1
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Doyle HR. Squaring the Circle. Brain death and organ transplantation. Curr Opin Organ Transplant 2024; 29:212-218. [PMID: 38483113 DOI: 10.1097/mot.0000000000001104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW The adoption of brain death played a crucial role in the development of organ transplantation, but the concept has become increasingly controversial. This essay will explore the current state of the controversy and its implications for the field. RECENT DEVELOPMENTS The brain death debate, long limited to the bioethics community, has in recent years burst into the public consciousness following several high-profile cases. This has culminated in the reevaluation of the Uniform Determination of Death Act (UDDA), which is in the process of being updated. Any change to the UDDA has the potential to significantly impact the availability of organs. SUMMARY The current update to the UDDA introduces an element of uncertainty, one the brain death debate had not previously had.
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Affiliation(s)
- Howard R Doyle
- Albert Einstein College of Medicine, Division of Critical Care Medicine, Bronx, New York, USA
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2
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Choi W. The conceptual injustice of the brain death standard. THEORETICAL MEDICINE AND BIOETHICS 2024:10.1007/s11017-024-09663-5. [PMID: 38714610 DOI: 10.1007/s11017-024-09663-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/10/2024]
Abstract
Family disputes over the diagnosis of brain death have caused much controversy in the bioethics literature over the conceptual validity of the brain death standard. Given the tenuous status of brain death as death, it is pragmatically fruitful to reframe intractable debates about the metaphysical nature of brain death as metalinguistic disputes about its conceptual deployment. This new framework leaves the metaphysical debate open and brings into focus the social functions that are served by deploying the concept of brain death. In doing so, it highlights the epistemic injustice of medicolegal authorities that force people to uniformly accept brain death as a diagnosis of death based on normative considerations of institutional interests, such as saving hospital resources and organ supplies, rather than empirical evidence of brain death as death, which is insufficient at best and nonexistent at worst. In light of this injustice, I propose the rejection of the uniform standard of brain death in favor of a choice-based system that respects families' individualized views of death.
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Affiliation(s)
- William Choi
- Warren Alpert Medical School of Brown University, Providence, RI, USA.
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3
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DeCamp M, Carney JK, Snyder Sulmasy L. Standards and Ethics Issues in the Determination of Death. Ann Intern Med 2024; 177:690-691. [PMID: 38768489 DOI: 10.7326/l24-0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Affiliation(s)
- Matthew DeCamp
- University of Colorado Anschutz Medical Campus, Denver, Colorado
| | - Jan K Carney
- Larner College of Medicine at the University of Vermont, Burlington, Vermont, and Center for Ethics and Professionalism, American College of Physicians, Philadelphia, Pennsylvania
| | - Lois Snyder Sulmasy
- Center for Ethics and Professionalism, American College of Physicians, Philadelphia, Pennsylvania
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4
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Omelianchuk A, Lewis A. Standards and Ethics Issues in the Determination of Death. Ann Intern Med 2024; 177:689-690. [PMID: 38768490 DOI: 10.7326/l24-0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
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5
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Murphy NB, Shemie SD, Capron A, Truog RD, Nakagawa T, Healey A, Gofton T, Bernat JL, Fenton K, Khush KK, Schwartz B, Wall SP. Advancing the Scientific Basis for Determining Death in Controlled Organ Donation After Circulatory Determination of Death. Transplantation 2024:00007890-990000000-00733. [PMID: 38637919 DOI: 10.1097/tp.0000000000005002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
In controlled organ donation after circulatory determination of death (cDCDD), accurate and timely death determination is critical, yet knowledge gaps persist. Further research to improve the science of defining and determining death by circulatory criteria is therefore warranted. In a workshop sponsored by the National Heart, Lung, and Blood Institute, experts identified research opportunities pertaining to scientific, conceptual, and ethical understandings of DCDD and associated technologies. This article identifies a research strategy to inform the biomedical definition of death, the criteria for its determination, and circulatory death determination in cDCDD. Highlighting knowledge gaps, we propose that further research is needed to inform the observation period following cessation of circulation in pediatric and neonatal populations, the temporal relationship between the cessation of brain and circulatory function after the withdrawal of life-sustaining measures in all patient populations, and the minimal pulse pressures that sustain brain blood flow, perfusion, activity, and function. Additionally, accurate predictive tools to estimate time to asystole following the withdrawal of treatment and alternative monitoring modalities to establish the cessation of circulatory, brainstem, and brain function are needed. The physiologic and conceptual implications of postmortem interventions that resume circulation in cDCDD donors likewise demand attention to inform organ recovery practices. Finally, because jurisdictionally variable definitions of death and the criteria for its determination may impede collaborative research efforts, further work is required to achieve consensus on the physiologic and conceptual rationale for defining and determining death after circulatory arrest.
