Brain Death Guidelines Updated

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Brain Death Guidelines Updated

Special Report - July 6, 2010
The American Academy of Neurology (AAN) has issued an update to its 1995 guidelines on determining brain death in adults, which includes a step-by-step checklist of more than two dozen tests and criteria that must be met. Currently, the Uniform Determination of Death Act (UDDA) provides that a person is legally dead “who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem” as determined by “accepted medical standards.” Most states have adopted the UDDA definition with many states also requiring specific physician qualifications and confirmation by a second physician. The AAN’s 1995 guidelines were an effort to define “medical standards for the determination of brain death.” The updated guidelines emphasize the same three “clinical findings necessary to confirm irreversible cessation of all functions of the entire brain, including the brain stem: coma (with a known cause), absence of brainstem reflexes, and apnea [breathing has permanently stopped].”

According to the report, “Evidence-based guideline update: Determining brain death in adults,” which was published in the June 8 issue of Neurology, a great deal of variation exists among U.S. hospitals in relation to the determination of brain death. These variations are found in the determination of “prerequisites, the lowest acceptable core temperature, and the number of required examinations” as well as deficiencies in documentation. The report included five conclusions, based on a systematic review of relevant literature from 1996 to 2009.

In adults, recovery of neurologic function has not been reported after the clinical diagnosis of brain death has been established.
There is insufficient evidence to determine the minimally acceptable observation period to ensure that neurologic functions have ceased irreversibly.
For some patients diagnosed as brain dead, complex, non-brain-mediated spontaneous movements can falsely suggest retained brain function.
Apneic oxygenation diffusion to determine apnea is safe, but there is insufficient evidence to determine the comparative safety of techniques used for apnea testing.
Because of the high risk of bias and inadequate statistical precision, there is insufficient evidence to determine if any new ancillary tests accurately identify brain death.

The report concluded with a step-by-step guide and checklist for determining brain death. The four-step approach includes prerequisite clinical evaluation followed by neurologic assessment. It then suggests the use of ancillary tests like an EEG, cerebral angiography, and MRI, among others “when uncertainty exists about the reliability of parts of the neurologic examination.” Finally, the guidelines call for accurate documentation of completion of the checklist and time of brain death in the medical records.

For more information on end-of-life laws in North Carolina, see our recent magazine spotlights, “Slip-Sliding Down the Path of Euthanasia” and “The Silent Killer.”