Diagnostic Criteria For Brain Death Research Articles

Brain-based Criteria of Human Death. Study of the Issue

In this article I first tried to demonstrate that the theory of so-called braindeath is unsustainable from a scientific point of view. +e data that the medicalprofession provides on this subject clearly contradicts such a theory. It is impossibleto prove, on the basis of the knowledge available to this science thatpeople who are in a state of cerebral death are really dead. +e only thing thatthe doctor can say, without exceeding the limits of the discipline he represents,is that these people have a significant degree of brain damage. +is does notmean, however, that the brain is so damaged that is has ceased to perform all its functions. On the contrary, these patients usually show many symptomsof brain activity. Recognition of these sick people as dead, therefore, contradictsthe principles of the medical art.+e acceptance of the theory of so-called brain death has also given riseto many problems from the legal point of view. Recognition as a living or deceasedperson depends on the criteria for brain death, which vary from countryto country. +e law has therefore become arbitrary in such an important areaas human life and death.+e adoption of the theory of brain death on the basis of such un-robustscientific criteria has undoubtedly become possible only through the acceptanceof certain philosophical assumptions that reduce the human to his or herconsciousness. A permanent loss of consciousness was de facto considered to beevidence of human death. +is position contradicts the achievements of Christianthought in the field of philosophical anthropology, which emphasises theunity of the individual and the importance of his or her bodily aspect. Whatis even more important, however, is the fact that modern man tends to thinkin terms of moral utilitarianism. Many people believe that it is possible to sacrificethe life of a person who is seriously ill and who has no hope of improvement(in this case, a person with cerebral death syndrome) for the benefit of otherpatients. +is attitude explains the passivity of many circles and the failureto discuss such an important issue as the rightness or wrongness of the theoryof so-called brain death. It is not without significance that there is a specifictransplant lobby in individual countries, which puts moral pressure on entiresocieties to accept the removal of organs for transplantation from people whoare in a state of so-called brain death, and suppresses the discussion of moralproblems associated with it.It is necessary for the Catholic Church to develop a clear position on thismatter. +is has not yet happened. +ere is even a surprising lack of consensusamong various the authorities. However, some of the hierarchy of the CatholicChurch have already spoken on this matter. +ese include Cardinal Meissner,Archbishop of Cologne, who clearly rejected the theory of brain death as incompatiblewith the principles of the Church’s teaching8'. Pope John Paul IIalso wrote in the encyclical Evangelium Vitae: “Nor can we remain silent aboutthe existence of other, better camouflaged but no less dangerous forms of euthanasia.We would be dealing with them, for example, if, in order to obtain moreorgans for transplantation, we proceeded to collect these organs from donorsbefore they were declared dead according to objective and adequate criteria.”Although these words do not mention the concept of brain death, theyrefer to it indirectly. +is paper was written in order to draw attention to justsuch a moral problem hidden in the concept of so-called brain death.In conclusion, I would like to give the floor to one of the participantsin the discussion on brain death, Dr Tomoko Abe. She wrote: “It is true thatthe latest developments in science and technology have brought many benefits.At the same time, however, they have brought unprecedented confusion in philosophyand culture to our societies. Due to the destructive tendencies of thepresent day, it is becoming increasingly important to establish social standardsto protect the most vulnerable members of society, such as young children andunconscious patients who cannot defend themselves. We therefore concludethat the current diagnostic criteria for brain death should be abolished andthat a worldwide ban on transplants from people with cerebral death syndromeshould be introduced.”88Dr. Abe is not alone in a desire to overthrow the theory of so-called braindeath and to consider its criteria as non-scientific. +e same is demanded bymany other authors. +e voice of the Catholic Church in this matter is undoubtedlyone of the most important. As the greatest authority in the world in mattersof morality and human rights, it cannot fail to explain the issue of so-calledbrain death in its teaching.

Update of the diagnostic criteria of brain death: application and training of physicians.

ObjectiveTo evaluate the medical knowledge regarding the application of the diagnostic criteria for brain death and to correlate it with training parameters for this diagnosis according to Federal Council of Medicine resolution 2,173 of 2017.MethodWe interviewed 174 physicians with experience with comatose patients. A structured questionnaire adapted from previous studies was used. The associations of the variables were tested using the chi-square test for independence. A multivariate logistic model was fitted for associations with p values ≤ 0.20.ResultsAmong the interviewees, 40% had been working for more than 1 year in intensive care, and 23% had initiated ten or more brain death protocols complying with the new resolution. Forty-five percent of the interviewees reported having difficulty following the criteria, 94% acknowledged the need for complementary tests for diagnosis, and 8% of them reported the existence of incorrect tests. The difficulty with these criteria decreased with an increase in the number of years of medical training (OR = 0.487; p = 0.045; 95%CI 0.241 - 0.983) and with a higher number of initiated brain death protocols (OR = 0.223; p = 0.0001; 95%CI 0.117 - 0.424).ConclusionsDifficulties in the application of brain death criteria were identified by a significant portion of the sample. However, among other factors, more years of training and a greater number of initiated brain death protocols were associated with greater ease in the application of brain death criteria according to the guidelines provided in Resolution 2,173 of the Federal Council of Medicine.

