Determination Of Brain Death Research Articles

Simulation training in brain death determination.

Skill in the determination of brain death is traditionally acquired during training in an apprenticeship model. Brain death is not frequently determined, and thus exposure to the techniques used is marginal. Brain death is therefore ideally suited for competency-based education models such as simulation. Simulation can ensure that all trainees have direct experience in brain death determination irrespective of their specialty, program design, or institutional protocol. In this review, the authors discuss the advantages and barriers to simulation and how to develop simulation scenarios for instruction in the determination of brain death. Future research should focus on validation of brain death simulation methods and assessment tools as well as the impact of simulation on performance in clinical practice.

Brain death: the European perspective.

Some of the seminal steps toward the recognition and definition of brain death were European. There is a general consensus on both the medical concept of brain death in Europe as well as the minimum fundamental clinical standards that are required for its diagnosis-the absence of consciousness, brainstem reflexes, and the ability to breathe in the absence of reversible or confounding conditions. Two aspects of brain death determination are addressed in this article. The authors analyze how brain death is diagnosed across Europe, identifying both the similarities and differences that exist between countries (the latter mainly concerning ancillary tests, timing, and the number of physicians involved in the brain death determination). In addition, they describe the very considerable variations in when brain death determinations are made between and within individual European countries, and propose that they are due to differences in the end-of-life care practices in patients with irreversible brain injuries, medical attitudes, and organ donation practices. Although legislation is available to standardize the brain death diagnosis process in most individual European countries, there are still disparities across Europe as a whole. The current variation in practice makes a continental consensus for the definition of brain death imperative.

Pediatric brain death determination.

Clinical guidelines for the determination of brain death in children were first published in 1987. These guidelines were revised in 2011 under the auspices of the Society of Critical Care Medicine, the American Academy of Pediatrics, and the Child Neurology Society, and provide the minimum standards that must be satisfied before brain death can be declared in infants and children. After achieving physiologic stability and exclusion of confounders, two examinations including apnea testing separated by an observation period (24 hours for term newborns up to 30 days of age, and 12 hours for infants and children from 31 days up to 18 years) are required to establish brain death. Apnea testing should demonstrate a final arterial PaCO2 20 mm Hg above the baseline and ≥ 60 mm Hg with no respiratory effort during the testing period. Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. The committee concluded that ancillary studies may be used (1) when components of the examination or apnea testing cannot be completed, (2) if uncertainty about components of the neurologic examination exists, (3) if a medication effect may be present, or (4) to reduce the interexamination observation period. When ancillary studies are used, a second clinical examination and apnea test should still be performed and components that can be completed must remain consistent with brain death.

Brain death: the United kingdom perspective.

The United Kingdom (UK) has incorporated a brainstem formulation into its brain death criteria since the first guidelines were published in 1976. A clinical diagnosis incorporating three sequential but interdependent steps is sufficient for the determination of brain death in the UK. There must be no doubt that the patient's comatose condition is due to irreversible brain damage of known etiology, and potentially reversible causes of coma and apnea, such as drug effects, metabolic or endocrine disturbances, or hypothermia, must be excluded. A clinical examination of brainstem reflexes and an apnea test is then undertaken. Confirmatory tests are not required in the UK, but may be useful to reduce any element of uncertainty or minimize the period of observation prior to the diagnosis of brainstem death if the preconditions for clinical testing are not met, or if a comprehensive neurologic examination is not possible. Brainstem death must be diagnosed by two doctors who must be present at each of the two sets of clinical tests that are required to determine death. Although death is not confirmed until the second test has been completed, the legal time of death is when the first test confirms the absence of brainstem reflexes.

The clinical determination of brain death: rational and reliable.

The clinical determination of brain death: rational and reliable.

Brain death guidelines explained.