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Affiliation(s)
- Nicholas B Murphy
- Departments of Medicine and Philosophy, Western University, London, ON, Canada
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
- System Development, Canadian Blood Services, Ottawa, ON, Canada
| | - Alex Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | - Thomas Nakagawa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Divisions of Emergency and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Kathleen Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bryanna Schwartz
- Heart Development and Structural Diseases Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
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6
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Varelas P, Greer D. The authors reply. Crit Care Med 2024; 52:e214-e215. [PMID: 38483237 DOI: 10.1097/ccm.0000000000006208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Affiliation(s)
| | - David Greer
- Department of Neurology, Boston University, Boston, MA
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7
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Sulmasy DP, DeCock CA, Tornatore CS, Roberts AH, Giordano J, Donovan GK. A Biophilosophical Approach to the Determination of Brain Death. Chest 2024; 165:959-966. [PMID: 38599752 DOI: 10.1016/j.chest.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/30/2023] [Accepted: 12/09/2023] [Indexed: 04/12/2024] Open
Abstract
Technical and clinical developments have raised challenging questions about the concept and practice of brain death, culminating in recent calls for revision of the Uniform Determination of Death Act (UDDA), which established a whole brain standard for neurologic death. Proposed changes range from abandoning the concept of brain death altogether to suggesting that current clinical practice simply should be codified as the legal standard for determining death by neurologic criteria (even while acknowledging that significant functions of the whole brain might persist). We propose a middle ground, clarifying why whole brain death is a conceptually sound standard for declaring death, and offering procedural suggestions for increasing certainty that this standard has been met. Our approach recognizes that whole brain death is a functional, not merely anatomic, determination, and incorporates an understanding of the difficulties inherent in making empirical judgments in medicine. We conclude that whole brain death is the most defensible standard for determining neurologic death-philosophically, biologically, and socially-and ought to be maintained.
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Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC; Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC; Department of Medicine, Georgetown University, Washington, DC; Department of Philosophy, Georgetown University, Washington, DC.
| | - Christopher A DeCock
- Essentia Health, Grand Forks, ND; University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | | | - Allen H Roberts
- Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC; Department of Medicine, Georgetown University, Washington, DC
| | - James Giordano
- Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC; Department of Neurology, Georgetown University, Washington, DC
| | - G Kevin Donovan
- Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC
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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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9
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McGee A, Gardiner D. Brainstem Death Is Dead. Long Live Brainstem Death! THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:114-116. [PMID: 38236886 DOI: 10.1080/15265161.2023.2278572] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
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10
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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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Lewis A, Kirschen MP, Greer D. The 2023 AAN/AAP/CNS/SCCM Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline: A Comparison With the 2010 and 2011 Guidelines. Neurol Clin Pract 2023; 13:e200189. [PMID: 37829552 PMCID: PMC10567121 DOI: 10.1212/cpj.0000000000200189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 07/07/2023] [Indexed: 10/14/2023]
Abstract
In collaboration with the American Academy of Pediatrics, Child Neurology Society, and Society for Critical Care Medicine, the American Academy of Neurology formulated an updated, evidence-informed consensus-based guideline for pediatric and adult brain death/death by neurologic criteria (BD/DNC) determination. In comparison with the prior guidelines, the revisions and additions in this guideline, which are summarized in this review, are intended to (1) ensure recommendations are conservative, yet practical, and emphasize circumstances in which BD/DNC determination should be delayed or deferred, so as to minimize the risk of a false-positive BD/DNC determination; and (2) provide guidance about aspects of BD/DNC determination that clinicians find challenging and/or controversial. We hope that clinicians throughout the United States will use this information to revise their hospital BD/DNC determination policies to conform to the standardized process for BD/DNC determination described in the new guideline, to ensure that every BD/DNC evaluation is consistent and accurate.
