The Intersection of Neurology and Religion: A Survey of Hospital Chaplains on Death by Neurologic Criteria

Current Challenges in Neurocritical Care: A Narrative Review

Neurocritical care as a field aims to treat patients who are neurologically critically ill due to a variety of pathologies. As a recently developed subspecialty, the field faces challenges, several of which are outlined in this review. The authors discuss aneurysmal subarachnoid hemorrhage, status epilepticus, and traumatic brain injury as specific disease processes with opportunities for growth in diagnosis, management, and treatment, as well as disorders of consciousness that can arise as a result of many neurological injuries. They also address logistical challenges, such as the need for specialized resources needed to successfully run a neurosciences intensive care unit (neuro-ICU), the variations in training of those who staff neuro-ICUs, and different interdisciplinary team structures. Although an immense amount of data is collected in the neuro-ICU, leveraging the data for clinical research is an area with room for further innovation. Additionally, developing accurate basic science models for these disease processes is an ongoing area of exploration. Finally, the authors explore psychosocial challenges present in the care of neurologically critically ill patients, including limitations in prognostication and religious and cultural perceptions of brain death.

Brain Death Knowledge and Attitudes Among Fourth-Year Medical Students at Umm Al-Qura University

Background Despite clear definitions of brain death, students and medical professionals may have varying understandings. This study investigated the knowledge and attitudes of medical students regarding brain death. Methods A cross-sectional survey was administered to 142 fourth-year medical students at Umm Al-Qura University. The survey used single-choice and Likert scale questions to assess knowledge of brain death definition, diagnosis procedures, and student attitudes. Prior to administration, the questionnaire underwent content validation by experts in medicine, ethics, and public health. Results A significant proportion of students lacked knowledge of the legal definition of brain death in Saudi Arabia (26.1%), brain death diagnostic procedures (43.7%), and prerequisites for declaring brain death (38%). While some students expressed confidence in diagnosing brain death, concerns about misdiagnosis were also present. Conclusion Fourth-year medical students in this study demonstrated significant knowledge gaps regarding brain death. Medical education programs may need to be revised to provide more comprehensive training on brain death and its implications. Additionally, public awareness campaigns could improve understanding and facilitate informed decision-making about organ donation. Further research, including multicenter studies, is warranted to confirm these findings and guide educational interventions.

An Update on Brain Death/Death by Neurologic Criteria since the World Brain Death Project

The World Brain Death Project (WBDP) is a 2020 international consensus statement that provides historical background and recommendations on brain death/death by neurologic criteria (BD/DNC) determination. It addresses 13 topics including: (1) worldwide variance in BD/DNC, (2) the science of BD/DNC, (3) the concept of BD/DNC, (4) minimum clinical criteria for BD/DNC determination, (5) beyond minimum clinical BD/DNC determination, (6) pediatric and neonatal BD/DNC determination, (7) BD/DNC determination in patients on ECMO, (8) BD/DNC determination after treatment with targeted temperature management, (9) BD/DNC documentation, (10) qualification for and education on BD/DNC determination, (11) somatic support after BD/DNC for organ donation and other special circumstances, (12) religion and BD/DNC: managing requests to forego a BD/DNC evaluation or continue somatic support after BD/DNC, and (13) BD/DNC and the law. This review summarizes the WBDP content on each of these topics and highlights relevant work published from 2020 to 2023, including both the 192 citing publications and other publications on BD/DNC. Finally, it reviews questions for future research related to BD/DNC and emphasizes the need for national efforts to ensure the minimum standards for BD/DNC determination described in the WBDP are included in national BD/DNC guidelines and due consideration is given to the recommendations about social and legal aspects of BD/DNC determination.

The impact of clinical education on knowledge and attitudes towards brain death among Polish medical students - a cross-sectional study

BACKGROUND

Understanding brain death is essential for progress in organ transplantation; however, it remains a challenging ethical matter. In 2019, Poland revised its legislation on brain death to align with international standards. This study aimed to evaluate the knowledge and worldview concerning brain death among Polish medical students, categorised according to their stage of education.

METHODS

An online questionnaire was administered to 169 medical students from four Polish medical universities. The participants were divided into preclinical (n = 94) and clinical (n = 75) groups. The questionnaire consisted of two parts, with the first part comprising 13 questions focusing on knowledge about brain death and the process of its determination. The second part contained six questions related to the participants' worldview regarding brain death, particularly concerning organ transplantation.

RESULTS

The average score obtained by the respondents was 7.53 (± 2.35; min. 1, max. 13) in knowledge checking part of the developed questionnaire (maximal score:13). Students in the clinical stage of their education achieved significantly higher scores compared to preclinical students (mean 8.84; ± 1.89 vs mean 6.49; ± 2.15; p < 0.001). Significant correlations were found between the results of the knowledge part of the questionnaire and responses to worldview questions.

