Controversies in Brain Death Declaration: Legal and Ethical Implications in the ICU

Prevalence of Arginine Vasopressin Deficiency among Children and Adolescents Declared Dead by Neurologic Criteria

OBJECTIVES

To determine the prevalence of arginine vasopressin deficiency (AVP-D) in children and adolescents declared brain dead (BD)/death by neurologic criteria (DNC) and to evaluate the association between cause of brain injury and the development of AVP-D.

STUDY DESIGN

We retrospectively analyzed 53 pediatric BD/DNC patients ages 0-21 years from 2013 to 2023 at a single tertiary children's hospital to assess the prevalence of AVP-D and compare those patients with and without AVP-D. AVP-D frequency by injury mechanism (anoxic brain injury, traumatic brain injury, malignancy) was also analyzed.

RESULTS

Of the 53 patients declared BD/DNC, 47 (88.7%, 95% CI 77.9% to 95.3%) were diagnosed with AVP-D. The prevalence of AVP-D was similar according to the cause of brain injury (84.4%, 100.0%, and 92.3% for anoxic brain injury, traumatic brain injury, and brain tumor, respectively; P = .410). Clinical characteristics and length of stays were similar between AVP-D and non-AVP-D groups. The estimated glomerular filtration rate (mL/min/1.73 m2) was lower in children without AVP-D (78 [51-165] vs 178 [133-253]; P = .009).

CONCLUSIONS

The prevalence of AVP-D is high in children and adolescents declared BD/DNC, and it is not significantly different based on the cause of BD/DNC. The absence of AVP-D was associated with reduced renal function. Additional multicenter studies are needed to assess clinical characteristics and renal function with preserved neuroendocrine function in children with BD/DNC.

Exploring Ethical Dimensions in Neuropalliative Care

Neurologic illnesses can be challenging to diagnose, involve changes in consciousness, and are often complicated by prognostic uncertainty. These disorders can affect how individuals interact with their environment, and as a result, many ethical concerns may arise related to their medical care. Key ethical issues in neuropalliative care include shared decision-making, evolving autonomy and capacity, best interest and harm principles, beneficence and nonmaleficence, futile and inappropriate care, justice and equity, and ableism. The four core principles of medical ethics, beneficence, nonmaleficence, justice, and autonomy, are foundational in considering approaches to these ethical challenges. Shared decision-making is rooted in the principle of autonomy. Evolving autonomy and capacity evoke autonomy, beneficence, and nonmaleficence. The best interest and harm principles are rooted in beneficence and nonmaleficence. Questions of futility and inappropriate care are founded in the principles of nonmaleficence, autonomy, and justice. Ableism invokes questions of nonmaleficence, autonomy, and justice. Practitioners of neurology will encounter ethical challenges in their practice. Framing decisions around the core ethical principles of beneficence, nonmaleficence, autonomy, and justice will help clinicians navigate challenging situations while acknowledging and respecting each patient's individual story.

Brain Death: Medical, Ethical, Cultural, and Legal Aspects

The development of critical care stimulated brain death criteria formulation in response to concerns on treatment resources and unregulated organ procurement. The diagnosis centered on irreversible loss of brain function and subsequent systemic physiologic collapse and was subsequently codified into law. With improved critical care, physiologic collapse (while predominant) is not inevitable-provoking criticisms of the ethical and legal foundation for brain death. Other criteria have been unsuccessfully proposed, but irreversibility remains the conceptual foundation. Conflicts can arise when families reject the diagnosis-resulting in ethical, cultural, and communication challenges and implications for diversity, equity, and inclusion.

Brain death/death by neurologic criteria: What you need to know

ABSTRACT

Since the beginning of time, man has been intrigued with the question of when a person is considered dead. Traditionally, death has been considered the cessation of all cardiorespiratory function. At the end of the last century a new definition was introduced into the lexicon surrounding death in addition to cessation of cardiac and respiratory function: Brain Death/Death by Neurologic Criteria (BD/DNC). There are medical, legal, ethical, and even theological controversies that surround this diagnosis. In addition, there is no small amount of confusion among medical practitioners regarding the diagnosis of BD/DNC. For families enduring the devastating development of BD/DNC in their loved one, it is the duty of the principal caregiver to provide a transparent presentation of the clinical situation and clear definitive explanation of what constitutes BD/DNC. In this report, we present a historical outline of the development of BD/DNC as a clinical entity, specifically how one goes about making a determination of BD/DNC, what steps are taken once a diagnosis of BD/DNC is made, a brief discussion of some of the ethical/moral issues surrounding this diagnosis, and finally the caregiver approach to the family of a patient who had been declared with BD/DNC. It is our humble hope that with a greater understanding of the myriad of complicated issues surrounding the diagnosis of BD/DNC that the bedside caregiver can provide needed closure for both the patient and the family enduring this critical time in their life.

