Depictions of 'brain death' in the media: medical and ethical implications

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.

Disclosing Results of Tests for Covert Consciousness: A Framework for Ethical Translation

The advent of neurotechnologies including advanced functional magnetic resonance imaging and electroencephalography to detect states of awareness not detectable by traditional bedside neurobehavioral techniques (i.e., covert consciousness) promises to transform neuroscience research and clinical practice for patients with brain injury. As these interventions progress from research tools into actionable, guideline-endorsed clinical tests, ethical guidance for clinicians on how to responsibly communicate the sensitive results they yield is crucial yet remains underdeveloped. Drawing on insights from empirical and theoretical neuroethics research and our clinical experience with advanced neurotechnologies to detect consciousness in behaviorally unresponsive patients, we critically evaluate ethical promises and perils associated with disclosing the results of clinical covert consciousness assessments and describe a semistructured approach to responsible data sharing to mitigate potential risks.

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.

Rationale for revisions to the definition of death and criteria for its determination in Canada

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.

Public Understandings of the Definition and Determination of Death: A Scoping Review

Background.

Advances in medicine and technology that have made it possible to support, repair, or replace failing organs challenge commonly held notions of life and death. The objective of this review is to develop a comprehensive description of the current understandings of the public regarding the meaning/definition and determination of death.

Methods.

This scoping review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Online databases were used to identify articles published from 2003 to 2021. Two reviewers (S.S. and K.Z.) screened the articles using predefined inclusion and exclusion criteria, extracted data for specific content variables, and performed descriptive examination. Complementary searches of reference lists complemented the final study selection. A search strategy using vocabulary of the respective databases was created, and criteria for the inclusion and exclusion of the articles were established.

Results.

Seven thousand four hundred twenty-eight references were identified. Sixty were retained for analysis, with 4 additional references added from complementary searches. A data extraction instrument was developed to iteratively chart the results. A qualitative approach was conducted to thematically analyze the data. Themes included public understanding/attitudes toward death and determination of death (neurological determination and cardiocirculatory determination of death), death and organ donation, public trust and legal variability, and media impacts.

Conclusions.

This review provides a current and comprehensive overview of the literature related to the general public’s understanding and attitudes toward death and death determination and serves to highlight the gaps in this topic.

Formal Training Improves Resident Understanding and Communication Regarding Brain Death/Death by Neurologic Criteria

OBJECTIVE

Residents often are involved in discussions with families regarding brain death/death by neurologic criteria (BD/DNC); however, they receive no standardized training on this topic. We hypothesized that residents are uncomfortable with explaining BD/DNC and that formal didactic and simulated training will improve residents' comfort and skill in discussions surrounding BD/DNC.

DESIGN

We partnered with our organ procurement organization (OPO) to create an educational program regarding BD/DNC consisting of a didactic component, and role-play scenarios with immediate individualized feedback. Residents completed pre- and post-training surveys.

SETTING

This study included participants from 16 academic and community institutions across New Jersey, Pennsylvania, and Delaware that are within our OPO's region.

PARTICIPANTS

Subjects were recruited using convenience sampling based on the institution and training programs' willingness to participate. A total of 1422 residents at participated in the training from 2009 to 2020.  1389 (97.7%) participants competed the pre-intervention survey, while 1361 (95.7%) completed the post-intervention survey.

RESULTS

Prior to the training, only 56% of residents correctly identified BD/DNC as synonymous with death. Additionally, 40% of residents had explained BD/DNC to families at least once, but 41% of residents reported never having been taught how to do so. The biggest fear reported in discussing BD/DNC with families was being uncomfortable in explaining BD/DNC (48%). After participating in the training, 99% of residents understood the definition of BD/DNC and 92% of residents felt comfortable discussing BD/DNC with families.

CONCLUSIONS

Participation in a standardized curriculum improves residents' understanding of BD/DNC and their comfort in discussing BD/DNC with families.

