Editors' Note: Determination of Death by Neurologic Criteria Around the World

Abstract

Dr. Lewis et al. reviewed official national protocols for the determination of brain death or death by neurologic criteria (BD/DNC) from contacts in 83 countries and found considerable variation in these protocols, leading them to recommend that a worldwide consensus be reached on the minimum standards for BD/DNC. In response, Dr. Sethi agrees that there is a need for worldwide consensus, but cautions against compromising on the standards of BD/DNC determination to accommodate different beliefs or demands for organs. In another response, Dr. Machado notes that whereas some patients with primary posterior fossa lesions who fulfill clinical BD criteria/DNC may show preservation of electroencephalographic activity, evoked potential, and autonomic function, some isolated brainstem lesions may theoretically cause a fully apneic locked-in syndrome potentially fulfilling clinical BD criteria, despite potential preservation of some consciousness, citing the case of Jahi McMath. Dr. Machado calls for further research and discussion regarding the use of ancillary tests for BD in the presence of primary posterior fossa lesions. Responding to these comments, the authors agree that the standards for BD/DNC must be conservative and rigorous to avoid false positive determinations and to ensure that a person considered dead in one place is not considered alive in another. The authors note that the worldwide variation in the process of BD/DNC determination, demonstrated in their paper, prompted the creation of the World Brain Death Project, an international, multidisciplinary collaboration to identify the minimum criteria for BD/DNC and serve as guidance for professional societies and countries to revise or develop guidelines on BD/DNC. They hope that this project will help improve consistency in BD/DNC determination and increase public trust in BD/DNC, without compromising the stringency of the process. They note that highly publicized lawsuits related to BD/DNC, like the case of Jahi McMath, prompted the American Academy of Neurology and other stakeholders to advocate for regulatory oversight for uniformity of BD/DNC policies in US Healthcare Institutions. They also note that the World Brain Death Project will also seek to address the present variability in BD/DNC determination in complex situations such as patients with posterior fossa injuries, on extracorporeal membrane oxygenation, or treated with targeted temperature management. This exchange highlights challenging considerations that arise in the pursuit of greater worldwide uniformity in BD/DNC determination. Dr. Lewis et al. reviewed official national protocols for the determination of brain death or death by neurologic criteria (BD/DNC) from contacts in 83 countries and found considerable variation in these protocols, leading them to recommend that a worldwide consensus be reached on the minimum standards for BD/DNC. In response, Dr. Sethi agrees that there is a need for worldwide consensus, but cautions against compromising on the standards of BD/DNC determination to accommodate different beliefs or demands for organs. In another response, Dr. Machado notes that whereas some patients with primary posterior fossa lesions who fulfill clinical BD criteria/DNC may show preservation of electroencephalographic activity, evoked potential, and autonomic function, some isolated brainstem lesions may theoretically cause a fully apneic locked-in syndrome potentially fulfilling clinical BD criteria, despite potential preservation of some consciousness, citing the case of Jahi McMath. Dr. Machado calls for further research and discussion regarding the use of ancillary tests for BD in the presence of primary posterior fossa lesions. Responding to these comments, the authors agree that the standards for BD/DNC must be conservative and rigorous to avoid false positive determinations and to ensure that a person considered dead in one place is not considered alive in another. The authors note that the worldwide variation in the process of BD/DNC determination, demonstrated in their paper, prompted the creation of the World Brain Death Project, an international, multidisciplinary collaboration to identify the minimum criteria for BD/DNC and serve as guidance for professional societies and countries to revise or develop guidelines on BD/DNC. They hope that this project will help improve consistency in BD/DNC determination and increase public trust in BD/DNC, without compromising the stringency of the process. They note that highly publicized lawsuits related to BD/DNC, like the case of Jahi McMath, prompted the American Academy of Neurology and other stakeholders to advocate for regulatory oversight for uniformity of BD/DNC policies in US Healthcare Institutions. They also note that the World Brain Death Project will also seek to address the present variability in BD/DNC determination in complex situations such as patients with posterior fossa injuries, on extracorporeal membrane oxygenation, or treated with targeted temperature management. This exchange highlights challenging considerations that arise in the pursuit of greater worldwide uniformity in BD/DNC determination.