Public Reason, Bioethics, and Public Policy: A Seductive Delusion or Ambitious Aspiration?

Can Rawlsian public reason sufficiently justify public policies that regulate or restrain controversial medical and technological interventions in bioethics (and the broader social world), such as abortion, physician aid-in-dying, CRISPER-cas9 gene editing of embryos, surrogate mothers, pre-implantation genetic diagnosis of eight-cell embryos, and so on? The first part of this essay briefly explicates the central concepts that define Rawlsian political liberalism. The latter half of this essay then demonstrates how a commitment to Rawlsian public reason can ameliorate (not completely resolve) many of the policy disagreements related to bioethically controversial medical interventions today. The goal of public reason is to reduce the size of the disagreement by eliminating features of the disagreement that violate the norms of public reason. The norms of public reason are those norms that are politically necessary to preserve the liberal, pluralistic, democratic character of this society. What remains is reasonable disagreement to be addressed through normal democratic deliberative processes. Specific issues addressed from a public reason perspective include personal responsibility for excessive health costs, the utility of a metaphysical definition of death for organ transplantation, and the moral status of excess embryos generated through IVF and/or their use in medical research.

Translational Neuroethics: A Vision for a More Integrated, Inclusive, and Impactful Field

As early-career neuroethicists, we come to the field of neuroethics at a unique moment: we are well-situated to consider nearly two decades of neuroethics scholarship and identify challenges that have persisted across time. But we are also looking squarely ahead, embarking on the next generation of exciting and productive neuroethics scholarship. In this article, we both reflect backwards and turn our gaze forward. First, we highlight criticisms of neuroethics, both from scholars within the field and outside it, that have focused on speculation and lack of skepticism; the dearth of consideration of broader social issues such as justice and equality, both with regard to who speaks for neuroethics as a field and who benefits from its recommendations and findings; and the insufficient focus on the practical impact of our ethical work. Second, we embrace the concept of "translational neuroethics" to outline a vision for neuroethics that is integrated, inclusive, and impactful. Integration can help us identify more pertinent, real-world issues, and move away from speculation; inclusivity can help ensure that the questions we attend to are not merely relevant to a single subgroup but aim toward just distribution of benefits; and impact can help us think beyond guidelines and recommendations to focus on implementation. Our goal is for this call to action to help shape neuroethics into a discipline that develops rigorous research agendas through relationships with interdisciplinary partners, that is broadly inclusive and attends to issues beyond novel neurotechnologies, and that is devoted to the translation of scholarship into practice.

Navigating disagreement and conflict in the context of a brain-based definition of death

In this paper, we discuss situations in which disagreement or conflict arises in the critical care setting in relation to the determination of death by neurologic criteria, including the removal of ventilation and other somatic support. Given the significance of declaring a person dead for all involved, an overarching goal is to resolve disagreement or conflict in ways that are respectful and, if possible, relationship preserving. We describe four different categories of reasons for these disagreements or conflicts: 1) grief, unexpected events, and needing time to process these events; 2) misunderstanding; 3) loss of trust; and 4) religious, spiritual, or philosophical differences. Relevant aspects of the critical care setting are also identified and discussed. We propose several strategies for navigating these situations, appreciating that these may be tailored for a given care context and that multiple strategies may be helpfully used. We recommend that health institutions develop policies that outline the process and steps involved in addressing situations where there is ongoing or escalating conflict. These policies should include input from a broad range of stakeholders, including patients and families, as part of their development and review.

A review of current controversies in determining death by neurologic criteria in children

PURPOSE OF REVIEW

Death by neurologic criteria (DNC) is the irreversible cessation of all functions of the entire brain, including the brainstem. It is legally recognized as equivalent to cardiopulmonary death. Legal and ethical controversies surrounding DNC have emerged as a result of several highly publicized cases that have eroded public trust in our ability to declare DNC accurately. In this review, we focus on recently published primary data about DNC and address some of these controversies.

RECENT FINDINGS

Approximately 21% of children who die in pediatric intensive care units (PICU) are declared DNC. Although 60% of physicians report that they have been asked to maintain organ support after DNC declaration, less than 1% of patients remain physically present in the PICU more than 5 days after DNC declaration. We discuss strategies for safely conducting the apnea test, indications and prevalence of ancillary testing, and objections to DNC, including issues of consent and requests for ongoing organ support.

SUMMARY

In order to maintain public trust, published guidelines must be followed to accurately and consistently diagnose DNC. We must develop strategies to respond to objections to DNC determination. Ongoing research is needed to improve the safety of apnea testing and indications for and interpretation of ancillary testing.