Brain death is diagnosed in the minority of patients with acute severe brain injury. Guidelines have been developed in many countries in the world and physicians usually work through a set of criteria. The clinical evaluation starts with determination of futility of any medical or surgical intervention and an unmistakable certainty that the underlying diagnosis is correct. The actual neurologic evaluation in a patient suspected of being brain dead requires 25 tests and verifications. Brain death determination demands perfect diagnostic accuracy and thus requires skill and expertise. The overriding principle is simple: establish cause, exclude confounders, determine futility of interventions, examine brainstem reflexes, and test for apnea. In this review, the author revisits the American Academy of Neurology guidelines, and examines the details behind the guidelines. The 2010 guidelines have eliminated unnecessary tests and observation delays, and maintain a principle of simplicity.

Why is diagnosing brain death so confusing?

Although detailed practice parameters have been developed to help guide physicians in brain death determination, guidelines based on these parameters widely vary. The recent case of Jahi McMath not only highlights social misconceptions but also serves as a call to action to decrease medical variability and confusion regarding brain death determination. This review discusses common sources of variations in brain death determination - we divide these sources into before, during, and after brain death declaration. We use four key studies to elucidate variable practice in brain death determination. Poor training of examiners and patient qualifications for brain death examination prior to testing, incomplete apnea testing, repeat examinations during testing, and the sometimes unjustified use of ancillary testing are highlighted as main areas for improvement. Improved physician training and certification, as well as better standardization of hospital protocols, may be answers to more universal practice. Diagnosing brain death is confusing because of numerous variations in practice, but this variation can be improved. Improved and standardized physician training can help create a formal certification process for examiners and help create uniformity in brain death determination. National standards will also help decrease variability of practice.

Organ Donation in Israel—Achievements and Challenges

Israel's organ transplantation history dates back to 1964 when the first kidney transplantation from a living related donor was performed; the first kidney transplantation from a deceased donor followed in 1965. Currently, organ transplantations are performed in 6 Israeli medical centers with 6 kidney, 3 liver, 3 hearts, and 2 lung transplantation programs. All donor management and organ allocation are centrally coordinatedbytheIsraelNationalTransplantCenter(INTC) which was established in 1994 as a department within the Ministry of Health and functions through the work of nurse donor coordinators in each of the 16 large hospitals in Israel. An additional intensive care unit physician has been assigned in each of these 16 hospitals with responsibilities in supporting coordinators with donor management, appealing, and consenting for organ donation and the donation process. 1 TheINTC's responsibilities include maintainingupdated lists of transplant candidates and the coordination of procurements and organ allocation to all transplant programs. External auditors review all medical records of fatalities with the diagnosis of brain pathologies at regular intervals to assure identification of brain death and quality of donor management. A recent report documented that 98% potential brain-dead donors have been identified. Brain Death Determination and Deceased Donation Israel is a multicultural society with different religions— Jews, Muslims,Christians, and Druzes—and multiple ethnicities. Despite of Israel's economic strength and well-organized health care, deceased organ donation rates have consistently been low compared to most other Western countries. The most common reason for refusal to donate had traditionally been based on religious objections. 2 Many Jewish rabbinical leaders support the concept of brain death and consider organ donation as a noble decree. At the same time, a minority of only 8% of the population are ultraorthodox Jews who follow a strict interpretation of Halacha laws that define the time of death as the moment of cessation of cardiac and respiratory function, and therefore do not accept brain death. Yet, at times of despair, many of the additional 12% of the Jewish population who define themselves as “religious” and 13% who are “religious-traditionalists” tend to favor the stringent ultraorthodox interpretation of death criteria and therefore reject organ donation after brain death. 2 Moreover, 1.7 of 8.2 million Israelis are Arabs, mostly Muslims (83%), with additional cultural and religious barriers to organ donation. In 2008, the Israeli Parliament has adopted the BrainRespiratory Death law representing a consensus between medical community and religious authorities that define the criteria and diagnosis of brain death. 3 Brain death is documented by mandatory performances of an apnea test and an ancillary imaging test demonstrating the absence of blood circulation within the brain. Despite its strict implementation, the law has not yet received the anticipated response among rabbinical leaders, who still shy away from advocating organ donation. An additional cause of low donation rates is the so-called free-riding behavior of those who reject brain death and thus organ donation, yet do not abstain from being active candidates for organ transplantation themselves. This phenomenon causes significant antagonism toward organ donation in many circles and has been repeatedly cited in public opinion surveys in Israel as one of the major reasons for the low consent rate for organ donation. 2 To overcome this behavior and to incentivize deceased organ donation, the new Organ Transplant law includes a unique clause which grants prioritization to candidates who have either been registered as organ donors for at least 3 years before being listed, or have a first degree relative who has been a deceased organ donor, or have previously donated a kidney or a liver-lobe 2 Al ower priority is granted also to candidates whose first degree relative has been a registered donor for at least 3 years; however, this category of prioritization will soon be eliminated. 4 The preliminary results after implementation of this new policy show a significant rise in the number of new registered donors per month, and, most importantly, a significant increase in the actual consent rate for deceased organ donation from

