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Lewis A. An Update on Brain Death/Death by Neurologic Criteria since the World Brain Death Project. Semin Neurol 2024. [PMID: 38621707 DOI: 10.1055/s-0044-1786020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
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.
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Affiliation(s)
- Ariane Lewis
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, NYU Langone Medical Center, New York
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Greer DM, Lewis A, Kirschen MP. New developments in guidelines for brain death/death by neurological criteria. Nat Rev Neurol 2024; 20:151-161. [PMID: 38307923 DOI: 10.1038/s41582-024-00929-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/04/2024]
Abstract
The declaration of brain death (BD), or death by neurological criteria (DNC), is medically and legally accepted throughout much of the world. However, inconsistencies in national and international policies have prompted efforts to harmonize practice and central concepts, both between and within countries. The World Brain Death Project was published in 2020, followed by notable revisions to the Canadian and US guidelines in 2023. The mission of these initiatives was to ensure accurate and conservative determination of BD/DNC, as false-positive determinations could have major negative implications for the medical field and the public's trust in our ability to accurately declare death. In this Review, we review the changes that were introduced in the 2023 US BD/DNC guidelines and consider how these guidelines compare with those formulated in Canada and elsewhere in the world. We address controversies in BD/DNC determination, including neuroendocrine function, consent and accommodation of objections, summarize the legal status of BD/DNC internationally and discuss areas for further BD/DNC research.
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Affiliation(s)
- David M Greer
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
- Boston Medical Center, Department of Neurology, Boston, MA, USA.
| | - Ariane Lewis
- NYU Langone Medical Center, Departments of Neurology and Neurosurgery, New York, NY, USA
| | - Matthew P Kirschen
- The Children's Hospital of Philadelphia, Department of Anaesthesiology and Critical Care Medicine, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Lewis A. An Overview of Ethical Issues Raised by Medicolegal Challenges to Death by Neurologic Criteria in the United Kingdom and a Comparison to Management of These Challenges in the USA. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:79-96. [PMID: 36634197 DOI: 10.1080/15265161.2022.2160516] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Although medicolegal challenges to the use of neurologic criteria to declare death in the USA have been well-described, the management of court cases in the United Kingdom about objections to the use of neurologic criteria to declare death has not been explored in the bioethics or medical literature. This article (1) reviews conceptual, medical and legal differences between death by neurologic criteria (DNC) in the United Kingdom and the rest of the world to contextualize medicolegal challenges to DNC; (2) summarizes highly publicized legal cases related to DNC in the United Kingdom, including the nuanced 2022 case of Archie Battersbee, who was transiently considered dead by neurologic criteria, but ultimately determined to be in a vegetative state/unresponsive-wakeful state; and (3) provides an overview of ethical issues raised by medicolegal challenges to DNC in the United Kingdom and a comparison to the management of these challenges in the USA.
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Díaz-Cobacho G, Molina-Pérez A, Rodríguez-Arias D. Death pluralism: a proposal. Philos Ethics Humanit Med 2023; 18:10. [PMID: 37528432 PMCID: PMC10394888 DOI: 10.1186/s13010-023-00139-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 06/19/2023] [Indexed: 08/03/2023] Open
Abstract
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.
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Affiliation(s)
| | - Alberto Molina-Pérez
- Instituto de Estudios Sociales Avanzados (IESA), CSIC, IESA-CSIC, Córdoba, Spain.
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Abstract
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.
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Affiliation(s)
- Danielle Feng
- Department of Neurology, Harbor-UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90502, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY 10016, USA; Department of Neurosurgery, NYU Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY 10016, USA.
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Stewart S, McKitty A, Chidwick P, Healey A, van Beinum A. Trust and conflict in death determination-reflections on the legacy of Taquisha McKitty. Can J Anaesth 2023; 70:603-609. [PMID: 37157048 PMCID: PMC10166452 DOI: 10.1007/s12630-023-02443-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/07/2022] [Accepted: 09/21/2022] [Indexed: 05/10/2023] Open
Affiliation(s)
| | | | - Paula Chidwick
- William Osler Health System, Brampton and Etobicoke, ON, Canada
| | - Andrew Healey
- William Osler Health System, Brampton and Etobicoke, ON, Canada
- Trillium Gift of Life Network, Toronto, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Amanda van Beinum
- Centre for Health Law, Policy, and Ethics, University of Ottawa, 100 Thomas More Private, Ottawa, ON, K1N 6N5, Canada.
