If you present to a hospital with locked-in-syndrome you better hope this is known about and followed.
How Should Doctors Determine Brain Death?
AAN calls for uniform, guideline-based policies and practices
The
American Academy of Neurology (AAN) called for uniform brain death laws,
policies, and practices in a new position statement.
The position paper, published in Neurology, defines brain death -- otherwise known as death by neurologic criteria -- as the individual's death due to irreversible loss of function of the entire brain in accordance with the Uniform Determination of Death Act (UDDA), a model state law that was approved for the U.S. in 1981.
The statement has three goals, lead author James Russell, DO, MS, of Lahey Hospital and Medical Center in Burlington, Massachusetts, told MedPage Today.
"First, it provides AAN, American Neurological Association, and Child Neurology Society endorsement of the [UDDA's] conclusion, which identified brain death as equivalent to cardiorespiratory death," he said.
Second, it provides endorsement from all three organizations that the 2010 guidelines for adults and 2011 guidelines for children are "the currently and widely recognized medical standards for brain death determination," Russell added.
And third, it offers guidance about how to "reconcile requests to abstain from brain death testing or to continue organ-sustaining technology after a diagnosis of brain death has been rendered," he said.
To the AAN's knowledge, no cases have occurred in which the adult or pediatric guidelines led to inaccurate determination of death with return of any brain function, including consciousness, brainstem reflexes, or breathing. But so far, only Nevada has adopted legislation that requires using the guidelines as the medical standard for determining brain death.
Every state has accepted the UDDA definition of brain death as legal death, but in most states, medical standards for determining brain death are unspecified. This lack of specificity, coupled with inconsistencies within institutions, has led to differing interpretations in high-profile legal cases.
"The AAN statement was prompted by several recent medicolegal cases that highlighted controversies in brain death and questioned whether it should be considered an accepted and valid medical standard," said James Bernat, MD, of the Geisel School of Medicine at Dartmouth College in Hanover, New Hampshire, who helped develop the conceptual foundation of brain death that formed the basis of the UDDA.
The AAN's position provides an "authoritative consensus declaration on the practice of brain death determination," Bernat told MedPage Today. "It clarifies that, despite legitimate areas of controversy, physicians conducting a brain death determination can feel secure that it represents the medical standard of care."
The problem is not just uncertainty about what constitutes brain death, noted Arthur Caplan, PhD, director of medical ethics at NYU Langone Hospital in New York City, who was not involved with the AAN paper.
"It's uncertainties about what power family members have to compel the continuation of treatment, even in the face of death," Caplan told MedPage Today. "We see a swinging of the pendulum toward patient autonomy. Some doctors have become nervous and think they have to listen to patients, even when they're asking for things that are impossible, or outside the standard of care, or simply wrong."
"This paper affirms that parental and family rights have limits, and family members shouldn't be allowed to coerce treatments, while recognizing they do need accommodation in terms of explanations or meetings with ethics committees," Caplan continued. "But death is not a state that requires continuation of treatment, and this paper says that pretty clearly."
The AAN position statement provides guidance for clinicians when families do not accept a determination of death and request continued life support. It also supports legislation modeled after the Nevada statute in every state, uniform policies in medical facilities that comply with brain death guidelines, and programs to credential physicians to determine death by neurological criteria.
The position paper, published in Neurology, defines brain death -- otherwise known as death by neurologic criteria -- as the individual's death due to irreversible loss of function of the entire brain in accordance with the Uniform Determination of Death Act (UDDA), a model state law that was approved for the U.S. in 1981.
The statement has three goals, lead author James Russell, DO, MS, of Lahey Hospital and Medical Center in Burlington, Massachusetts, told MedPage Today.
"First, it provides AAN, American Neurological Association, and Child Neurology Society endorsement of the [UDDA's] conclusion, which identified brain death as equivalent to cardiorespiratory death," he said.
Second, it provides endorsement from all three organizations that the 2010 guidelines for adults and 2011 guidelines for children are "the currently and widely recognized medical standards for brain death determination," Russell added.
And third, it offers guidance about how to "reconcile requests to abstain from brain death testing or to continue organ-sustaining technology after a diagnosis of brain death has been rendered," he said.
To the AAN's knowledge, no cases have occurred in which the adult or pediatric guidelines led to inaccurate determination of death with return of any brain function, including consciousness, brainstem reflexes, or breathing. But so far, only Nevada has adopted legislation that requires using the guidelines as the medical standard for determining brain death.
Every state has accepted the UDDA definition of brain death as legal death, but in most states, medical standards for determining brain death are unspecified. This lack of specificity, coupled with inconsistencies within institutions, has led to differing interpretations in high-profile legal cases.
"The AAN statement was prompted by several recent medicolegal cases that highlighted controversies in brain death and questioned whether it should be considered an accepted and valid medical standard," said James Bernat, MD, of the Geisel School of Medicine at Dartmouth College in Hanover, New Hampshire, who helped develop the conceptual foundation of brain death that formed the basis of the UDDA.
The AAN's position provides an "authoritative consensus declaration on the practice of brain death determination," Bernat told MedPage Today. "It clarifies that, despite legitimate areas of controversy, physicians conducting a brain death determination can feel secure that it represents the medical standard of care."
The problem is not just uncertainty about what constitutes brain death, noted Arthur Caplan, PhD, director of medical ethics at NYU Langone Hospital in New York City, who was not involved with the AAN paper.
"It's uncertainties about what power family members have to compel the continuation of treatment, even in the face of death," Caplan told MedPage Today. "We see a swinging of the pendulum toward patient autonomy. Some doctors have become nervous and think they have to listen to patients, even when they're asking for things that are impossible, or outside the standard of care, or simply wrong."
"This paper affirms that parental and family rights have limits, and family members shouldn't be allowed to coerce treatments, while recognizing they do need accommodation in terms of explanations or meetings with ethics committees," Caplan continued. "But death is not a state that requires continuation of treatment, and this paper says that pretty clearly."
The AAN position statement provides guidance for clinicians when families do not accept a determination of death and request continued life support. It also supports legislation modeled after the Nevada statute in every state, uniform policies in medical facilities that comply with brain death guidelines, and programs to credential physicians to determine death by neurological criteria.
The Brain
Death Summit, subsequent meetings, and conference calls of the Brain
Death Working Group have been financially supported by the American
Academy of Neurology.
Authors report no disclosures relevant to the manuscript.
Authors report no disclosures relevant to the manuscript.
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