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Affiliation(s)
- Ariane Lewis
- NYU Langone Medical Center (AL), NY; The Children's Hospital of Philadelphia (MPK), PA; Boston University School of Medicine and Boston Medical Center (DG), MA
| | - Matthew P Kirschen
- NYU Langone Medical Center (AL), NY; The Children's Hospital of Philadelphia (MPK), PA; Boston University School of Medicine and Boston Medical Center (DG), MA
| | - David Greer
- NYU Langone Medical Center (AL), NY; The Children's Hospital of Philadelphia (MPK), PA; Boston University School of Medicine and Boston Medical Center (DG), MA
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12
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Jaffa MN, Kirschen MP, Tuppeny M, Reynolds AS, Lim-Hing K, Hargis M, Choi RK, Schober ME, LaBuzetta JN. Enhancing Understanding and Overcoming Barriers in Brain Death Determination Using Standardized Education: A Call to Action. Neurocrit Care 2023; 39:294-303. [PMID: 37434103 DOI: 10.1007/s12028-023-01775-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/02/2023] [Indexed: 07/13/2023]
Affiliation(s)
- Matthew N Jaffa
- Division of Neurocritical Care, Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
| | - Matthew P Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Misti Tuppeny
- Division of Neuroscience and Behavioral Health, Department of Nursing Education and Quality, Advent Health, Orlando, FL, USA
| | - Alexandra S Reynolds
- Departments of Neurosurgery and Neurology, Mount Sinai Health System, New York, NY, USA
| | - Krista Lim-Hing
- Neurocritical Care Division, Department of Neurosurgery, Northwell Health, Bay Shore, NY, USA
| | - Mitch Hargis
- Division of Neurocritical Care, Department of Neurosciences, Novant Health Forsyth Medical Center, Winston-Salem, NC, USA
| | - Richard K Choi
- Division of Neurosciences, ChristianaCare, Newark, DE, USA
| | - Michelle E Schober
- Pediatric Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jamie Nicole LaBuzetta
- Division of Neurocritical Care, Department of Neurosciences, University of California San Diego Health, 9444 Medical Center Dr., East Campus Office Building 3-028, La Jolla, CA, 92037-7740, USA.
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13
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Nair-Collins M. Abortion, Brain Death, and Coercion. JOURNAL OF BIOETHICAL INQUIRY 2023; 20:359-365. [PMID: 37380827 PMCID: PMC10624703 DOI: 10.1007/s11673-023-10268-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/22/2022] [Indexed: 06/30/2023]
Abstract
A "universalist" policy on brain death holds that brain death is death, and neurologic criteria for death determination are rightly applied to all, without exemptions or opt outs. This essay argues that advocates of a universalist brain death policy defend the same sort of coercive control of end-of-life decision-making as "pro-life" advocates seek to achieve for reproductive decision-making, and both are grounded in an illiberal political philosophy. Those who recognize the serious flaws of this kind of public policy with respect to abortion must apply the same logic to brain death.
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Affiliation(s)
- Michael Nair-Collins
- Florida State University College of Medicine, 1115 West Call Street, Tallahassee, FL, 32304, USA.
