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Brain Death: The Neurologist's Perspective

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Brain Death: The Neurologist's Perspective

  1. 1. Brain Death: TheBrain Death: The Neurologist’s PerspectiveNeurologist’s Perspective Stephen T. Mernoff, MDStephen T. Mernoff, MD Clinical Assistant Professor of Neurology, Brown MedicalClinical Assistant Professor of Neurology, Brown Medical SchoolSchool Medical Director, Neurorehabilitation Program, RehabilitationMedical Director, Neurorehabilitation Program, Rehabilitation Hospital of Rhode IslandHospital of Rhode Island Staff Neurologist, Roger Williams Medical CenterStaff Neurologist, Roger Williams Medical Center
  2. 2. LawLaw && OrderOrder
  3. 3. I thought this would be easyI thought this would be easy ►i.e. a 15 minute discussion outlining thei.e. a 15 minute discussion outlining the standard, uniformly accepted and appliedstandard, uniformly accepted and applied criteria for brain death and the method for itscriteria for brain death and the method for its determinationdetermination
  4. 4. 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 appliedNot one universally and consistently applied algorithm for determinationalgorithm for determination ►““If one subject in health law and bioethicsIf one subject in health law and bioethics can be said to be at once well settled andcan be said to be at once well settled and persistently unresolved, it is how topersistently 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
  5. 5. VersaliusVersalius ►Madrid, 1564Madrid, 1564 ►AnatomistAnatomist ►At autopsy: thorax openedAt autopsy: thorax openedheart beating!heart beating! ►Forced to leave SpainForced to leave Spain This event and othersThis event and others  need for formalneed for formal pronouncement of deathpronouncement of death
  6. 6. Death: traditional cardiopulmonaryDeath: traditional cardiopulmonary definitiondefinition ►AsystoleAsystole ANDAND ►ApneaApnea
  7. 7. Mollaret P and Goulon M. Le comaMollaret P and Goulon M. Le coma ddéépasspassé [“a state beyond coma”]é [“a state beyond coma”].. RevRev Neurol 1959;101:3-15Neurol 1959;101:3-15 ►Concept of Brain Death introduced: authorsConcept of Brain Death introduced: authors believed there was a definable conditionbelieved there was a definable condition from which recovery was impossiblefrom which recovery was impossible ►Criteria suggestedCriteria suggested ►Not recognized widelyNot recognized widely
  8. 8. ““Harvard Criteria”Harvard Criteria” Report of the Ad Hoc Committee of the Harvard Medical School toReport 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 ventilation and ICU’smechanical ventilation and ICU’s  Organ transplantation:Organ transplantation: cadaver (non-heart-beating)cadaver (non-heart-beating) donorsdonors but some surgeons harvesting from patients withbut some surgeons harvesting from patients with neurologic catastrophes:neurologic catastrophes: patients diedpatients 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 functionWhen 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
  9. 9. Harvard CriteriaHarvard Criteria Report of the Ad Hoc Committee of the Harvard Medical School to Examine theReport 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- 340340 ► Purpose: “…to define irreversible coma as a newPurpose: “…to define irreversible coma as a new criterion for death.”criterion for death.” ► ““There are two reasons why there is need for aThere are two reasons why there is need for a definition:definition:  1) improvements in resuscitative and supportive1) improvements in resuscitative and supportive measures…sometimes…only partial success…result ismeasures…sometimes…only partial success…result is an individual whose heart continues to beat but whosean individual whose heart continues to beat but whose brain is irreversibly damaged. The burdern is great onbrain is irreversibly damaged. The burdern is great on patients who suffer permanent loss of intellect, on theirpatients who suffer permanent loss of intellect, on their families, on the hositals, and those in need of hospitalfamilies, on the hositals, and those in need of hospital beds already occupied by those comatose patients.”beds already occupied by those comatose patients.”
  10. 10. Harvard CriteriaHarvard Criteria Report of the Ad Hoc Committee of the Harvard Medical School to Examine theReport 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- 340340 ► Note: presented in narrative rather thanNote: presented in narrative rather than algorithmic form; stricter than ever before, but notalgorithmic 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 newPurpose: “…to define irreversible coma as a new criterion for death.”criterion for death.” ► ““There are two reasons why there is need for aThere are two reasons why there is need for a definition:definition:  2) Obsolete criteria for the definition of death can lead to2) Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation.”controversy in obtaining organs for transplantation.”