Pediatric brain death certification: a narrative review

In the five decades since its inception, brain death has become an accepted medical and legal concept throughout most of the world. There was initial reluctance to apply brain death criteria to children as they are believed more likely to regain neurologic function following injury. In spite of early trepidation, criteria for pediatric brain death certification were first proposed in 1987 by a multidisciplinary committee comprised of experts in the medical and legal communities. Protocols have since been developed to standardize brain death determination, but there remains substantial variability in practice throughout the world. In addition, brain death remains a topic of considerable ethical, philosophical, and legal controversy, and is often misrepresented in the media. In the present article, we discuss the history of brain death and the guidelines for its determination. We provide an overview of past and present challenges to its concept and diagnosis from biophilosophical, ethical and legal perspectives, and highlight differences between adult and pediatric brain death determination. We conclude by anticipating future directions for brain death as related to the emergence of new technologies. It is our position that providers should endorse the criteria for brain death diagnosis in children as proposed by the Society of Critical Care Medicine (SCCM), American Academy of Pediatrics (AAP), and Child Neurology Society (CNS), in order to prevent controversy and subjectivity surrounding what constitutes life versus death.

Neurosurgery in Contemporary Medical Dramas: How Grey's Anatomy & Co. May Affect Perception of Neurosurgery in the Media

BACKGROUND

 Neurosurgery is a common topic in contemporary medical dramas. This study aimed to examine depictions of several neurosurgical diseases and techniques as well as the perception of the personality of neurosurgeons in the media, focusing on their impact on the physician-patient relationship.

METHODS

 TV series and movies with a main focus on neurosurgeons and/or neurosurgical diseases were identified by consulting the International Movie Database (IMDb).

RESULTS

 After investigation of many TV series and movies, we identified five main topics: vascular neurosurgery, neuro-oncology, neurointensive care, neurosurgical techniques, and neurosurgeon's personality. The portrayal of neurosurgery in medical drama is characterized to a large extent by sensationalism, a lot of misinformation, and an unfavorable portrayal of neurosurgeons, although it is assumed that expert advice was sought in advance of every production.

CONCLUSIONS

 Considering the popularity of medical dramas and movies dealing with medical topics, we must consider the general public's picture of neurosurgery to be widely influenced by the media.

Understanding of Brain Death Among Health-Care Professionals at a Transplant Center

Introduction:

There is considerable variation in brain death understanding and policies between medical institutions, however, studies have not yet compared different health-care professionals working in the same hospital.

Research Questions:

The overall aim of this study was to evaluate understanding of brain death among health-care professionals within intensive care units (ICUs) at a single institution.

Design:

Study participants included 217 attending physicians, residents, nurses, medical students, and other ICU team members in 6 ICUs. Participants completed a 21-question survey pertaining to knowledge of brain death and related institutional policies as well as opinions about brain death.

Results:

We found a wide range of brain death understanding among health-care professionals in ICUs. Attending physicians have the greatest understanding (94.7%), followed by nurses (72.4%). In contrast, approximately half of the students and residents do not have a basic understanding of brain death. Brain death understanding was correlated to health-care role, years of experience, and whether the participant had formal training in brain death. Although most participants had been involved in cases of brain death, a much smaller number had received formal training on death by neurological criteria.

Discussion:

The present study observed a paucity of clinical training in brain death among health-care professionals in the study ICUs. There is an opportunity for improved clinical education on brain death that could improve communication with families about brain death and potentially increase the number of organs transplanted.

[Coincidence of Advance Directive and Organ Donor Consent: What Do The Persons Concerned Want? A Survey of German Elderly Citizens]

AIMS

In the case of acute brain injury, decision-making uncertainties can arise when both an advance decision to refuse treatment and a prior consent to post-mortem organ donation are present. It is yet unknown how the persons concerned view this potential conflict. The present study aims to investigate how frequent this situation is, whether the persons concerned are aware of the potential conflict and what they would prioritize.

METHODS

Semi-quantitative cross-sectional survey of senior citizens of a metropolitan region in Germany using a literature-based questionnaire.

