Editors' note: Brain death, the determination of brain death, and member guidance for brain death accommodation requests: AAN position statement

Abstract

On behalf of the Brain Death Working Group, Dr. Russell and colleagues have provided medical professionals and the public with formal guidance as to the definition and determination of brain death. This AAN position statement answers many lingering questions faced by neurologists, intensivists, and critical care providers about when and how to perform an assessment of brain death. Among declarations made in this guideline are that brain death is a clinical diagnosis based on the loss of function of the brain as a whole; that medical providers have no legal obligation to provide organ support to patients with brain death (applies to all US states with the exception of New Jersey); and that providers are permitted to conduct brain death testing—including the apnea test—without consent of the patient's surrogate. In response to this position paper, Dr. Nitin Sethi expresses concern regarding the rights of AAN members to recuse themselves from brain death determination or management. Such a recusal might be perceived by family members or caregivers as medical uncertainty regarding a diagnosis of brain death. However, the AAN position statement is consistent with a long-standing moral imperative that extricates AAN members from having to make a brain death determination—or provide continued care to the deceased—when such management conflicts with their own personal beliefs. In a separate comment, Dr. Calixto Machado highlights the importance of this document in that it provides a standardized definition and management strategy of brain death including the performance of the apnea test, which can be referenced by health care professionals and legal authorities. Finally, Dr. Nathaniel Robbins addresses the inherent limitations of clinical brain death determination, which is wholly reliant on motor output and an intact brain stem. Although absence of brain stem function is prognostically useful in and of itself, Robbins asserts, it should not indicate that all functions of the brain have ceased. Higher cortical functions may be preserved and are clinically untestable. In response, Dr. Russell emphasizes that injury to the “brain as a whole” is what constitutes brain death and understanding the nature of the injury limits the possibility of a false-positive declaration. As we are not required to demonstrate that all myocardial cells have died in the event of cardiac death, we need not prove that all nerve cells have died to make a determination of brain death. On behalf of the Brain Death Working Group, Dr. Russell and colleagues have provided medical professionals and the public with formal guidance as to the definition and determination of brain death. This AAN position statement answers many lingering questions faced by neurologists, intensivists, and critical care providers about when and how to perform an assessment of brain death. Among declarations made in this guideline are that brain death is a clinical diagnosis based on the loss of function of the brain as a whole; that medical providers have no legal obligation to provide organ support to patients with brain death (applies to all US states with the exception of New Jersey); and that providers are permitted to conduct brain death testing—including the apnea test—without consent of the patient's surrogate. In response to this position paper, Dr. Nitin Sethi expresses concern regarding the rights of AAN members to recuse themselves from brain death determination or management. Such a recusal might be perceived by family members or caregivers as medical uncertainty regarding a diagnosis of brain death. However, the AAN position statement is consistent with a long-standing moral imperative that extricates AAN members from having to make a brain death determination—or provide continued care to the deceased—when such management conflicts with their own personal beliefs. In a separate comment, Dr. Calixto Machado highlights the importance of this document in that it provides a standardized definition and management strategy of brain death including the performance of the apnea test, which can be referenced by health care professionals and legal authorities. Finally, Dr. Nathaniel Robbins addresses the inherent limitations of clinical brain death determination, which is wholly reliant on motor output and an intact brain stem. Although absence of brain stem function is prognostically useful in and of itself, Robbins asserts, it should not indicate that all functions of the brain have ceased. Higher cortical functions may be preserved and are clinically untestable. In response, Dr. Russell emphasizes that injury to the “brain as a whole” is what constitutes brain death and understanding the nature of the injury limits the possibility of a false-positive declaration. As we are not required to demonstrate that all myocardial cells have died in the event of cardiac death, we need not prove that all nerve cells have died to make a determination of brain death.