  11. 11. Harvard CriteriaHarvard Criteria Report of the Ad Hoc Committee of the Harvard Medical School to Examine theReport 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- 340340 ► ““An organ, brain or other, that no longer functions and hasAn organ, brain or other, that no longer functions and has no possibility of functioning again is for all practicalno possibility of functioning again is for all practical purposes dead.”purposes dead.” ► A. determine presence of “aA. determine presence of “a permanentlypermanently nonfunctioningnonfunctioning brain.”brain.”  1.1. UnreceptivityUnreceptivity andand UnresponsitivityUnresponsitivity: “total unawareness to: “total unawareness to externally applied stimuli…even the most intensely painful stimuliexternally applied stimuli…even the most intensely painful stimuli evoke no vocal or other response, not even a groan, withdrawal ofevoke 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 orno spontaneous movements or spontaneous respiration (turn off respirator for 3 minutes; prior tospontaneous respiration (turn off respirator for 3 minutes; prior to trial breathing room air fortrial breathing room air for ≥≥10 minutes and pCO10 minutes and pCO22 normal) ornormal) or response to pain, touch, sound or light for an hour.response to pain, touch, sound or light for an hour.
  12. 12. Harvard CriteriaHarvard Criteria Report of the Ad Hoc Committee of the Harvard Medical School to Examine theReport 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- 340340 ► A. determine presence of “aA. 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
  13. 13. Harvard CriteriaHarvard Criteria Report of the Ad Hoc Committee of the Harvard Medical School to Examine theReport 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- 340340 ► B. confirmatory dataB. confirmatory data  4. isoelectric EEG (specifies technique; have EKG and noncephalic4. isoelectric EEG (specifies technique; have EKG and noncephalic leads to r/o confounders “At least 10 full minutes of recording areleads 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 beIf EEG unavailable, “the absence of cerebral function has to be determined by purely clinical signs…or by absence of circulation asdetermined by purely clinical signs…or by absence of circulation as judged by standstill of blood in the retinal vessels, or by absence ofjudged by standstill of blood in the retinal vessels, or by absence of cardiac activity.”cardiac activity.” ► A and B all need to beA and B all need to be repeated 24 hours later withrepeated 24 hours later with nono ΔΔ AND in theAND 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, andand determined only by a physiciandetermined only by a physician
  14. 14. Harvard CriteriaHarvard Criteria Report of the Ad Hoc Committee of the Harvard Medical School to Examine theReport 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- 340340 ►If criteria are met, “Death is to be declaredIf criteria are met, “Death is to be declared andand thenthen the respirator turned off. Thethe respirator turned off. The decision to do this and the responsibility fordecision 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 morecharge, in consultation with one or more physicians who have been directly involvedphysicians who have been directly involved in the case. It is unsound and undesirable toin the case. It is unsound and undesirable to force the family to make the decision.”force the family to make the decision.”
  15. 15. Harvard CriteriaHarvard Criteria Report of the Ad Hoc Committee of the Harvard Medical School to Examine theReport 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- 340340 ►ControversyControversy  Physicians concerned: desire to remove burdenPhysicians concerned: desire to remove burden of decision off the transplant surgeonof decision off the transplant surgeon  Public concern: press concerned that BrighamPublic 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 HistoryMurray JE. Surgery of the soul: reflectins on a curious career. Canton, MA: Science History Publications, 2001.Publications, 2001.  Subsequent literature concerned that criteriaSubsequent literature concerned that criteria biased by participation of transplant surgeonsbiased by participation of transplant surgeons on the committee whose programs couldon the committee whose programs could advance with brain death definedadvance with brain death defined ►WijdicksWijdicks NEUROLOGY 2003;61:970-976NEUROLOGY 2003;61:970-976 finds little basis for thisfinds little basis for this in his review of the committee’s documentsin his review of the committee’s documents
  16. 16. Guidelines for the Determination ofGuidelines for the Determination of DeathDeath JAMA 11/13/1981;246(19),2184-2186JAMA 11/13/1981;246(19),2184-2186 ► Report of the Medical Consultants on theReport of the Medical Consultants on the Diagnosis of Death to the President’s CommissionDiagnosis of Death to the President’s Commission for the Study of Ethical Problems in Medicine andfor the Study of Ethical Problems in Medicine and Biomedical and Behavioral ResearchBiomedical and Behavioral Research ► Developed as an aid to implementation of theDeveloped 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 EthicalPresident’s Commission for the Study of Ethical Problems in Medicine and Biomedical andProblems in Medicine and Biomedical and Behavioral Research, AAN, AESBehavioral Research, AAN, AES
  17. 17. Guidelines for the Determination ofGuidelines for the Determination of DeathDeath 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 andirreversible cessation of circulatory and respiratory functions, or (2) irreversiblerespiratory 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. Aincluding the brain stem, is dead. A determination of death must be made indetermination of death must be made in accordance with accepted medical standards.”accordance with accepted medical standards.”