- Department of Sociology and Anthropology, Carleton University, Ottawa, ON, Canada.
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Pope TM, Chandler JA, Hartwick M. Consent for determination of death by neurologic criteria in Canada: an analysis of legal and ethical authorities, and consensus-based working group recommendations. Can J Anaesth 2023; 70:570-584. [PMID: 37131032 PMCID: PMC10153780 DOI: 10.1007/s12630-023-02430-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 05/04/2023] Open
Abstract
This article addresses the following question: should physicians obtain consent from the patient (through an advance directive) or their surrogate decision-maker to perform the assessments, evaluations, or tests necessary to determine whether death has occurred according to neurologic criteria? While legal bodies have not yet provided a definitive answer, significant legal and ethical authority holds that clinicians are not required to obtain family consent before making a death determination by neurologic criteria. There is a near consensus among available professional guidelines, statutes, and court decisions. Moreover, prevailing practice does not require consent to test for brain death. While arguments for requiring consent have some validity, proponents cannot surmount weightier considerations against imposing a consent requirement. Nevertheless, even though clinicians and hospitals may not be legally required to obtain consent, they should still notify families about their intent to determine death by neurologic criteria and offer temporary reasonable accommodations when feasible. This article was developed with the legal/ethics working group of the project, A Brain-Based Definition of Death and Criteria for its Determination After Arrest of Circulation or Neurologic Function in Canada developed in collaboration with the Canadian Critical Care Society, Canadian Blood Services, and the Canadian Medical Association. The article is meant to provide support and context for this project and is not intended to specifically advise physicians on legal risk, which in any event is likely jurisdiction dependent because of provincial or territorial variation in the laws. The article first reviews and analyzes ethical and legal authorities. It then offers consensus-based recommendations regarding consent for determination of death by neurologic criteria in Canada.
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Affiliation(s)
- Thaddeus M Pope
- Mitchell Hamline School of Law, 875 Summit Avenue, Saint Paul, MN, 55105, USA.
| | - Jennifer A Chandler
- Faculties of Law and Medicine, Bertram Loeb Research Chair, University of Ottawa, Ottawa, ON, Canada
| | - Michael Hartwick
- Department of Medicine, Divisions of Critical Care and Palliative Medicine, University of Ottawa, Ottawa, ON, Canada
- Trillium Gift of Life, Ottawa, ON, Canada
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Murphy NB, Hartwick M, Wilson LC, Simpson C, Shemie SD, Torrance S, Chandler JA. Rationale for revisions to the definition of death and criteria for its determination in Canada. Can J Anaesth 2023; 70:558-569. [PMID: 37131021 PMCID: PMC10203013 DOI: 10.1007/s12630-023-02407-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 05/04/2023] Open
Abstract
Clarity regarding the biomedical definition of death and the criteria for its determination is critical to inform practices in clinical care, medical research, law, and organ donation. While best practices for death determination by neurologic criteria and circulatory criteria were previously outlined in Canadian medical guidelines, several issues have arisen to force their reappraisal. Ongoing scientific discovery, corresponding changes in medical practice, and legal and ethical challenges compel a comprehensive update. Accordingly, the A Brain-Based Definition of Death and Criteria for its Determination After Arrest of Neurologic or Circulatory Function in Canada project was undertaken to a develop a unified brain-based definition of death, and to establish criteria for its determination after devastating brain injury and/or circulatory arrest. Specifically, the project had three objectives: (1) to clarify that death is defined in terms of brain functions; (2) to clarify how a brain-based definition of death is articulated; and (3) to clarify the criteria for determining if the brain-based definition is met. The updated death determination guideline therefore defines death as the permanent cessation of brain function and describes corresponding circulatory and neurologic criteria to ascertain the permanent cessation of brain function. This article explores the challenges that prompted revisions to the biomedical definition of death and the criteria for its determination and outlines the rationales underpinning the project's three objectives. By clarifying that all death is defined in terms of brain function, the project seeks to align guidelines with contemporary medicolegal understandings of the biological basis of death.
