Inconsistencies Between the Criterion and Tests for Brain Death

Abstract

The whole-brain criterion of death provides that a person who has irreversibly lost all clinical functions of the brain is dead. Bedside brain death (BD) tests permit physicians to determine BD by showing that the whole-brain criterion of death has been fulfilled. In a nonsystematic literature review, we identified and analyzed case reports of a mismatch between the whole-brain criterion of death and bedside BD tests. We found examples of patients diagnosed as BD who showed (1) neurologic signs compatible with retained brain functions, (2) neurologic signs of uncertain origin, and (3) an inconsistency between standard BD tests and ancillary tests for BD. Two actions can resolve the mismatch between the whole-brain criterion of death and BD tests: (1) loosen the whole-brain criterion of death by requiring only the irreversible cessation of relevant brain functions and (2) tighten BD tests by requiring an ancillary test proving the cessation of intracranial blood flow. Because no one knows the precise brain functions whose loss is necessary to fulfill the whole-brain criterion of death, we advocate tightening BD tests by requiring the absence of intracranial blood flow.

Truly Reconciling the Case of Jahi McMath

“…Lewis condescendingly dismisses my assertions that Jahi does not fulfill the California statutory definition of death and that the Guidelines do not comport with the UDDA. Apart from the specifics of Jahi's case, the Guidelines explicitly allow for some retained brain functions (including some that would qualify as "critical" according to Bernat's distinction [20], or as "clinical" according to the insistence of Bernat, Wijdicks and others [20,21]) [3,11,22,23]. Therefore, the Guidelines, by their own wording, do not identify the "irreversible cessation of all functions of the entire brain" required by the UDDA [6, p. 73], despite having become, through political decree within professional societies, the "accepted medical standards" that the UDDA defers to.…”

What Should We Do About the Mismatch Between Legal Criteria for Death and How Brain Death Is Diagnosed?

“…3 Although the American Academy of Neurology (AAN) and other organizations have outlined "accepted medical standards" for determining brain death (BD) by neurological criteria, 4,5,6 controversy is ongoing because testing pursuant to these standards can only approximate BD as codified in law. 7,8 Several recent high-profile cases have highlighted this mismatch, 7 although they are not unique. 9 This mismatch has reignited controversy among BD experts, 10 spawned lay misunderstanding, 11 and could threaten public trust in physicians, their BD diagnoses, or BD as a concept.…”

The ethics of testing and research of manufactured organs on brain-dead/recently deceased subjects

“…Adherence to guidelines for brain death determination in adults put forth by the American Academy of Neurology in 2010 and by the Society of Critical Care Medicine, American Academy of Pediatrics and Child Neurology Society in 2011 is recommended to avoid inconsistency 15. Notably, although some have questioned whether these standards comport with the requirements of the Uniform Determination of Death Act, they are considered the accepted medical standards for determination of brain death 16 17…”