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14
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Sulmasy DP, DeCock CA. Rethinking Brain Death-Why "Dead Enough" Is Not Good Enough: The UDDA Revision Series. Neurology 2023; 101:320-325. [PMID: 37429707 PMCID: PMC10437022 DOI: 10.1212/wnl.0000000000207407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/28/2023] [Indexed: 07/12/2023] Open
Abstract
The emergence of cases of so-called "chronic brain death" seems to undermine the biophilosophical justification of brain death as true death, which was grounded in the idea that death entails the loss of integration of the organism. Severely neurologically damaged patients who can persist for years with proper support seem to be integrated organisms, and common sense suggests that they are not dead. We argue, however, that mere integration is not enough for an organism to be alive, but that living beings must be substantially self-integrating (i.e., a living organism must itself be the primary source of its integration and not an external agent such as a scientist or physician). We propose that irreversible apnea and unresponsiveness are necessary but not sufficient to judge that a human being has lost enough capacity for self-integration to be considered dead. To be declared dead, the patient must also irrevocably have lost either (1) cardiac function or (2) cerebrosomatic homeostatic control. Even if such bodies can be maintained with sufficient technological support, one may reasonably judge that the locus of integration effectively has passed from the patient to the treatment team. While organs and cells may be alive, one may justifiably declare that there is no longer a substantially autonomous, whole, living human organism. This biophilosophical conception of death implies that the notion of brain death remains viable, but that additional testing will be required to ensure that the individual is truly brain dead by virtue of having irrevocably lost not only the capacity for spontaneous respiration and conscious responsiveness but also the capacity for cerebrosomatic homeostatic control.
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Affiliation(s)
- Daniel P Sulmasy
- From the The Kennedy Institute of Ethics (D.P.S.), Georgetown University, Washington, DC; and Essentia Health and The University of North Dakota School of Medicine and Health Sciences (C.A.D.), Fargo.
| | - Christopher A DeCock
- From the The Kennedy Institute of Ethics (D.P.S.), Georgetown University, Washington, DC; and Essentia Health and The University of North Dakota School of Medicine and Health Sciences (C.A.D.), Fargo
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15
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Lewis A, Kirschen MP. Potential Threats and Impediments to the Clinical Practice of Brain Death Determination: The UDDA Revision Series. Neurology 2023; 101:270-279. [PMID: 37429711 PMCID: PMC10424838 DOI: 10.1212/wnl.0000000000207404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/28/2023] [Indexed: 07/12/2023] Open
Abstract
The Uniform Determination of Death Act (UDDA) revision series in Neurology® originated in response to the plan of the Uniform Law Commission to create a revised Uniform Determination of Death Act (rUDDA) to address contemporary controversies associated with brain death/death by neurologic criteria (BD/DNC) determination. This article contextualizes these, and other, controversies and reviews the extent to which they represent potential threats and impediments to the clinical practice of BD/DNC determination. It also explains the reasons that our rapidly evolving understanding of the brain's ability to recover from injury should not influence the clinical practice of BD/DNC determination. Finally, it explores the myriad ways in which the American Academy of Neurology has addressed potential threats and impediments to the clinical practice of BD/DNC determination and the implications potential changes to the UDDA may have on the future of the clinical practice of BD/DNC determination.
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Affiliation(s)
- Ariane Lewis
- From the NYU Langone Medical Center (A.L.), New York, NY; and The Children's Hospital of Philadelphia (M.P.K.), Philadelphia, PA.
| | - Matthew P Kirschen
- From the NYU Langone Medical Center (A.L.), New York, NY; and The Children's Hospital of Philadelphia (M.P.K.), Philadelphia, PA
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16
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Deng B, Ying J, Mu D. Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury. Brain Sci 2023; 13:1165. [PMID: 37626521 PMCID: PMC10452596 DOI: 10.3390/brainsci13081165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.
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Affiliation(s)
- Bixin Deng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
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17
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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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18
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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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19
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Robbins NM. What Is the Ideal Brain Criterion of Death? Clinical and Practical Considerations: The UDDA Revision Series. Neurology 2023; 101:83-85. [PMID: 37429724 DOI: 10.1212/wnl.0000000000207335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 03/07/2023] [Indexed: 07/12/2023] Open
Affiliation(s)
- Nathaniel M Robbins
- From the Geisel School of Medicine at Dartmouth (N.M.R.), Hanover; and Dartmouth-Hitchcock Medical Center (N.M.R.), Lebanon, NH.
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20
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Bernat JL. Challenges to Brain Death in Revising the Uniform Determination of Death Act: The UDDA Revision Series. Neurology 2023; 101:30-37. [PMID: 37400259 DOI: 10.1212/wnl.0000000000207334] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 03/07/2023] [Indexed: 07/05/2023] Open
Affiliation(s)
- James L Bernat
- From the Dartmouth Geisel School of Medicine, Hanover, NH.