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Affiliation(s)
- Nicholas B Murphy
- Department of Medicine, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
- Department of Philosophy, Western University, London, Canada
| | - Michael Hartwick
- Divisions of Critical Care and Palliative Medicine, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Trillium Gift of Life, Ottawa, ON, Canada
| | | | - Christy Simpson
- Department of Bioethics, Dalhousie University, Halifax, NS, Canada
- Canadian Blood Services, Halifax, NS, Canada
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
- Department of Pediatrics, McGill University, Montreal, QC, Canada
- MUHC Research Institute, Montreal, QC, Canada
- Canadian Blood Services, Montreal, QC, Canada
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Simpson C, Lee-Ameduri K, Hartwick M, Shaul RZ, Kanji A, Healey A, Murphy NB, Pope TM. Navigating disagreement and conflict in the context of a brain-based definition of death. Can J Anaesth 2023; 70:724-735. [PMID: 37131031 PMCID: PMC10202992 DOI: 10.1007/s12630-023-02417-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/03/2022] [Accepted: 09/20/2022] [Indexed: 05/04/2023] Open
Abstract
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.
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Affiliation(s)
- Christy Simpson
- Department of Bioethics, Dalhousie University, Halifax, NS, Canada.
- Canadian Blood Services, Ottawa, ON, Canada.
| | - Katarina Lee-Ameduri
- St. Boniface Hospital, Reseau Compassion Network, Winnipeg, MB, Canada
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Michael Hartwick
- Department of Medicine, Divisions of Critical Care and Palliative Medicine, University of Ottawa, Ottawa, ON, Canada
- Trillium Gift of Life, Ottawa, ON, Canada
| | - Randi Zlotnik Shaul
- Bioethics Department, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Aly Kanji
- McGill University, Montreal, QC, Canada
| | - Andrew Healey
- Trillium Gift of Life Network, Hamilton, ON, Canada
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Nicholas B Murphy
- Departments of Medicine and Philosophy, Western University, London, ON, Canada
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Seshadri A, Cuschieri J, Kaups KL, Knowlton LM, Kutcher ME, Pathak A, Rappold J, Rinderknecht T, Stein DM, Young J, Michetti CP. Organ donation in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open 2023; 8:e001107. [PMID: 37205276 PMCID: PMC10186482 DOI: 10.1136/tsaco-2023-001107] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/26/2023] [Indexed: 05/21/2023] Open
Affiliation(s)
- Anupamaa Seshadri
- Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Joseph Cuschieri
- Surgery at ZSFG, University of California San Francisco, San Francisco, California, USA
| | - Krista L Kaups
- Department of Surgery, UCSF Fresno, Fresno, California, USA
| | | | - Matthew E Kutcher
- Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Abhijit Pathak
- Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | - Deborah M Stein
- Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Jason Young
- Surgery, University of Utah Health, Salt Lake City, Utah, USA
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Lewis A. Should the Revised Uniform Determination of Death Act Address Objections to the Use of Neurologic Criteria to Declare Death? Neurocrit Care 2022; 37:377-385. [PMID: 35854082 DOI: 10.1007/s12028-022-01567-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/23/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Ariane Lewis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, New York University Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY, 10016, USA.
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Gelb DJ. Building a Fence Around Brain Death: The Shielded-Brain Formulation. Neurology 2021; 97:780-784. [PMID: 34413182 DOI: 10.1212/wnl.0000000000012641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/03/2021] [Indexed: 01/16/2023] Open
Abstract
The concept of brain death was proposed more than 50 years ago, and it has been incorporated in laws and clinical practice, but it remains a source of confusion, debate, and litigation. Because of persistent variability in clinical standards and ongoing controversies regarding policies, the Uniform Law Commission, which drafted the Uniform Determination of Death Act in 1980, has appointed a committee to study whether the act should be revised. This article reviews the history of the concept of brain death and its philosophical underpinnings, summarizes the objections that have been raised to the prevailing philosophical formulations, and proposes a new formulation that addresses those objections while preserving current practices.
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