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Neurological Sciences : Official... Sep 2021One of the first attempts to define brain death (BD) dates from 1963, and since then, the diagnosis criteria of that entity have evolved. In spite of the publication of... (Review)
Review
One of the first attempts to define brain death (BD) dates from 1963, and since then, the diagnosis criteria of that entity have evolved. In spite of the publication of practice parameters and evidence-based guidelines, BD is still causing concern and controversies in the society. The difficulties in determining brain death and making it understood by family members not only endorse futile therapies and increase health care costs, but also hinder the organ transplantation process. This review aims to give an overview about the definition of BD, causes, physiopathology, diagnosis criteria, and management of the potential brain-dead donor. It is important to note that the BD determination criteria detailed here follow the AAN's recommendations, but the standard practice for BD diagnosis varies from one country to another.
Topics: Brain Death; Family; Humans; Tissue Donors; Tissue and Organ Procurement
PubMed: 34138388
DOI: 10.1007/s10072-021-05360-6 -
Canadian Journal of Anaesthesia =... Apr 2023This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as...
This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as recommendations for death determination by circulatory criteria for potential organ donors and death determination by neurologic criteria for all mechanically ventilated patients regardless of organ donation potential. This Guideline is endorsed by the Canadian Critical Care Society, the Canadian Medical Association, the Canadian Association of Critical Care Nurses, Canadian Anesthesiologists' Society, the Canadian Neurological Sciences Federation (representing the Canadian Neurological Society, Canadian Neurosurgical Society, Canadian Society of Clinical Neurophysiologists, Canadian Association of Child Neurology, Canadian Society of Neuroradiology, and Canadian Stroke Consortium), Canadian Blood Services, the Canadian Donation and Transplantation Research Program, the Canadian Association of Emergency Physicians, the Nurse Practitioners Association of Canada, and the Canadian Cardiovascular Critical Care Society.
Topics: Child; Humans; Canada; Tissue Donors; Tissue and Organ Procurement; Brain; Physicians; Death; Brain Death
PubMed: 37131020
DOI: 10.1007/s12630-023-02431-4 -
The Lancet. Neurology Sep 2004We review the nosological criteria and functional neuroanatomical basis for brain death, coma, vegetative state, minimally conscious state, and the locked-in state.... (Review)
Review
We review the nosological criteria and functional neuroanatomical basis for brain death, coma, vegetative state, minimally conscious state, and the locked-in state. Functional neuroimaging is providing new insights into cerebral activity in patients with severe brain damage. Measurements of cerebral metabolism and brain activations in response to sensory stimuli with PET, fMRI, and electrophysiological methods can provide information on the presence, degree, and location of any residual brain function. However, use of these techniques in people with severe brain damage is methodologically complex and needs careful quantitative analysis and interpretation. In addition, ethical frameworks to guide research in these patients must be further developed. At present, clinical examinations identify nosological distinctions needed for accurate diagnosis and prognosis. Neuroimaging techniques remain important tools for clinical research that will extend our understanding of the underlying mechanisms of these disorders.
Topics: Brain; Brain Death; Diagnostic Imaging; Humans; Persistent Vegetative State; Point-of-Care Systems; Quadriplegia
PubMed: 15324722
DOI: 10.1016/S1474-4422(04)00852-X -
Neurology India 2018Until six decades ago, death was considered to be a specific point in time, referring to the moment at which life ends. With the availability of ventilators, even...
Until six decades ago, death was considered to be a specific point in time, referring to the moment at which life ends. With the availability of ventilators, even determining when death has occurred is becoming difficult, as cessation of life functions is often not simultaneous across organ systems. With increasing accessibility to intensive care units (ICUs) even in Tier II and Tier III cities, and the government making it mandatory to notify brain death to facilitate cadaveric organ transplants, it behooves the neurosurgeon and neurologist to totally understand the minutiae of brain death. The author reflects on his personal experience in certifying brain death, over two decades, in a quaternary care hospital. Knowing the pathophysiology of brain stem dysfunction will help the clinician better understand the rationale of the mandatory clinical tests prescribed. The necessity for an early diagnosis and the pitfalls in the clinical diagnosis of brain death, the limitations of the so-called confirmatory tests, and the concerns and ethical issues will be highlighted. Review of the world literature demonstrates that there is no international consensus even on what constitutes brain death. An individual could be considered legally dead in one country but not in another!
