POINT: Whether Informed Consent Should Be Obtained for Apnea Testing in the Determination of Death by Neurologic Criteria? Yes

Shewmon, D. Alan

doi:10.1016/j.chest.2021.11.026

Cited by 11 publications

(7 citation statements)

References 13 publications

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“…The primary argument used to justify the need for consent before BD/DNC testing is that there is risk to the patient—that a patient who is not brain dead before testing could be harmed by the testing itself. 1,2 Specifically, take as an example a patient who has suffered a neurologic catastrophe (a requirement before any consideration of BD/DNC testing) from a massive intracerebral hemorrhage. The patient undergoes standard neurologic examinations at the bedside (for which specific consent is never obtained, nor is it required), including detailed cranial nerve testing and assessment for response to noxious stimulation on the cranium, torso, and extremities.…”

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confidence: 99%

Should the Brain Death Exam With Apnea Test Require Surrogate Informed Consent? No

Greer

2023

Neurology

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When a patient is admitted to a hospital for treatment, it is a general policy and practice that the patient (or their surrogate, if the patient is incapacitated) consents to be treated. Of course, this is not a blanket or all-encompassing consent, and any diagnostic workup or treatment that may pose a risk to the patient necessitates a separate “informed” consent, in which the risks and benefits are explained to the patient or their surrogate and a decision can be made to proceed with, or decline, such treatment. In general, informed consent is obtained when there is (1) medical risk and (2) a diagnostic workup or treatment that is beyond the norm. For example, a simple venipuncture for laboratory studies does not generally require informed consent because it is considered part of standard care; however, placement of a central venous catheter generally does require consent because it carries greater risk and is beyond the “basics” of standard care.

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Should the Brain Death Exam With Apnea Test Require Surrogate Informed Consent? No

Greer

2023

Neurology

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“…Third, the AT can be a self-fulfilling test in that, if the patient is close to but not yet BD pre-AT, the hypercarbia produced can cause cerebral vasodilation, increasing cerebral blood volume, which increases ICP, and hence decreases CPP, directly contributing to patients being BD post-AT (6)(7)(8)(9)(10)15). Reduced CPP during AT can also occur due to hypotension, which occurred in 15 of 105 AT (14%).…”

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confidence: 99%

“…It is unclear how many patients had primary brainstem injury or how many of these were among the 15 patients who had an electroencephalogram (1). Finally, global ischemic penumbra occurs as a mathematical necessity during progression to BD as ICP progressively rises and CPP progressively drops (6–8). This can result in loss of brain functions with retained viability and may not be ruled out by radionuclide cerebral blood flow testing (which was done in three patients in this series) (6–8).…”

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confidence: 99%

“…Second, the AT is done to test medullary respiratory function, watching for spontaneous breathing as the medulla is stimulated with high Pa co 2 levels (9); however, the AT does not test isolated lower medullary respiratory center(s) function at all (2, 6, 7, 10). Isolated lower medullary respiratory function is suppressed by hyperoxia, does not respond to hypercarbia, and would induce a gasping respiratory pattern in response to hypoxia (10–13).…”

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confidence: 99%

“…Moreover, the current study found that an AT did not determine the irreversible loss of pontomedullary function in response to hypercarbia, as there was one of 58 patients (1.7%) who had no spontaneous breathing on one AT but had spontaneous breathing on the next AT (also reported elsewhere) (14). There are at least six case reports of reversible apnea after the diagnosis of BD according to guidelines (6, 7, 15).…”

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confidence: 99%

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Consent for the Apnea Test: Asking the Wrong Question*

Joffe

2023

Pediatric Critical Care Medicine

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I n this issue of Pediatric Critical Care Medicine, Sveen et al (1) wrote that "some parents and providers have asserted informed consent is required for [the apnea test] AT due to the risk of serious adverse events" and concluded that their study's "findings may inform the ongoing debate regarding whether specific informed consent should be required for AT. " They based this on their empirical findings of adverse event rates that occurred during the apnea test (AT), and the "general consent for medical treatment" upon admission to the hospital (1).The authors report a retrospective study of all 105 ATs done in 58 patients at Cincinnati Children's Hospital Medical Center from July 2013 to June 2020. Adverse events during the AT were defined as hypotension (mean arterial pressure < 5th percentile for age), hypoxia (pulse oximetry saturation < 85%), new or increased pneumothorax, arrhythmia, new intracranial hypertension (intracranial pressure [ICP] > 20 mm Hg), or cardiac arrest. No patients had arrhythmia, new intracranial hypertension (because all had this prior to the AT), or cardiac arrest. Adverse events (hypotension, hypoxia, and/or pneumothorax) occurred in 21 of 105 AT (20%), and led to premature termination of the AT in five of 105 (5%), with the rest "managed medically… with transient increase in vasoactive support, or with completion of the AT" (1). The "transient" increases in vasoactive support lasted "less than 1 hour" (1). The six or seven patients monitored had 15 AT with no change in ICP from pre-AT (median, 72 mm Hg; interquartile range [IQR], 61-82 mm Hg) to post-AT (median, 72 mm Hg; IQR, 60-83 mm Hg). One patient had absent breathing on the second AT but spontaneous breathing on the third AT. There were no "vital sign changes consistent with herniation" identified, although presumably, most patients had brain herniation as part of the usual pathophysiology of brain death (BD) (1).Limitations of the study discussed by the authors included that the study was single center and retrospective, that it was possible AT was deferred in some patients felt to be at high risk of decompensation, and that the few patients with ICP monitoring had severe intracranial hypertension at baseline "preventing any assessment regarding potential AT effects on cerebral perfusion" (1). In these patients, the cerebral perfusion pressure (CPP) was likely already above the critical closing pressure of cerebral vessels pre-AT. There was a lack of arterial access during 20 AT, making accurate assessment of transient hypotension in those patients impossible. Nevertheless, given that adverse events occurred in only 20% of AT and "resolved with medical care" or premature termination of the AT "without further intervention, " the findings "may inform the ongoing debate regarding whether specific consent should be required for AT" (1). *See also p. 399.

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Is Consent Required for Clinicians to Make a Determination of Death by Neurologic Criteria?

Pope

2022

Advances in Neuroethics

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POINT: Whether Informed Consent Should Be Obtained for Apnea Testing in the Determination of Death by Neurologic Criteria? Yes

Cited by 11 publications

References 13 publications

Should the Brain Death Exam With Apnea Test Require Surrogate Informed Consent? No

Should the Brain Death Exam With Apnea Test Require Surrogate Informed Consent? No

Consent for the Apnea Test: Asking the Wrong Question*

Is Consent Required for Clinicians to Make a Determination of Death by Neurologic Criteria?

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