Inconsistency in Brain Death Determination Should Not Be Tolerated

Abstract

Since it was proposed in 1980, the Uniform Determination of Death Act has provided the legal basis for determination of death by neurological criteria. The act contains language that allows for acceptable medical standards to be used to determine death. Since 1995, the American Academy of Neurology has provided guidelines for brain death determination (revised in 2010), but nationwide adherence to these guidelines has been incomplete. This variability could lead to misdiagnosis and erosion of public trust in this important medical practice. Physicians must work together as a profession to push for uniformity and accuracy in death diagnosis. Defining Brain DeathAlthough the concept of death is as old as life itself, the concept of brain death is a relatively young one. Only in the mid-20th century did technology advance to the point of allowing for organ support in the event that brain function ceased. With the advent of mechanical ventilation, artificial nutrition, and the modern intensive care unit, patients who suffered an irreversible intracranial catastrophe could continue to have their other organs supported and maintained. In 1968, a committee of physicians from Harvard Medical School published a report titled "A Definition of Irreversible Coma." 1 In 1980, the Uniform Determination of Death Act (UDDA) was proposed in order to establish a legal and uniform definition of death-determined by "acceptable medical standards"that was "clear and socially accepted," with the intention of its being adopted in every US jurisdiction. 2,3 This model statute provided the legal basis for death by neurological criteria, stating that an individual could now be determined to be dead if they had sustained "irreversible cessation of all functions of the entire brain, including the brain stem." 2 What "acceptable medical standards" meant was left to be determined by the medical community, leading to the creation of societal guidelines in subsequent years.Following the Harvard report and the UDDA, in 1995, the American Academy of Neurology (AAN) provided consensus practice parameters for the determination of death by neurological criteria in adults. 4 These guidelines stated that brain death has occurred when "the irreversible loss of function of the brain, including the brain stem," has been determined by the demonstration of complete loss of consciousness (coma), brain stem

Rationale for revisions to the definition of death and criteria for its determination in Canada

“… 53 , 70 This variability threatens public confidence and raises legal questions that must be addressed to reduce uncertainty and help shield physicians and hospitals from potential litigation. 71 Canadian legislation governing death determination in the context of organ donation generally mandates that death must be determined in accordance with “accepted medical practice.” 19 The updated guideline describing criteria and diagnostic tests for death determination will help to harmonize practices across Canada and avert legal challenges by ensuring the community-derived, evidence-based, professional organization-endorsed reference standard for “accepted medical practice” is up to date.…”

“…Clear guidance on the criteria and methods for death determination is equally important for minimizing the risk of diagnostic errors. 71 Although clinical diagnostic tests for DNC are widely agreed to be reliable when performed correctly, 72 recent legal cases in the USA highlight the need for greater certainty in the face of disputes among medical professionals regarding the determination of brain death. 31 Lack of uniformity in practices for death determination and nonadherence to best practice guidelines introduce a risk of diagnostic error (i.e., false positives), which threaten to undermine confidence in medicine.…”

“… 31 Lack of uniformity in practices for death determination and nonadherence to best practice guidelines introduce a risk of diagnostic error (i.e., false positives), which threaten to undermine confidence in medicine. 71 …”

cDCDD-NRP is consistent with US legal standards for determining death

“…According to the UDDA, a determination of death is to be made in accordance with “accepted medical standards.” 9 What constitutes accepted medical standards under the UDDA “was left to be determined by the medical community.” 10 This includes what constitutes the “irreversible cessation” of a function and how medical professionals come to its determination. 11 This also includes a medical professional's consideration of the intentions of the patient and the patient's family regarding life‐sustaining efforts or procedures, and the effectiveness or futility of such efforts, which Glazier and Capron object to as being absent from the legal construct.…”

Education Research: Changes in Medical Students' Knowledge and Attitudes Toward Clinical Death After Teaching the Philosophy of Death

“…This has motivated a call for widespread educational initiatives that better prepare medical professionals to diagnose and discuss WBD. 12,13 Furthermore, although there is a growing literature on medical students' knowledge about WBD, there is scant evidence related to students' attitudes toward different views of death.…”