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Handbook of Clinical Neurology 2019Declaration of brain death requires demonstration of irreversible injury to the whole brain including the brainstem. Current guidelines rely on bedside clinical... (Review)
Review
Declaration of brain death requires demonstration of irreversible injury to the whole brain including the brainstem. Current guidelines rely on bedside clinical examination to determine that the patient has irreversible coma, absent cranial nerve reflexes, and apnea. Neurophysiologic testing to support the clinical diagnosis of brain death has primarily consisted of EEG and evoked potentials-typically a combination of somatosensory evoked potential and brainstem auditory evoked potential. The diagnostic accuracy of these ancillary tests has been studied for the last few decades but the role of ancillary neurophysiologic testing in brain death continues to be a source of controversy. This chapter reviews the relevant studies and guidelines about EEG and evoked potentials in ancillary testing for brain death. Clinical scenarios in which neurophysiologic testing may aid the declaration of brain death include equivocal results of clinical examination findings, inability to perform some aspects of the neurologic examination, concern for residual sedative effects, suspected spinal cord or neuromuscular injury, and posterior fossa lesions with brainstem involvement. In these scenarios, EEG and evoked potentials may offer supportive evidence for irreversible injury to the whole brain. This chapter also discusses differences between current adult and pediatric guidelines for the role of ancillary testing in brain death.
Topics: Brain Death; Humans; Practice Guidelines as Topic
PubMed: 31307622
DOI: 10.1016/B978-0-444-64142-7.00042-4 -
Handbook of Clinical Neurology 2013The diagnosis of brain death should be based on a simple premise. If every possible confounder has been excluded and all possible treatments have been tried or... (Review)
Review
The diagnosis of brain death should be based on a simple premise. If every possible confounder has been excluded and all possible treatments have been tried or considered, irreversible loss of brain function is clinically recognized as the absence of brainstem reflexes, verified apnea, loss of vascular tone, invariant heart rate, and, eventually, cardiac standstill. This condition cannot be reversed - not even partly - by medical or surgical intervention, and thus is final. Many countries in the world have introduced laws that acknowledge that a patient can be declared brain-dead by neurologic standards. The U.S. law differs substantially from all other brain death legislation in the world because the U.S. law does not spell out details of the neurologic examination. Evidence-based practice guidelines serve as a standard. In this chapter, I discuss the history of development of the criteria, the current clinical examination, and some of the ethical and legal issues that have emerged. Generally, the concept of brain death has been accepted by all major religions. But patients' families may have different ideas and are mostly influenced by cultural attitudes, traditional customs, and personal beliefs. Suggestions are offered to support these families.
Topics: Brain Death; Humans
PubMed: 24182378
DOI: 10.1016/B978-0-444-53501-6.00016-0 -
Journal of Intensive Care Medicine Sep 2015In the United States, each year 1% to 2% of deaths are brain deaths. Considerable variation in the practice of determining brain death still remains, despite the... (Review)
Review
In the United States, each year 1% to 2% of deaths are brain deaths. Considerable variation in the practice of determining brain death still remains, despite the publication of practice parameters in 1995 and an evidence-based guideline update in 2010. This review is intended to give bedside clinicians an overview of definition, the causes and pitfalls of misdiagnosing brain death, and a focus on the specifics of the brain death determination process.
Topics: Brain Death; Cerebral Angiography; Diagnostic Errors; Electroencephalography; Humans; Practice Guidelines as Topic; Radionuclide Imaging; United States
PubMed: 24227449
DOI: 10.1177/0885066613511053 -
Current Opinion in Anaesthesiology Oct 2022Brain death, also known as death by neurologic criteria (DNC), is a well-established concept. In this article, we present a short history of the concept and give an... (Review)
Review
PURPOSE OF REVIEW
Brain death, also known as death by neurologic criteria (DNC), is a well-established concept. In this article, we present a short history of the concept and give an overview of recent changes and a practical update on diagnosis and definitions of brain death/DNC. Unresolved issues will be discussed.
