensus Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensus

in diagnostic criteria 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 69% Legal standards on organ transplantation present in 69%

(55 of 80 countries)(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 of All guidelines specified exclusion of confounders, presence of

irreversible coma, absent motor response, and absent brainstem irreversible coma, absent motor response, and absent brainstem reflexesreflexes

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 (40%) Confirmatory laboratory testing mandatory in 28 of 70 (40%)

guidelinesguidelines

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

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

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

Misconceptions:Misconceptions:► 1. There is one nationally or internationally 1. There is one nationally or internationally

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

1968 Harvard criteria, 1981 Presidents Commission, 1968 Harvard criteria, 1981 Presidents Commission, 1995 Practice Parameters; 1999 Canadian criteria)1995 Practice Parameters; 1999 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” ?sufficient Misconceptions: “Brain Death” ?sufficient for withdrawal of mechanical ventilationfor withdrawal of mechanical ventilation

► Case: ICU patient; multi-organ failure, comatose since Case: ICU patient; multi-organ failure, comatose since cardiopulmonary arrest. Caregivers feel ongoing tx futile cardiopulmonary arrest. Caregivers feel ongoing tx futile but family wants to continue. Neurology consult requested but family wants to continue. Neurology consult requested to determine if “Brain Death” applies to ?convince family to to determine if “Brain Death” applies to ?convince family to change to CMO. Implication also that if Brain Death change to CMO. Implication also that if Brain Death determined, ICU could d/c vent even if family disagreed. determined, ICU could d/c vent even if family 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 prognosis communication with family so they understand fully the prognosis and valid option to withdraw interventions (even ventilation)and valid option to withdraw interventions (even ventilation)

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

mechanical ventilationmechanical ventilation► ““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 decision-concept often being invoked for decision-making even when there is no potential for making even when there is no potential for organ donationorgan donation

misconceptionsmisconceptions

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

correctly identified clinical criteria for brain death correctly identified clinical criteria for brain death and/or correctly identified patients as dead vs. and/or correctly identified patients as dead vs. alive in case scenariosalive 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 Van

Norman GA, A matter of life and death. Anesthesiology 1999;91:275-87Norman GA, A matter of life and death. Anesthesiology 1999;91:275-87 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 spontaneous despite the presence of spontaneous respirations and in one of them movement respirations and in one of them movement during organ retrieval leading to use of muscle during organ retrieval leading to use of muscle relaxants and general anesthesiarelaxants and general anesthesia

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 and (eventually patient discharged home alert and oriented)oriented)

ControversiesControversies

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

Going forwardGoing forward

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

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

Going ForwardGoing Forward Doig CJ and Burgess E, Brain Death: resolving Doig CJ and Burgess E, Brain Death: resolving inconsistencies in the ethical declaration of death. Can J Anesth 2003;50(7):725-inconsistencies in the ethical declaration of death. Can J Anesth 2003;50(7):725-

3131

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

lack specificitylack specificity Inconsistency of clinical criteriaInconsistency of clinical criteria

Going forwardGoing forward► A need for more uniform criteria: note difficulty I A need for more uniform criteria: note difficulty I

had in obtaining “front-line” (i.e. hospital) level had in obtaining “front-line” (i.e. hospital) level information and variability between hospitals within information and variability between hospitals within the state!the state! Within the stateWithin the state nationallynationally ?internationally?internationally

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

Brain Death: The Neurologist's Perspective

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