Update of clinical practice guidelines for brain death determination in an academic heath center.

Brain death (BD) is determined after a patient has sustained some form of a catastrophic neurologic injury that results in an irreversible loss of cerebral and brain steam function. Variability is caused by the small number of patients who progress to BD annually causing a lack of opportunity for physicians and healthcare staff to stay competent in performing the examination. The current University of Cincinnati Medical Center policy on BD had not been updated since publication of the 2010 American Academy of Neurology guidelines on this subject. The diagnosis of BD in the medical community is an acceptable medical diagnosis, but the examination is difficult to perform, and explaining this diagnosis to a family can be challenging related to the emotions involved with discussing end of life. The goal of updating the current policy was to decrease variability in testing through consistency of practice among clinicians performing the examination. An integrative review of the evidence-based literature was conducted to identify articles discussing both BD confirmation and secondary confirmatory testing. Using this integrative review, results from hospital-based chart reviews, and targeted provider surveys, a policy update was completed. The bedside medical clinicians were provided this policy with evidence-based guidelines regarding performance of the clinical examination and confirmatory testing needed to diagnose BD and then communicate this diagnosis to the family. The current hospital policy lacked two important components of any BD policy: (a) the apnea test techniques and (b) guidance regarding secondary confirmatory testing. Both components were added during revision of the policy. Implementation of the new policy occurred through computer-based training that incorporated both didactic education of the updates and a video demonstration of a BD examination. A better defined policy for determining BD is essential. In addition, the implementation and quality assurance elements of the policy are necessary for efficiency and clinical decision making. By updating the policy within the University of Cincinnati Medical Center, the clinicians have been equipped with the latest evidence to perform the clinical examination for diagnosis of BD and then appropriately communicate this diagnosis to the family.

EEG guidelines in the diagnosis of brain death

In France, for the determination and diagnostic validation of brain death the law requires either two EEG recordings separated by a 4-hour observation period, both showing electrocerebral inactivity; or cerebral angiography examination. Since EEG is available in most hospitals and clinics, it is often used in this indication, at the patient's bedside, especially in the context of organ donation. However, very precise methodology must be followed. The last French guidelines date back to 1989, before the development of digital EEG recording. We present the new guidelines from the Société de Neurophysiologie Clinique de Langue Française. Electrocerebral inactivity may be confirmed when a 30-minute good quality EEG recording shows complete electrocerebral silence, defined as no cerebral activity greater than 2 uV, having first ruled out the possible influence of sedative drugs, metabolic disorders or hypothermia. In the presence of sedative drugs, CT brain angiography will be the gold standard test for this diagnosis. In the newborn, the utmost caution is indicated since electrocerebral inactivity can be observed in the absence of cerebral death. In the infant, the criterion for the observation period to be respected between both EEG recordings needs to be more clearly refined.

