Brain Death Declaration
Sean J. Evans, M.D. Associate Professor UCSD Department of Neurosciences What’s on tap…
What is brain death?
How do I think about it?
What do the guidelines say?
Complicating issues…
What can we learn from an unfortunate case?
A brief history…
1960s-Organ donation drives a recognition of need for legal status
1968-Harvard Medical School proposes criteria for patients that could be declared dead prior to cardiopulmonary failure
1970-Kansas adopts legal brain death declaration
1981-Uniform Determination of Death Act Uniform Determination of Death Act
Section 1 Additions – An individual who as – New York and New sustained either (1) Jersey irreversible cessation of Exceptions based on circulatory and religious belief of the respiratory functions, or family. (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards. What is brain death?
Irreversible loss of function of the brain, including the brainstem. Also called “death by brain criteria” Allows for spinal cord and peripheral nerve function
How do I think about it?
Be as obnoxious as I can be, and see if the brain can respond to me!
Helps if the things you do are universally accepted as obnoxious… How do I think about it?
What can I prod? How do I think about it?
How to prod?
Exclude sedating drugs by showing level below therapeutic, or by observing 5 half lives.
Therapeutic for alcohol = >0.08
Phenobarbital Min Tox 30 ug/ml Pentobarbital Min Tox 5 ug/ml
Guidelines!
Guidelines
Must Have Must NOT Have – Clinical or Imaging – Severe confounding evidence of medical condition neurologic – Intoxication catastrophe – Hypothermia <90F compatible with irreversible cessation of brain function Guidelines
Clinical exam must include – Coma, no cerebral response to pain – No pupillary responses – No occular movements to VOR or Calorics (50ml of ice water and 1 minute of observation with 5 minutes in between ears) – No corneal response – No jaw jerk – No grimace to pain – No gag – No cough Guidelines
Clinical exam must include – No respiration Ideally confirmed by apnea test – Pre-oxygenate – Pretest ABG – Off ventilator for 8 minutes, observe for respiratory movements – Post-test ABG, CO2 rise of >20 to minimum of 60. – Abort if SBP<90, desaturation, or arrhythmia Guidelines
Confirmation – Best confirmation is time 6 hours for adults 12 hours for 1-18 years 24 hours for 2-12 months 48 hours for 7-60 days Unclear under 7 days – Second best is confirmatory test Complicating issues…
Can’t tolerate an apnea test… Seizures… Infants… Temperature… Intoxicants… Metabolic… Trauma…
Complicating Issues
Confirmatory tests – Angiography – Electrocerebral Silence – Transcranial Ultrasound – Technetium 99 Scan – SSEPs Guidelines
Documentation – Etiology and irreversibility of condition – Absence of brainstem reflexes – Absence of motor response to pain – Absence of respiration with CO2>60 – Justification for and result of confirmatory tests – Interval of neurologic examination What can we learn from an unfortunate case?
On December 12, 2013, after suffering complications of an elective tonsillectomy and adenoidectomy, Jahi McMath, a 13 year old girl, was declared dead by brain criteria following assessments by a neurologist and a pediatric intensivist at Children’s Hospital & Research Center Oakland.
“The family, by contrast, claimed that their child was not dead because she had a continually beating heart and was moving in response to touch.” What can we learn from an unfortunate case?
“Judge Grillo…issued a temporary restraining order stopping the hospital from disconnecting her ventilator…appointed an independent physician…(a pediatric neuro-oncologist from Stanford University)…to evaluate Jahi.”
“The neurologic examination of the court-appointed neurologist shows a full neurologic examination, apnea test, isoelectric EEG, and a nuclear scan with no demonstrable uptake.”
What can we learn from an unfortunate case?
Ultimately, Jahi was legally treated as deceased, and a death certificate was issued on January 3, 2014, with a date of death of December 12, 2013.
Judge Grillo issued multiple TROs requiring the hospital to maintain ventilation of Jahi’s body, but denying the family’s request for further invasive procedures to facilitate transport of Jahi’s body in a ventilated state.
Jahi’s body was transported to an outside facility on January 6th and reportedly remained ventilated a year later. What can we learn from an unfortunate case?
No legal precedent was set regarding brain death declaration, only in the disposition of the remains of a deceased individual.
California law does not allow the argument that a family’s religious beliefs preclude declaration of death by brain criteria.
What can we learn from an unfortunate case?
Could this have been avoided with better education?
This is incredibly rare! Questions?
Burkle et al., Why brain death is considered death and why there should be no confusion, Neurology, 2014;83:1-6
Evidence Based Guideline Update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology, Neurology, 2010;74;1911- 1918
Practice Parameters: Determining Brain Death in Adults, Neurology, 1995;45:1012-1014
Guidelines for the Determination of Brain Death in Children, Pediatrics, 1987;80:298-300