RESULTS

A total of 236 senior citizens participated in the survey, amounting to 52% of those invited. While 54% of the participants reported to have written advance directives, 46% had expressed their consent to post-mortem organ donation in written or oral form. Altogether, 29% of all participants had issued both types of written documents. The consent to organ donation correlated significantly with the presence of an advance directive. Only 47% of the advance directives contained, according to their authors, statements about organ donation. Dying outside of intensive care was the priority for 51%, while 17% favored donating their organs. About half of the participants accepted transient intensive care measures in the case of presumed or expected brain death, but only a fourth also accepted cardiopulmonary resuscitation in those situations. Knowledge about brain death was scant and the attitudes towards it were rather critical.

CONCLUSION

The coincidence of advance directives and organ donation consent is not uncommon in senior citizens and could contribute to low organ donation rates. The heterogeneous attitudes of the surveyed persons as well as their poor knowledge about brain death and the potential conflict studied here underscore the necessity of a high-quality advance care planning process.

Frequency of use of the religious exemption in New Jersey cases of determination of brain death

BACKGROUND

The 1981 Uniform Determination of Death Act (UDDA) established the validity of both cardio-respiratory and neurological criteria of death. However, many religious traditions including most forms of Haredi Judaism (ultra-orthodox) and many varieties of Buddhism strongly disagree with death by neurological criteria (DNC). Only one state in the U.S., New Jersey, allows for both religious exemptions to DNC and provides continuation of health insurance coverage when an exception is invoked in its 1991 Declaration of Death Act (NJDDA). There is yet no quantitative or qualitative data on the frequencies of religious exemptions in New Jersey. This study gathered information about the frequency of religious exemptions and policy in New Jersey that was created out of respect for religious beliefs.

METHODS

Literature and internet searches on topics related to religious objections to DNC were conducted. Fifty-three chaplains and heads of bioethics committees in New Jersey hospitals were contacted by phone or email requesting a research interview. Respondents answered a set of questions about religious exemptions to DNC at the hospital where they worked that explored the frequency of such religious exemptions in the past five years, the religious tradition indicated, and whether any request for a religious exemption had been denied. This study was approved by the Northeastern University Institutional Review Board (IRB #: 16-03-15).

RESULTS

Eighteen chaplains and bioethics committee members participated in a full research interview. Of these, five reported instances of religious exemptions to DNC occurring at the hospital at which they worked for a total of approximately 30-36 known exemptions in the past five years. Families sought religious exemptions because of faith in an Orthodox Judaism tradition and nonreligious reasons. No failed attempts to obtain an exemption were reported.

CONCLUSIONS

Religious exemptions to DNC in New Jersey do occur, although very infrequently. Prior to this study, there was no information on their frequency. Considering religious exemptions do occur, there is a need for national or state policies that addresses both religious objections to DNC and hospital resources. More information is needed to better understand the impact of granting religious exemptions before new policy can be established.

Investigation of Public Perception of Brain Death Using the Internet

BACKGROUND

Brain death is a difficult concept for the public to comprehend, resulting in a reliance on alternative resources for clarity. This study aims to understand the public's perception of brain death via analysis of information on the Internet, determine the accuracy of that information, and understand how its perception affects the physician-patient relationship.

METHODS

We conducted a prospective cross-sectional study to evaluate information available to the public about brain death. The top 10 Google websites were analyzed for language complexity and accuracy in describing brain death. The top 10 YouTube videos were examined for content and the comments qualitatively analyzed for themes.

RESULTS

Inaccuracies describing brain death inconsistent with national guidelines were prevalent amongst 4 of 10 Google websites, 6 of 10 YouTube videos, and 80% of YouTube comments. On average, Google websites were written at a 12th grade level and 90% mentioned organ donation. Videos were frequently emotional (78%); 33% included negative comments toward physicians, of which 50% mentioned organ donation. All videos included clarification comments questioning the differences between brain death, death, coma, and persistent vegetative states.