Jahi McMath and the Ethics of the Brain Death Standard

How does one account for “the discrepancy” between the evidence of total and irreversible brain death and the current evidence of recovered brain function? This is the question that is raised by recent legal action in the case of 13-year old Jahi McMath, certified dead on the basis of neurological criteria but maintained in mechanical ventilation and medical/nursing care since then at the insistence of the parents who claim she is alive. In this brief discussion, the medical and legal issues are reviewed. Here the argument is advanced that this is not a case that means there should be a re-evaluation of the neurological criteria for determination of brain death. Instead, this case is to be understood as the exception that proves the rule. DOI: http://dx.doi.org/10.3329/bioethics.v5i3.21533 Bangladesh Journal of Bioethics 2014; 5(3):18-22

Clinical utility of arterial spin-labeling as a confirmatory test for suspected brain death.

Diagnosis of brain death is made on the basis of 3 essential findings: coma, absence of brain stem reflexes, and apnea. Although confirmatory tests are not mandatory in most situations, additional testing may be necessary to declare brain death in patients in whom results of specific components of clinical testing cannot be reliably evaluated. Recently, arterial spin-labeling has been incorporated as part of MR imaging to evaluate cerebral perfusion. Advantages of arterial spin-labeling include being completely noninvasive and providing information about absolute CBF. We retrospectively reviewed arterial spin-labeling findings according to the following modified criteria based on previously established confirmatory tests to determine brain death: 1) extremely decreased perfusion in the whole brain, 2) bright vessel signal intensity around the entry of the carotid artery to the skull, 3) patent external carotid circulation, and 4) "hollow skull sign" in a series of 5 patients. Arterial spin-labeling findings satisfied the criteria for brain death in all patients. Arterial spin-labeling imaging has the potential to be a completely noninvasive confirmatory test to provide additional information to assist in the diagnosis of brain death.

Determining brain death by EEG method activities of nurse-technician

Brain death or electrocerebral silence (ESC) represents an irreversible loss of brain function, including the brain stem. The final diagnosis of brain death requires evidence that the brain, as an organ, has stopped functioning. One of the additional methods in determining brain death is electroencephalography (EEG). Role of a well-trained and competent EEG technician when registering electroencephalograph at patients in the possible state of brain death is very important and almost equally as important as the role of a professional interpreting that recording later.

Clinical Brain Death with False Positive Radionuclide Cerebral Perfusion Scans.

Practice guidelines from the American Academy of Neurology for the determination of brain death in adults define brain death as “the irreversible loss of function of the brain, including the brainstem.” Neurological determination of brain death is primarily based on clinical examination; if clinical criteria are met, a definitive confirmatory test is indicated. The apnea test remains the gold standard for confirmation. In patients with factors that confound the clinical determination or when apnea tests cannot safely be performed, an ancillary test is required to confirm brain death. Confirmatory ancillary tests for brain death include (a) tests of electrical activity (electroencephalography (EEG) and somatosensory evoked potentials) and (b) radiologic examinations of blood flow (contrast angiography, transcranial Doppler ultrasound (TCD), and radionuclide methods). Of these, however, radionuclide studies are used most commonly. Here we present data from two patients with a false positive Radionuclide Cerebral Perfusion Scan (RCPS).

Determination of brain death for adult patients with ECMO

ECMO support in ARDS is an emerging strategy when conventional treatment modalities fail. ECMO has advantages on oxygenation and circulation but also it has some unfavorable effects. The most serious complication is brain death due to cerebrovascular hemorrhage. An apnea test is the most important component in confirming brain death. For patients supported by ECMO, apnea testing remains challenging. Brain-death diagnosis is often made without an apnea test.

Diffusion Weighted MRI: A Practical and Quick Approach to Evaluate Brain Death

It is significantly important to define brain death with greater precision in terms of timing and accuracy. While in the past determination of brain death is simply based on conventional angiography, now with major technological advances the Diffusion-weighted MRI is a new method sensitive to cerebral ischemia which gives on the molecular level the deeply ischemic nature of the changes. Its value in brain death has been shown in various studies. In our study, we did a comparative overview of diffusion-weighted imaging (DWI) with and magnetic resonance angiography (MRA) considering the contribution of ADC measurements from brain parenchyma, in the patients diagnosed with brain death by clinical criteria. We studied 16 brain deaths in serial studies, in which there is a prominent difference between the white and gray matter ADC values on diffusion MRI. In the postmortem brains, ADC values comparing with the normal brain parenchyma, were reduced 65% in white matter and 42% in gray matter. Also, the patients’ ADC values of gray and white matter were significantly lower than those of irreversible brain-ischemia patients’ in ADC values. In comparison to most of the other studies, in our study population studied is large, in which is a comprehensive study that results consistent with the literature. As a result we propose that in the definition of brain death Diffusion MRI and ADC measurements are reliable to show diffuse ishemic changes of brain parenchyma.