CONCLUSIONS

The stage of education influenced the knowledge of brain death among medical students, although the overall test scores were unsatisfactory. Higher test scores were associated with worldview responses indicating compliance with the current legislation in Poland and evidence-based medicine.

Death pluralism: a proposal

The debate over the determination of death has been raging for more than fifty years. Since then, objections against the diagnosis of brain death from family members of those diagnosed as dead-have been increasing and are causing some countries to take novel steps to accommodate people's beliefs and preferences in the determination of death. This, coupled with criticism by some academics of the brain death criterion, raises some questions about the issues surrounding the determination of death. In this paper, we discuss some of the main approaches to death determination that have been theoretically proposed or currently put into practice and propose a new approach to death determination called "weak pluralism" as a reasonable ethical and political alternative to respect diversity in death determination.

Brain Death: Ethical and Legal Challenges

Although the fundamental principle behind the Uniform Determination of Death Act (UDDA), the equivalence of death by circulatory-respiratory and neurologic criteria, is accepted throughout the United States and much of the world, some families object to brain death/death by neurologic criteria. Clinicians struggle to address these objections. Some objections have been brought to court, particularly in the United States, leading to inconsistent outcomes and discussion about potential modifications to the UDDA to minimize ethical and legal controversies related to the determination of brain death/death by neurologic criteria.

International variability in the diagnosis and management of disorders of consciousness

This manuscript explores the international variability in the diagnosis and management of disorders of consciousness (DoC). The identification, evaluation, intervention, exploration, prognostication and limitation of therapy for patients with DoC is reviewed through an international lens. The myriad factors that impact the diagnosis and management of DoC including 1) financial, 2) legal and regulatory, 3) cultural, 4) religious and 5) psychosocial considerations are discussed. As data comparing patients with DoC internationally are limited, findings from the general critical care or neurocritical care literature are described when information specific to patients with DoC is unavailable. There is a need for improvements in clinical care, education, advocacy and research related to patients with DoC worldwide. It is imperative to standardize methodology to evaluate consciousness and prognosticate outcome. Further, education is needed to 1) generate awareness of the impact of the aforementioned considerations on patients with DoC and 2) develop techniques to optimize communication about DoC with families. It is necessary to promote equity in access to expertise and resources for patients with DoC to enhance the care of patients with DoC worldwide. Improving understanding and management of patients with DoC requires harmonization of existing datasets, development of registries where none exist and establishment of international clinical trial networks that include patients in all phases along the spectrum of care. The work of international organizations like the Curing Coma Campaign can hopefully minimize international variability in the diagnosis and management of DoC and optimize care.

A thematic analysis of a survey of hospital chaplains on death by neurologic criteria

INTRODUCTION

Little is known about chaplains' views on brain death/death by neurologic criteria (BD/DNC). Thematic analysis of comments made by hospital chaplains about BD/DNC can illuminate their perspectives on working with patients, families, and interdisciplinary teams during assessment for BD/DNC.

MATERIALS AND METHODS

In an electronic survey distributed to members of five chaplaincy organizations between February and July 2019, we elicited free-text comments about BD/DNC. We performed a thematic analysis of the comments.

RESULTS

Four themes were present: (1) definition of life and death, (2) respect with a subtheme of physician obligation, (3) collaboration with a subtheme of communication, and (4) education with a subtheme of scepticism.

CONCLUSIONS

Hospital chaplains are essential members of the interdisciplinary team involved in BD/DNC evaluation. They aim to ensure the interaction between families and the interdisciplinary team at the boundary of life and death and the intersection between religion and medicine is respectful, collaborative, and educational.

Should the Revised Uniform Determination of Death Act Address Objections to the Use of Neurologic Criteria to Declare Death?

In response to concerns about the declaration of death by neurologic criteria, the Uniform Law Commission created a drafting committee to update the Uniform Determination of Death Act (UDDA) in the Fall of 2021. One of the key questions for the committee to address was the following: Should the revised UDDA address objections to the use of neurologic criteria to declare death? This article (1) provides historical background and survey results that demonstrate the need to address this question; (2) summarizes the ethical principles that support and oppose accommodation of objections to the use of neurologic criteria to declare death; (3) reviews accommodation in other areas of medicine and law; (4) discusses existing legal and hospital guidance on management of these objections; (5) examines perspectives of stakeholder medical societies and expert health care professionals, lawyers, ethicists, and philosophers on whether the revised UDDA should address these objections; (6) identifies some questions for the drafting committee to consider when deciding whether the revised UDDA should address objections to the use of neurologic criteria to declare death; and (7) summarizes the potential downstream effects of the drafting committee's decision.