CONCLUSIONS

The study revealed a significant amount of inaccurate information about brain death, affecting the public's understanding of the concept of brain death and resulting in negative emotions specifically toward physicians, and the link between brain death and organ donation. The medical community can improve understanding through consistent, simplified language, dissociating brain death from organ donation, and recognizing the emotions tied to discussions of brain death.

Radionuclide Evaluation of Brain Death in the Post-McMath Era

The pronouncement of death is a determination of paramount social, legal, and ethical import. The novel construct of "brain death" was introduced 50 years ago, yet there persist gaps in understanding regarding this diagnosis on the part of medical caregivers and families. The tragic, much-publicized case of Jahi McMath typifies potential problems that can be encountered with this diagnosis and serves as an effective point of departure for discussion. This article recapitulates the historical development of brain death and the evolution of scintigraphic examinations as ancillary or confirmatory studies, emphasizing updated clinical and imaging practice guidelines and the current role of scintigraphy. The limitations of clinical and radionuclide studies are then reviewed. Finally, the article examines whether radionuclide examinations might be able to play an expanded role in the determination of brain death by improving accuracy and facilitating effective communication with family members.

Public education and misinformation on brain death in mainstream media

INTRODUCTION

We sought to evaluate the caliber of education mainstream media provides the public about brain death.

METHODS

We reviewed articles published prior to July 31, 2015, on the most shared/heavily trafficked mainstream media websites of 2014 using the names of patients from two highly publicized brain death cases, "Jahi McMath" and "Marlise Muñoz."

RESULTS

We reviewed 208 unique articles. The subject was referred to as being "alive" or on "life support" in 72% (149) of the articles, 97% (144) of which also described the subject as being brain dead. A definition of brain death was provided in 4% (9) of the articles. Only 7% (14) of the articles noted that organ support should be discontinued after brain death declaration unless a family has agreed to organ donation. Reference was made to well-known cases of patients in persistent vegetative states in 16% (34) of articles and 47% (16) of these implied both patients were in the same clinical state.

CONCLUSIONS

Mainstream media provides poor education to the public on brain death. Because public understanding of brain death impacts organ and tissue donation, it is important for physicians, organ procurement organizations, and transplant coordinators to improve public education on this topic.

[Assessment of the transplantation scandal by the media : scientific discourse analysis of selected German newspapers]

BACKGROUND

The press is an important medium and plays a significant role as an information source for people. Moreover, the daily press transmits opinion-forming contents. During the German "transplantation scandal" various articles were published in the German press focusing on organ donation, transplantation, allocation of organs and brain death determination. Selected important newspaper articles were analyzed using a scientific text analysis as it was assumed that the publications might have had an important influence on attitudes or mistrust of transplantation medicine.

MATERIAL AND METHODS

A total of 216 articles from Süddeutsche Zeitung, Die Welt, Frankfurter Allgemeine Zeitung and Die Zeit published between summer 2012 and early 2013, which focused on the transplantation scandal were analyzed using a modern form of scientific text analysis. From these articles 12 categories of contents were identified which were analyzed quantitatively and qualitatively.

RESULTS

Most articles were published between June and August 2012 when the accusations of organ allocation manipulation were made public. A second wave was found in the early months of 2013, when the court proceedings against the predominantly blamed physician began. Most of the categories (63.8 %) transmitted a negative evaluative opinion (i.e. loss of confidence, enrichment of the persons involved, fraud, misconduct, rejection of brain death and disturbing the peace of the dead) leading to mistrust of transplantation per se, while the minority (36.2 %) were categorized as endeavoring to convey objective information, focus on ethical responsibility for organ donation or the problems of organ shortage. Furthermore, a striking increase of articles doubting the concept of brain death was observed.

CONCLUSION

German newspapers as important opinion-leading and opinion-forming media have a substantial impact in accomplishing the demands for objective and factual information of transplantation medicine. Physicians, ethicists, journalists and politicians are invoked to have a closer collaboration in the future.