RECENT FINDINGS
There is variability in brain death/DNC determination worldwide. In recent years, successful attempts have been made to harmonize these criteria and, consequently, to improve public trust in the process and diagnosis. An international multidisciplinary collaboration has been created and it has published minimum criteria, provided guidance for professionals and encouragement to revise or develop guidelines on brain death/DNC worldwide.
SUMMARY
There are two sets of criteria for declaration of death. First, if there is neither cardiac output nor respiratory effort, then cardiopulmonary criteria are used. Second, if both the cerebrum and brainstem have completely and permanently lost all functions, and there is a persistent coma, absent brainstem reflexes and no spontaneous respiratory effort, death can be declared on the basis of brain death/DNC. Although attempts to formulate uniform criteria are ongoing, consensus has been reached on the minimum criteria. Some inconsistencies and questions remain.
Topics: Brain Death; Consensus; Humans
PubMed: 35942705
DOI: 10.1097/ACO.0000000000001173 -
Neurologic Clinics Aug 2023Although the fundamental principle behind the Uniform Determination of Death Act (UDDA), the equivalence of death by circulatory-respiratory and neurologic criteria, is... (Review)
Review
Although the fundamental principle behind the Uniform Determination of Death Act (UDDA), the equivalence of death by circulatory-respiratory and neurologic criteria, is accepted throughout the United States and much of the world, some families object to brain death/death by neurologic criteria. Clinicians struggle to address these objections. Some objections have been brought to court, particularly in the United States, leading to inconsistent outcomes and discussion about potential modifications to the UDDA to minimize ethical and legal controversies related to the determination of brain death/death by neurologic criteria.
Topics: Humans; Brain Death; United States
PubMed: 37407100
DOI: 10.1016/j.ncl.2023.03.004 -
The Medico-legal Journal Mar 2019The concept of brain death has been a very intriguing topic and has taken many forms over the years. Brain stem death is a complex state of inactivity defined by the... (Review)
Review
The concept of brain death has been a very intriguing topic and has taken many forms over the years. Brain stem death is a complex state of inactivity defined by the loss of reflexes of the pathways that pass through the brain stem, the 'shaft' of the brain which links the spinal cord to the cerebral cortex and the cerebellum where there is apnoea, loss of eye movement and pain sensation. There are many criteria, based on which a person can be said to be brain dead. The best recognised of these are the Harvard, Minnesota and Philadelphia criteria. India follows the UK notion of brain stem death, and the Transplantation of Human Organs Act was passed in 1994 by the Indian parliament, which legalised brain-stem death, and in 1995 ordered the brain death certification procedure, which is certified by a 'Board of Medical Experts'. Also, there are some legal and ethical implications that have to be considered in cases of disagreement in diagnosis among the panel of doctors, time of death in cases when patients' relatives disagree or request more time for organ donation or to disconnect the life support system. In routine clinical practice, the issues pertaining to brain stem death should be dealt with by experienced physicians, counselling the family members or relatives and educating them about organ donation.
Topics: Brain Death; Brain Stem; History, 19th Century; History, 20th Century; Humans; Tissue and Organ Procurement
PubMed: 30785835
DOI: 10.1177/0025817218822008 -
Journal of Neurology, Neurosurgery, and... Mar 2021Brain death, or death by neurological criteria (BD/DNC), has been accepted conceptually, medically and legally for decades. Nevertheless, some areas remain controversial... (Review)
Review
Brain death, or death by neurological criteria (BD/DNC), has been accepted conceptually, medically and legally for decades. Nevertheless, some areas remain controversial or understudied, pointing to a need for focused research to advance the field. Multiple recent contributions have increased our understanding of BD/DNC, solidified our practice and provided guidance where previously lacking. There have also been important developments on a global scale, including in low-to-middle income countries such as in South America. Although variability in protocols and practice still exists, new efforts are underway to reduce inconsistencies and better train practitioners in accurate and sound BD/DNC determination. Various legal challenges have required formal responses from national societies, and the American Academy of Neurology has filled this void with much needed guidance. Questions remain regarding concepts such as 'whole brain' versus 'brainstem' death, and the intersection of BD/DNC and rubrics of medical futility. These concepts are the subject of this review.