  18. 18. Guidelines for the Determination ofGuidelines for the Determination of DeathDeath JAMA 11/13/1981;246(19),2184-2186JAMA 11/13/1981;246(19),2184-2186: Criteria: Criteria ► Note: presented in somewhat narrative andNote: presented in somewhat narrative and somewhat algorithmic form; improvement fromsomewhat algorithmic form; improvement from Harvard criteria but still room for interpretation ofHarvard criteria but still room for interpretation of what to do and when.what to do and when. ► ““An individual presenting the findings inAn individual presenting the findings in eithereither section A (Cardiopulmonary)section A (Cardiopulmonary) oror section Bsection B (neurological) is dead….a diagnosis of death(neurological) is dead….a diagnosis of death requires thatrequires that bothboth cessation of functionscessation of functions andand irreversibility…be demonstrated.”irreversibility…be demonstrated.”
  19. 19. Guidelines for the Determination ofGuidelines for the Determination of DeathDeath JAMA 11/13/1981;246(19),2184-2186JAMA 11/13/1981;246(19),2184-2186: Criteria: Criteria ► ““A. An individual with irreversible cessation ofA. 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 clinicalis recognized by an appropriate clinical examination….at least absence of responsiveness,examination….at least absence of responsiveness, heartbeat, and respiratory effort….may require the useheartbeat, and respiratory effort….may require the use of…ECG.”of…ECG.”  2.2. IrreversibilityIrreversibility is recognized by persistent cessation ofis recognized by persistent cessation of functions during an appropriate period of observationfunctions 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, whetherdependent on whether is expected vs. unexpected, whether resuscitation attempted, or moment of possible death is witnessedresuscitation attempted, or moment of possible death is witnessed or not]or not]
  20. 20. Guidelines for the Determination ofGuidelines for the Determination of DeathDeath JAMA 11/13/1981;246(19),2184-2186JAMA 11/13/1981;246(19),2184-2186: Criteria: Criteria ►““B. An individual with irreversible cessationB. An individual with irreversible cessation of all functions of the entire brain, includingof all functions of the entire brain, including the brain stem, is dead….”the brain stem, is dead….”  ““1. Cessation1. Cessation is recognized when evaluation disclosesis recognized when evaluation discloses findings of afindings 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 confirmatoryMedical circumstances may require the use of confirmatory studies such as an EEG or blood-flow study.” [??Thosestudies such as an EEG or blood-flow study.” [??Those circumstances not specified!]circumstances not specified!] ► b. “Brainstem functions are absent” determined by testingb. “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;
  21. 21. Guidelines for the Determination ofGuidelines for the Determination of DeathDeath JAMA 11/13/1981;246(19),2184-2186JAMA 11/13/1981;246(19),2184-2186: Criteria: Criteria ►““B. An individual with irreversible cessationB. An individual with irreversible cessation of all functions of the entire brain, includingof all functions of the entire brain, including the brain stem, is dead….”the brain stem, is dead….”  ““1. Cessation1. Cessation is recognized when evaluation disclosesis recognized when evaluation discloses findings of afindings of a andand b:b: ► b. “Brainstem functions are absent” determined by testingb. “Brainstem functions are absent” determined by testing pupillary light, corneal, oculocephalic, oculovestibular,pupillary light, corneal, oculocephalic, oculovestibular, oropharyngeal, and respiratory (apnea) reflexes; “When theseoropharyngeal, and respiratory (apnea) reflexes; “When these reflexes cannot be adequately assessed, confirmatory tests arereflexes cannot be adequately assessed, confirmatory tests are recommended.”recommended.” ► Apnea testing specified: OApnea testing specified: O22 ventilation x 10 minutes then w/dventilation 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.”