A Biological Theory of Death: Characterization, Justification, and Implications

John P. Lizza has long been a major figure in the scholarly literature on criteria for death. His searching and penetrating critiques of the dominant biological paradigm, and his defense of a theory of death of the person as a psychophysical entity, have both significantly advanced the literature. In this special issue, Lizza reinforces his critiques of a strictly biological approach. In my commentary, I take up Lizza’s challenge regarding a biological concept of death. He is certainly right to point out that science is not value-free; however, this does not imply that there cannot be a characterization of biological death that can be shown to be superior to other concepts. After characterizing and justifying such a theory of biological death, I show that patients who meet the diagnostic criteria for brain death are unequivocally biologically alive. However, with respect to concepts of personhood and related ideas (as opposed to biology), I urge the acceptance of a pluralism of such concepts for matters of public policy.

Brain Death.

Death determined by neurologic criteria, commonly referred to as "brain death," occurs when function of the entire brain ceases, including the brain stem. Diagnostic criteria for brain death are explicit but controversy exists regarding nuances of the evaluation and potential confounders of the examination. Hospitals and ICU teams should carefully consider which clinicians will perform brain death testing and should use standard processes, including checklists to prevent diagnostic errors. Proper diagnosis is essential because misdiagnosis can be catastrophic. Timely, accurate brain death determination and aggressive physiologic support are cornerstones of both good end-of-life care and successful organ donation.

Guillain-Barré Syndrome with Absent Brainstem Reflexes – a Report of Two Cases

Guillain-Barré syndrome, known for its diverse, atypical and heterogeneous range of presentations, can rarely present in an apparent comatose state with absent brainstem reflexes. Two patients presented in an unresponsive state with flaccid quadriplegia, total areflexia with no response to cephalic or peripheral painful stimuli. Pupils were mid-dilated with absent direct and consensual light reflex. All cranial nerve reflexes were absent. Preliminary laboratory investigations and complementary tests were normal. Cerebrospinal fluid evaluation showed albumincytological dissociation. Brain magnetic resonance imaging and electroencephalogram were normal. Both were diagnosed as fulminant Guillain-Barre syndrome. Despite an absence of brainstem reflexes neither patient fulfilled diagnostic criteria for brain death.

Diagnose des Hirntodes: Grenzen der Angiographie nach osteoklastischer Trepanation

A 50-year-old man sustained severe skull-brain trauma with intracerebral bleeding, cortical contusion foci and fracture of the petrosal bone. He went into coma a few hours after the accident. Three days after surgical removal of an intracerebral bleeding via a frontoparietal osteoclastic trepanation (removal of a 4 x 5 cm piece of bone) there occurred complete brainstem areflexia, respiratory arrest and drop in temperature; the encephalogram was isoelectric. There was thus no clinical-neurological doubt of brain death. But cranial digital subtraction angiography, generally considered to give the most reliable evidence of irreversible loss of cerebral functions, showed contrast medium in the branches of the left cerebral artery. The diagnostic criteria of brain death, as proposed by the Federal German Chamber of Physicians (Bundesärztekammer), were thus not exactly met, and despite the clinically obvious brain death a contemplated removal of organs for transplantation was therefore not undertaken. The patient died 6 hours after the angiography. This case shows that the value of angiography for the diagnosis of brain death may sometimes be limited, at least in those cases in which osteoclastic trepanation has been performed or there are other causes for a skull defect, because they can prevent the rise of intracranial pressure which brings about the cerebral circulatory arrest.

Bispectral Index Monitoring in Confirmation of Brain Death in Children

Although the guidelines for the diagnosis of brain death in children are well established, the diagnosis is still under debate, and further confirmatory tests are required. Performing these confirmatory tests presents some drawbacks, such as high costs, the need for specialized personnel and technology, transportation of patients out of the intensive care unit, and the use of contrast media. Bispectral index monitoring can provide real-time, objective, continuous monitoring of the consciousness level in critically ill children. The aim of this prospective study was to define the role of bispectral index monitoring in the confirmation and diagnosis of brain death. Eight children who had fulfilled the diagnostic criteria of brain death were included in the study. The age of patients ranged from 3 months to 15 years. All patients had electrocerebral silence on their electroencephalographic recordings. After the diagnosis of brain death, at least 2-hour monitoring was performed, and all patients expressed a score of 0, indicating brain death. According to our study, the decrease in bispectral index score to 0 in patients with suspected brain death can support and confirm brain death diagnosis in children and can enable scheduling of expensive tests, such as cerebral angiography, in the appropriate time. Nevertheless, further studies are needed to determine the role of the bispectral index in the diagnosis and confirmation of brain death in children. In this article, we review clinical utility, application time, and interpretation of bispectral index monitoring in confirmation of brain death diagnosis in children.

