Before 1950, declaring somebody dead used to be a simple affair. Doctors used to declare a person with no heartbeat or respiration dead.
However, advent of ventilators and CPR changed everything. Declaring somebody dead became a complicated affair. With technology that can restart the heart or keep the heart and lungs going, determination of death moved to the brain.
How can somebody be declared dead as long as his brain continues to function? This unleashed ethical dilemmas, lawsuits and confusion among doctors and families.
A landmark consensus paper on brain death has been published in JAMA which tries to answer this important question.
The study aims to guide physicians in determining brain death as well as help families accept its irreversibility.
Gene Sung, director of the neurocritical care and stroke division at the Keck School of Medicine of USC, is senior author for the paper and a member of the World Brain Death Project’s steering committee.
“This is one of the most basic parts of being a physician—who’s alive? who’s dead? How does one make these determinations, and how do you tell family members their loved one has died?” said Sung, who also helped oversee the project’s 17 supplementary documents. “That’s why I started this project—we still have some difficulty in dealing with and understanding these problems.”
Recommendations of The Study
Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded.
Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea.
This is seen when:
(1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation;
(2) pupils are fixed in a midsize or dilated position and are nonreactive to light;
(3) corneal, oculocephalic, and oculovestibular reflexes are absent;
(4) there is no facial movement to noxious stimulation;
(5) the gag reflex is absent to bilateral posterior pharyngeal stimulation;
(6) the cough reflex is absent to deep tracheal suctioning;
(7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg.
If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability.
The study provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances.
Religious perceptions and family recommendations
The document—endorsed by almost 30 of the most important medical societies in the world in intensive care, neurology and neurosurgery—includes extensive flow charts, checklists and decision trees, as well as discussions of how world religions perceive brain death and recommendations for supporting families.
Brain death is distinct from a coma or a persistent vegetative state. Brain death is generally accepted in most faiths.