  22. 22. Guidelines for the Determination ofGuidelines for the Determination of DeathDeath JAMA 11/13/1981;246(19),2184-2186JAMA 11/13/1981;246(19),2184-2186: Criteria: Criteria ►““B. An individual with irreversible cessationB. An individual with irreversible cessation of all functions of the entire brain, includingof all functions of the entire brain, including the brain stem, is dead….”the brain stem, is dead….”  ““1. Cessation1. Cessation is recognized when evaluation disclosesis recognized when evaluation discloses findings of afindings of a andand b:b: ► ““Peripheral nervous system activity and spinal cord reflexesPeripheral nervous system activity and spinal cord reflexes may persist after death. True decerebrate or decorticatemay persist after death. True decerebrate or decorticate posturing or seizures are inconsistent with the diagnosis ofposturing or seizures are inconsistent with the diagnosis of death.”death.”
  23. 23. Guidelines for the Determination ofGuidelines for the Determination of DeathDeath JAMA 11/13/1981;246(19),2184-2186JAMA 11/13/1981;246(19),2184-2186: Criteria: Criteria ► ““B. An individual with irreversible cessation of allB. An individual with irreversible cessation of all functions of the entire brain, including the brainfunctions of the entire brain, including the brain stem, is dead….”stem, is dead….”  ““2. Irreversibility2. Irreversibility is recognized when evaluation discloses findingsis recognized when evaluation discloses findings of aof a andand bb andand c”c” oror by absence of blood flow to the brainby absence of blood flow to the brain ≥≥1010 minutes, shown by angiography :minutes, shown by angiography : ► a. The cause of coma is established and is sufficient to account for thea. 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 periodc. the cessation of all brain functions persists for an appropriate period of observation and/or trial or therapy” (6 hours; 12 hours if noof 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)
  24. 24. Practice parameters for determiningPractice parameters for determining brain death in adultsbrain death in adults (summary statement)(summary statement) NEUROLOGY 1995;45:1012-1014NEUROLOGY 1995;45:1012-1014 ► Report of the Quality Standards Subcommittee of theReport of the Quality Standards Subcommittee of the American Academy of NeurologyAmerican Academy of Neurology ► Brain Death Definition: “the irreversible loss of functin ofBrain Death Definition: “the irreversible loss of functin of the brain, including the brainstem.”the brain, including the brainstem.” ► Justification: “…need for standardization of the neurologicJustification: “…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; areProcess: 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 preciselyFormat: algorithm with precise definitions and precisely specified exam methodsspecified exam methods
  25. 25. 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 acute1.Clinical or neuroimaging evidence of an acute CNS catastrophe that is compatible with theCNS 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 temperature4. Core temperature ≥≥3232˚˚C(90C(90˚˚F)”F)”
  26. 26. 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 ►B. Coma, lack of brainstem reflexes, andB. Coma, lack of brainstem reflexes, and apneaapnea  1.Coma or unresponsiveness… (defined1.Coma or unresponsiveness… (defined specifically)specifically)  2. Absence of brainstem reflexes (defined2. 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
  27. 27. 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 ►B. Coma, lack of brainstem reflexes, andB. Coma, lack of brainstem reflexes, and apneaapnea  3. Apnea:3. Apnea: very specificvery specific description of apneadescription of apnea testing protocol e.g. core temptesting protocol e.g. core temp ≥ 36.5˚C; BP,≥ 36.5˚C; BP, volume, baseline POvolume, baseline PO22 and PCOand PCO22
  28. 28. 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: 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 NMAED’s, chemotherapeutic agents, or NM blocking agentsblocking agents ►D. Chronic COD. Chronic CO22 retentionretention
  29. 29. 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: III.III. Clinical observations compatible with the diagnosis of brainClinical 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