Topics: Brain Death; History, 20th Century; Humans; India; Intensive Care Units
PubMed: 29547144
DOI: 10.4103/0028-3886.227287 -
Neurologic Clinics May 1999Current law in the United States authorizes physicians to diagnose brain death by applying generally accepted neurologic criteria for determining loss of function of the... (Review)
Review
Current law in the United States authorizes physicians to diagnose brain death by applying generally accepted neurologic criteria for determining loss of function of the entire brain. This article offers a medical-legal perspective on problems that may arise with respect to the determination of brain death. These include the possibility of diagnostic error, conceptual disagreements that may constrain the use of neurologic criteria to diagnose death, and the conflation of brain death and loss of consciousness. This article also addresses legal aspects of the debate over whether to expand the definition of brain death to include permanent unconsciousness. Although existing laws draw a clear distinction between brain death and the persistent vegetative state, many courts have authorized removal of life support from individuals whose unconsciousness is believed to be permanent on proof that removal accords with preferences expressed before sentience was lost.
Topics: Adult; Advance Directives; Brain Death; Diagnostic Errors; Expert Testimony; Female; Humans; Legal Guardians; Life Support Care; Male; Neurologic Examination; United States
PubMed: 10196410
DOI: 10.1016/s0733-8619(05)70132-8 -
Experimental Physiology Dec 2019• What is the topic of this review? To explore the unique evolutionary origins of the human brain and critically appraise its energy budget, including limits of oxygen... (Review)
Review
NEW FINDINGS
• What is the topic of this review? To explore the unique evolutionary origins of the human brain and critically appraise its energy budget, including limits of oxygen and glucose deprivation during anoxia and ischaemia. • What advances does it highlight? The brain appears to be more resilient to substrate depletion than traditionally thought, highlighting greater resilience and an underappreciated capacity for functional recovery.
ABSTRACT
The human brain has evolved into an unusually large, complex and metabolically expensive organ that relies entirely on a continuous supply of O and glucose. It has traditionally been assumed that its exorbitant energy budget, combined with little to no energy reserves, renders it especially vulnerable to anoxia and ischaemia, with substrate depletion and progression towards cell death largely irreversible and rapid. However, new and exciting evidence suggests that neurons can survive for longer than previously thought, highlighting an unexpected resilience and underappreciated capacity for functional recovery that has changed the way we think about brain cell death. Nature has the potential to unlock some of the mysteries underlying ischaemic survival, with select vertebrates having solved the problem of anoxia-hypoxia tolerance over millions of years of evolution. Better understanding of their survival strategies, including remarkable adaptations in brain physiology and redox homeostasis, might help to identify new therapeutic targets for human diseases characterized by O deprivation, ischaemia-reperfusion injury and ageing.
Topics: Adaptation, Physiological; Animals; Brain Death; Energy Metabolism; Glucose; Humans; Hypoxia; Oxygen
PubMed: 31605408
DOI: 10.1113/EP088005 -
Journal of Bioethical Inquiry Sep 2023A "universalist" policy on brain death holds that brain death is death, and neurologic criteria for death determination are rightly applied to all, without exemptions or...
A "universalist" policy on brain death holds that brain death is death, and neurologic criteria for death determination are rightly applied to all, without exemptions or opt outs. This essay argues that advocates of a universalist brain death policy defend the same sort of coercive control of end-of-life decision-making as "pro-life" advocates seek to achieve for reproductive decision-making, and both are grounded in an illiberal political philosophy. Those who recognize the serious flaws of this kind of public policy with respect to abortion must apply the same logic to brain death.