Topics: Brain Death; Humans
PubMed: 33219040
DOI: 10.1136/jnnp-2020-323952 -
Revista Brasileira de Terapia Intensiva 2019Brain death, defined as the complete and irreversible loss of brain functions, has a history that is linked to the emergence of intensive care units and the advancement... (Review)
Review
Brain death, defined as the complete and irreversible loss of brain functions, has a history that is linked to the emergence of intensive care units and the advancement of artificial ventilatory support. In Brazil, by federal law, the criteria for the diagnosis of brain death have been defined by the Federal Council of Medicine since 1997 and apply to the entire Brazilian territory. Resolution 2,173/2017 of the Federal Council of Medicine updated the criteria for diagnosing brain death. These changes include the following: the requirement for the patient to meet specific physiological prerequisites and for the physician to provide optimized care to the patient before starting the procedures for diagnosing brain death and to perform complementary tests, as well as the need for specific training for physicians who make this diagnosis. Other changes include the reduction of the time interval between the two clinical examinations, the possibility of continuing procedures in the presence of unilateral ear or eye injury, the performance of a single apnea test and the creation of a statement of brain death determination that includes the recording of all procedures in a single document. This document, despite the controversy surrounding it, increases the safety necessary when establishing a diagnosis of such importance and has positive implications that extend beyond the patient and the physician to reach the entire health system.
Topics: Brain Death; Brazil; Diagnostic Techniques and Procedures; Humans
PubMed: 31618361
DOI: 10.5935/0103-507X.20190050 -
The American Journal of Nursing Mar 2020In 1968, the criteria for brain death were established by the Harvard Ad Hoc Committee. Despite what may appear to be unambiguous definitions, clinicians, ethicists, and... (Review)
Review
In 1968, the criteria for brain death were established by the Harvard Ad Hoc Committee. Despite what may appear to be unambiguous definitions, clinicians, ethicists, and the public have grappled with the concept of brain death since its inception. In light of recent public discourse on the topic, Harvard Medical School convened a conference to examine research and ethical inquiry conducted over the past 50 years related to death as defined by neurologic criteria. Drawing on the report produced by this conference, this article provides an overview of the development of brain death criteria, describes recent controversies and updates, and discusses implications of these criteria for nurses.
Topics: Bioethics; Brain Death; Family; History, 20th Century; History, 21st Century; Humans; Nurses; Practice Guidelines as Topic
PubMed: 32049689
DOI: 10.1097/01.NAJ.0000656332.62081.98 -
Seminars in Neurology Apr 2015Some of the seminal steps toward the recognition and definition of brain death were European. There is a general consensus on both the medical concept of brain death in... (Review)
Review
Some of the seminal steps toward the recognition and definition of brain death were European. There is a general consensus on both the medical concept of brain death in Europe as well as the minimum fundamental clinical standards that are required for its diagnosis-the absence of consciousness, brainstem reflexes, and the ability to breathe in the absence of reversible or confounding conditions. Two aspects of brain death determination are addressed in this article. The authors analyze how brain death is diagnosed across Europe, identifying both the similarities and differences that exist between countries (the latter mainly concerning ancillary tests, timing, and the number of physicians involved in the brain death determination). In addition, they describe the very considerable variations in when brain death determinations are made between and within individual European countries, and propose that they are due to differences in the end-of-life care practices in patients with irreversible brain injuries, medical attitudes, and organ donation practices. Although legislation is available to standardize the brain death diagnosis process in most individual European countries, there are still disparities across Europe as a whole. The current variation in practice makes a continental consensus for the definition of brain death imperative.
Topics: Brain Death; Consensus; Europe; Humans; Practice Guidelines as Topic
PubMed: 25839722
DOI: 10.1055/s-0035-1547533