  30. 30. 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: IV.IV. Confirmatory laboratory tests (Options)Confirmatory laboratory tests (Options) ►““Brain death is a clinical diagnosis. A repeatBrain death is a clinical diagnosis. A repeat clinical evaluation 6 hours later isclinical evaluation 6 hours later is recommended, but this interval is arbitrary.recommended, but this interval is arbitrary. A confirmatory test is not mandatory but isA confirmatory test is not mandatory but is desirable in patients in whom specificdesirable in patients in whom specific components of clinical testing cannot becomponents of clinical testing cannot be reliably performed or evaluated….mostreliably performed or evaluated….most sensitive test [is listed] first:sensitive test [is listed] first:
  31. 31. 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: IV.IV. Confirmatory laboratory tests (Options)(specific criteriaConfirmatory laboratory tests (Options)(specific criteria described for all)described for all) ►A. Conventional AngiographyA. Conventional Angiography ►B. EEG: no electrical activity overB. 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
  32. 32. 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: V.V. Medical record documentation (Medical record documentation (StandardStandard)) ► A. Etiology and irreversibility of conditionA. 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 ofE. Justification for confimatory test and result of confirmatory testconfirmatory test ► F. Repeat neurologic examinationF. Repeat neurologic examination Option:Option: thethe interval is arbitrary, but a 6-hour period isinterval is arbitrary, but a 6-hour period is reasonablereasonable
  33. 33. Canadian criteriaCanadian criteria Guidelines for the diagnosis ofGuidelines for the diagnosis of brain death. Canadian Neurocritical Care Group. Can J Neurol Scibrain death. Canadian Neurocritical Care Group. Can J Neurol Sci 1999;26:64-61999;26:64-6 ►I haven’t obtained this reference yet butI 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; asInterval between exams as short as 2 hours; as long as 24 hours for anoxic-ischemic insultlong as 24 hours for anoxic-ischemic insult
  34. 34. ““State Law”State Law” ► Practice parameters for determining brain death inPractice parameters for determining brain death in adultsadults (summary statement)(summary statement) NEUROLOGY 1995;45:1012-1014NEUROLOGY 1995;45:1012-1014  ““Regardless of the conclusions of this statement , theRegardless of the conclusions of this statement , the Quality Standards Subcommittee of the AAN recognizesQuality 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 BrainRIDOH has no specific policy or guidelines for Brain Death determination; leaves it to institutions to developDeath determination; leaves it to institutions to develop their owntheir own ► should Ethics Network look into standardization across theshould Ethics Network look into standardization across the state?state?
  35. 35. Brain Death Protocols in some RIBrain Death Protocols in some RI hospitalshospitals ►Hospital #1: no protocolHospital #1: no protocol ►Hospital #2: based on President’sHospital #2: based on President’s Commission but criteria somewhat vagueCommission but criteria somewhat vague and only semi-algorithmicand only semi-algorithmic ►Hospital #3: based on 1995 PracticeHospital #3: based on 1995 Practice Parameters; precise criteria and preciseParameters; precise criteria and precise algorithm providedalgorithm provided ►Other hospitals around the state?Other hospitals around the state?
  36. 36. Brain Death around the worldBrain Death around the world Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensusWijdicks EFM. Brain death worldwide: Accepted fact but no global consensus in diagnostic criteriain 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 ofAll guidelines specified exclusion of confounders, presence of irreversible coma, absent motor response, and absent brainstemirreversible 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 ofdifferences 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
  37. 37. Brain Death around the worldBrain Death around the world Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensusWijdicks EFM. Brain death worldwide: Accepted fact but no global consensus in diagnostic criteriain diagnostic criteria NEUROLOGY 2002;58:20-25NEUROLOGY 2002;58:20-25 ►Conclusion: “uniform agreement on theConclusion: “uniform agreement on the neurologic exam with exception of theneurologic exam with exception of the apnea test; but other major differencesapnea test; but other major differences found in the procedures for diagnosing brainfound in the procedures for diagnosing brain death in adults, and standardization shoulddeath in adults, and standardization should be considered.”be considered.”