Topics: Pregnancy; Female; Humans; Brain Death; Coercion; Abortion, Induced; Reproduction; Philosophy
PubMed: 37380827
DOI: 10.1007/s11673-023-10268-1 -
The Yale Journal of Biology and Medicine Dec 2019The diagnosis of brain death (BD) is legally and medically accepted. Recently, several high-profile cases have led to discussions regarding the integrity of current... (Review)
Review
The diagnosis of brain death (BD) is legally and medically accepted. Recently, several high-profile cases have led to discussions regarding the integrity of current criteria, and many physiologic problems have been identified to support the necessity for their reevaluation. These include a global variability of the criteria, the suggestion of a clinical "hierarchy," and the resultant approximation of BD. Further ambiguity has been exposed through case reports of reversible BD, and an inconsistent understanding from physicians who are viewed as experts in this domain. Meeting BD criteria clearly does not equate to a physiologic "death" of the brain, and a greater community perspective should be considered as the dialogue moves forward.
Topics: Brain Death; Guidelines as Topic; Humans; Physicians; Public Opinion
PubMed: 31866791
DOI: No ID Found -
Theoretical Medicine and Bioethics Oct 2019The dead donor rule holds that removing organs from living human beings without their consent is wrongful killing. The rule still prevails in most countries, and I...
The dead donor rule holds that removing organs from living human beings without their consent is wrongful killing. The rule still prevails in most countries, and I assume it without argument in order to pose the question: is it possible to have a metaphysically correct, clinically relevant analysis of human death that makes organ donation ethically permissible? I argue that the two dominant criteria of death-brain death and circulatory death-are both empirically and metaphysically inadequate as definitions of human death and therefore hold no epistemic value in themselves. I first set out a neo-Aristotelian theory of death as separation of soul (understood as organising principle) and body, which is then fleshed out as loss of organismic integrity. The brain and circulatory criteria are shown to have severe weaknesses as physiological manifestations of loss of integrity. Given the mismatch between what death is, metaphysically speaking, and the dominant criteria accepted by clinicians and philosophers, it turns out that only actual bodily decomposition is a sure sign of death. In this I differ from Alan Shewmon, whose important work I discuss in detail.
Topics: Brain Death; Ethics, Medical; Humans; Tissue and Organ Procurement
PubMed: 30945062
DOI: 10.1007/s11017-019-09479-8 -
Philosophy, Ethics, and Humanities in... Oct 2021Brain death has been accepted worldwide medically and legally as the biological state of death of the organism. Nevertheless, the literature has described persistent... (Review)
Review
Brain death has been accepted worldwide medically and legally as the biological state of death of the organism. Nevertheless, the literature has described persistent problems with this acceptance ever since brain death was described. Many of these problems are not widely known or properly understood by much of the medical community. Here we aim to clarify these issues, based on the two intractable problems in the brain death debates. First, the metaphysical problem: there is no reason that withstands critical scrutiny to believe that BD is the state of biological death of the human organism. Second, the epistemic problem: there is no way currently to diagnose the state of BD, the irreversible loss of all brain functions, using clinical tests and ancillary tests, given potential confounders to testing. We discuss these problems and their main objections and conclude that these problems are intractable in that there has been no acceptable solution offered other than bare assertions of an 'operational definition' of death. We present possible ways to move forward that accept both the metaphysical problem - that BD is not biological death of the human organism - and the epistemic problem - that as currently diagnosed, BD is a devastating neurological state where recovery of sentience is very unlikely, but not a confirmed state of irreversible loss of all [critical] brain functions. We argue that the best solution is to abandon the dead donor rule, thus allowing vital organ donation from patients currently diagnosed as BD, assuming appropriate changes are made to the consent process and to laws about killing.
Topics: Brain Death; Death; Humans; Organ Transplantation; Tissue Donors; Tissue and Organ Procurement
PubMed: 34625089
DOI: 10.1186/s13010-021-00107-9