How to settle confirmation of recipient's intent earlier than the second determination of brain death of the donor

How to settle confirmation of recipient's intent earlier than the second determination of brain death of the donor

Assessment of the transplantation scandal by the media : scientific discourse analysis of selected German newspapers

The press is an important medium and plays a significant role as an information source for people. Moreover, the daily press transmits opinion-forming contents. During the German "transplantation scandal" various articles were published in the German press focusing on organ donation, transplantation, allocation of organs and brain death determination. Selected important newspaper articles were analyzed using a scientific text analysis as it was assumed that the publications might have had an important influence on attitudes or mistrust of transplantation medicine. A total of 216 articles from Süddeutsche Zeitung, Die Welt, Frankfurter Allgemeine Zeitung and Die Zeit published between summer 2012 and early 2013, which focused on the transplantation scandal were analyzed using a modern form of scientific text analysis. From these articles 12 categories of contents were identified which were analyzed quantitatively and qualitatively. Most articles were published between June and August 2012 when the accusations of organ allocation manipulation were made public. A second wave was found in the early months of 2013, when the court proceedings against the predominantly blamed physician began. Most of the categories (63.8 %) transmitted a negative evaluative opinion (i.e. loss of confidence, enrichment of the persons involved, fraud, misconduct, rejection of brain death and disturbing the peace of the dead) leading to mistrust of transplantation per se, while the minority (36.2 %) were categorized as endeavoring to convey objective information, focus on ethical responsibility for organ donation or the problems of organ shortage. Furthermore, a striking increase of articles doubting the concept of brain death was observed. German newspapers as important opinion-leading and opinion-forming media have a substantial impact in accomplishing the demands for objective and factual information of transplantation medicine. Physicians, ethicists, journalists and politicians are invoked to have a closer collaboration in the future.

Criteria and practical guidance for determination of brain death in children (BQCC version)

Brain Injury Evaluation Quality Control Centre of National Health and Family Planning Commission

Dynamic Computed Tomography Angiography in Suspected Brain Death: A Noninvasive Biomarker

PurposeNeurologic determination of death or brain death is primarily a clinical diagnosis. This must respect all guarantees required by law and should be determined early to avoid unnecessary treatment and allow organ harvesting for transplantation. Ancillary testing is used in situations in which clinical assessment is impossible or confounded by other factors. Our purpose is to determine the utility of dynamic computed tomographic angiography (dCTA) as an ancillary test for diagnosis of brain death. Materials and MethodsWe retrospectively reviewed 13 consecutive patients with suspected brain death in the intensive care unit who had dCTA. Contrast appearance timings recorded from the dCTA data were compared to findings from 15 controls selected from patients who presented with symptoms of acute stroke but showed no stroke in follow-up imaging. ResultsThe dCTA allows us to reliably assess cerebral blood flow and to record time of individual cerebral vessels opacification. It also helps us to assess the intracranial flow qualitatively against the flow in extracranial vessels as a reference. We compared the time difference between enhancement of the external and internal carotid arteries and branches. In all patients who were brain dead, internal carotid artery enhancement was delayed, which occurred after external carotid artery branches were opacified. ConclusionIn patients with suspected brain death, dCTA reliably demonstrated the lack of cerebral blood flow, with extracranial circulation as an internal reference. Our initial results suggest that inversion of time of contrast appearance between internal carotid artery and external carotid artery branches at the skull base could predict a lack of distal intracranial flow.