  38. 38. Misconceptions:Misconceptions: ► 1. There is one nationally or internationally1. There is one nationally or internationally accepted standard for determination of brainaccepted standard for determination of brain death. In fact there is variability and inconsistencydeath. In fact there is variability and inconsistency over time and at single points in time including theover time and at single points in time including the present:present:  between published guidelines (differences betweenbetween 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
  39. 39. Misconceptions: “Brain Death” ?sufficientMisconceptions: “Brain Death” ?sufficient for withdrawal of mechanical ventilationfor withdrawal of mechanical ventilation ► Case: ICU patient; multi-organ failure, comatose sinceCase: ICU patient; multi-organ failure, comatose since cardiopulmonary arrest. Caregivers feel ongoing tx futilecardiopulmonary arrest. Caregivers feel ongoing tx futile but family wants to continue. Neurology consult requestedbut family wants to continue. Neurology consult requested to determine if “Brain Death” applies to ?convince family toto determine if “Brain Death” applies to ?convince family to change to CMO. Implication also that if Brain Deathchange 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 goodConsultant: don’t need “brain death” for this; need good communication with family so they understand fully the prognosiscommunication with family so they understand fully the prognosis and valid option to withdraw interventions (even ventilation)and valid option to withdraw interventions (even ventilation)
  40. 40. ?Misconceptions: “Brain Death” ??Misconceptions: “Brain Death” ? necessary for withdrawal ofnecessary for withdrawal of mechanical ventilationmechanical ventilation ►““brain death” originally motivated bybrain death” originally motivated by potential for organ transplantation butpotential for organ transplantation but concept often being invoked for decision-concept often being invoked for decision- making even when there is no potential formaking even when there is no potential for organ donationorgan donation
  41. 41. misconceptionsmisconceptions ►All medical personnel, especially ICU staffs,All medical personnel, especially ICU staffs, have consistent and accuratehave consistent and accurate understandings of brain death criteriaunderstandings of brain death criteria  64% physicians and 28% of non-physician staff64% physicians and 28% of non-physician staff correctly identified clinical criteria for brain deathcorrectly 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 deathBrain death ≡ loss of cortical function≡ loss of cortical function  i.e. need loss ofi.e. need loss of brainstembrainstem function as wellfunction as well
  42. 42. PitfallsPitfalls ►Incorrect application of accepted criteriaIncorrect application of accepted criteria VanVan 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 injuriese.g. 2 patients with devastating brain injuries certified as brain dead and referred for organcertified as brain dead and referred for organ donationdonation despite the presence of spontaneousdespite the presence of spontaneous respirations and in one of them movementrespirations and in one of them movement during organ retrieval leading to use of muscleduring organ retrieval leading to use of muscle relaxants and general anesthesiarelaxants and general anesthesia  e.g. brain death determined after patiente.g. brain death determined after patient received IV muscle relaxants and Mg lowreceived IV muscle relaxants and Mg low (eventually patient discharged home alert and(eventually patient discharged home alert and oriented)oriented)
  43. 43. ControversiesControversies ►Philosophically, why need loss of brainstemPhilosophically, why need loss of brainstem function as well? i.e. Harvard criteria basedfunction as well? i.e. Harvard criteria based onon irreversibility of comairreversibility of coma andand futility of care,futility of care, not “death of the person.”not “death of the person.”
  44. 44. Going forwardGoing forward ►Are current Brain Death criteria satisfactory?Are current Brain Death criteria satisfactory? Some are calling for additional study to seeSome are calling for additional study to see if they are as reliable as “conventionalif they are as reliable as “conventional wisdom” suggests and many believe.wisdom” suggests and many believe.  Dead, or Dead Enough? Current algorithms useDead, or Dead Enough? Current algorithms use certain measures; but those just measure braincertain measures; but those just measure brain activity above a certain thresholdactivity above a certain threshold along aalong a continuumcontinuum. Maybe some cells still functioning?. Maybe some cells still functioning? How to determine that threshold?How to determine that threshold?
  45. 45. Going ForwardGoing Forward Doig CJ and Burgess E, Brain Death: resolvingDoig 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 seeSome are calling for additional study to see if they are as reliable as “conventionalif they are as reliable as “conventional wisdom” suggests and many believe.wisdom” suggests and many believe.  Tests of cortical and subcortical brain functionTests of cortical and subcortical brain function lack specificitylack specificity  Inconsistency of clinical criteriaInconsistency of clinical criteria
  46. 46. Going forwardGoing forward ► A need for more uniform criteria: note difficulty IA need for more uniform criteria: note difficulty I had in obtaining “front-line” (i.e. hospital) levelhad in obtaining “front-line” (i.e. hospital) level information and variability between hospitals withininformation and variability between hospitals within the state!the state!  Within the stateWithin the state  nationallynationally  ?internationally?internationally ► Ethics network look into this, determine what theEthics 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 withinandadvocate for more uniform criteria within Rhode Island?Rhode Island?
  47. 47. Rosenbaum, S. Ethical conflicts.Rosenbaum, S. Ethical conflicts. Anesthesiology 1999;91:3-4Anesthesiology 1999;91:3-4 ►““If one subject in health law and bioethicsIf one subject in health law and bioethics can be said to be at once well settled andcan be said to be at once well settled and persistently unresolved, it is how topersistently unresolved, it is how to determine that death has occurred.”determine that death has occurred.”

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