Potential organ donors referred to Ontario neurosurgical centres

Eleven hospitals in Ontario are adult neurosurgical centres (ONCs). Patients transferred to ONCs from community hospitals with acute intracranial emergencies often have non-survivable injuries, and may be returned to the referring hospital for end-of-life care. These referring hospitals may not be familiar with neurological determination of death, or organ donation. Our objective was to determine the number of patients with severe brain injuries assessed in ONC emergency departments where progression to brain death may be reasonably expected, and to determine their outcome. A one-year retrospective cohort study was undertaken using a convenience sample of patients transferred to eight ONCs for neurosurgical assessment, with evidence of either (a) brain death in the emergency department, or (b) severe brain injury who met criteria of a reasonable likelihood of progression to brain death. The outcome of these patients to disposition from the ONC was determined by chart review. Three thousand four hundred and forty-seven patients were identified of whom 141 met inclusion criteria. Eleven patients (7.8%) were pronounced dead in the emergency department, 96 (68.1%) patients were admitted, and 34 (24.1%) were transferred back to their referring hospital. Fourteen patients (9.9%) became organ donors: two died in the emergency department and 12 died following admission. A significant number of patients transferred to ONCs have an injury with a likelihood of progressing to brain death, but only a small proportion of these patients become organ donors. Emergency department triage, assessment and admission decisions for patients with intracranial catastrophes should consider diagnostic criteria for brain death and recognition of donor potential as part of end-of-life care.

Diversification in the concept of "birth and death": the controversy about "brain death and organ transplantation" in Japan.

There is a lot of hesitation in Japan in defining brain death as the death of the individual and in proceeding to organ transplantation. Regarding the diagnostic criteria of brain death, those issued by the Japanese Ministry of Health and Welfare in 1985 are sufficient for judgment of brain death. Many people, however, do not accept brain death as death of the individual, and even those who admit brain death as death of the individual hesitate to approve of the actual removal of organs from brain dead patients. Thus, the controversy about brain death in Japan appears to be separated from the objective of organ transplantation.

Anencephaly: Selected Medical Aspects

Several elements of anencephaly are discussed: problems of diagnosis, its declining prevalence and the effect of prenatal screening and subsequent abortion, the extent of neurological functioning and consciousness of anencephalic infants, their life span and cause of death, and the utility of organs for transplantation. The author concludes that projections of the extremely small number of infants who will benefit from such transplants ten years from now should reduce the effort expended in modifying diagnostic criteria for brain death, changing statutory definitions of death, or relaxing fundamental principles of transplantation ethics in order to obtain organs from anencephalic infants.

Cerebral radionuclide angiography. Its application in the diagnosis of brain death.

CEREBRAL radionuclide angiography or angioscintigraphy was once a common diagnostic procedure, generally as an integral part of nuclear brain scanning. In recent years, however, computed tomography has largely replaced brain scanning, and cerebral angioscintigraphy is being used only as a noninvasive alternative to contrast angiography, particularly in situations where the dynamic status of circulation is under question, but the anatomic detail is of less concern. A prime example of such a situation is suspected brain death. In some 30 states of the Union, a patient is considered legally dead if his or her brain is dead. Brain death means the irreversible cessation of all functions of the brain, including those of the brainstem. Several sets of diagnostic criteria for brain death have been published. 1-4 With few exceptions, the general requirements are as follows: (1) the patient is in deep coma; (2) spontaneous respiration is absent; (3) all reflexes, especially

Cerebral Radionuclide Angiography

CEREBRAL radionuclide angiography or angioscintigraphy was once a common diagnostic procedure, generally as an integral part of nuclear brain scanning. In recent years, however, computed tomography has largely replaced brain scanning, and cerebral angioscintigraphy is being used only as a noninvasive alternative to contrast angiography, particularly in situations where the dynamic status of circulation is under question, but the anatomic detail is of less concern. A prime example of such a situation is suspected brain death. In some 30 states of the Union, a patient is considered legally dead if his or her brain is dead. Brain death means the irreversible cessation of all functions of the brain, including those of the brainstem. Several sets of diagnostic criteria for brain death have been published. 1-4 With few exceptions, the general requirements are as follows: (1) the patient is in deep coma; (2) spontaneous respiration is absent; (3) all reflexes, especially