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21
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Bernat JL. The Brain-as-a-Whole Criterion and the Uniform Determination of Death Act. AJOB Neurosci 2023; 14:271-274. [PMID: 37682673 DOI: 10.1080/21507740.2023.2243889] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
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22
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Nair-Collins M, Joffe AR. Frequent Preservation of Neurologic Function in Brain Death and Brainstem Death Entails False-Positive Misdiagnosis and Cerebral Perfusion. AJOB Neurosci 2023; 14:255-268. [PMID: 34586014 DOI: 10.1080/21507740.2021.1973148] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Some patients who have been diagnosed as "dead by neurologic criteria" continue to exhibit certain brain functions, most commonly, neuroendocrine functions. This preservation of neurologic function after the diagnosis of "brain death" or "brainstem death" is an ongoing source of controversy and concern in the medical, bioethics, and legal literatures. Most obviously, if some brain function persists, then it is not the case that all functions of the entire brain have ceased and hence, declaring such a patient to be "dead" would be a false positive, in any nation with so-called "whole brain death" laws. Furthermore, and perhaps more concerning, the preservation of any brain function necessarily entails the preservation of some amount of brain perfusion, thereby raising the concern as to whether additional areas of neural tissue may remain viable, including areas in the brainstem. These and other considerations cast significant doubt on the reliability of diagnosing either "brain death" or "brainstem death."
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Affiliation(s)
| | - Ari R Joffe
- University of Alberta and Stollery Children's Hospital
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23
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Shingina A, Mukhtar N, Wakim-Fleming J, Alqahtani S, Wong RJ, Limketkai BN, Larson AM, Grant L. Acute Liver Failure Guidelines. Am J Gastroenterol 2023; 118:1128-1153. [PMID: 37377263 DOI: 10.14309/ajg.0000000000002340] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/04/2023] [Indexed: 06/29/2023]
Abstract
Acute liver failure (ALF) is a rare, acute, potentially reversible condition resulting in severe liver impairment and rapid clinical deterioration in patients without preexisting liver disease. Due to the rarity of this condition, published studies are limited by the use of retrospective or prospective cohorts and lack of randomized controlled trials. Current guidelines represent the suggested approach to the identification, treatment, and management of ALF and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence was reviewed using the Grading of Recommendations, Assessment, Development and Evaluation process to develop recommendations. When no robust evidence was available, expert opinions were summarized using Key Concepts. Considering the variety of clinical presentations of ALF, individualization of care should be applied in specific clinical scenarios.
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Affiliation(s)
- Alexandra Shingina
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nizar Mukhtar
- Department of Gastroenterology, Kaiser Permanente, San Francisco, California, USA
| | - Jamilé Wakim-Fleming
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland Ohio, USA
| | - Saleh Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
- Liver Transplantation Unit, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | | | - Anne M Larson
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
| | - Lafaine Grant
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
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24
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Brown MB, Abramowicz AE, Panzica PJ, Weber G. Anesthetic Considerations of Organ Procurement After Brain and Cardiac Death: A Narrative Review. Cureus 2023; 15:e40629. [PMID: 37476138 PMCID: PMC10355135 DOI: 10.7759/cureus.40629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/22/2023] Open
Abstract
Organ donation procedures have become more frequent in the US as the need for transplants is increasing. Defining the anesthesiologist's role in organ donations after brain and cardiac death is important, as is understanding its ethics and practical physiologic and perioperative implications. Despite this, there are few papers specifically addressing the anesthetic management of organ donors. This review summarizes the preoperative, intraoperative, and postmortem considerations for the anesthesiologist involved in organ donation after either brain or cardiac death. A search of the published literature was performed using PubMed, Excerpta Medica dataBASE (EMBASE), and Google Scholar in March of 2022 for articles addressing anesthetic considerations of organ procurement surgeries after brain and cardiac death. This review demonstrates that anesthesiologists play a significant role in the organ procurement process. Their role in the perioperative management of the donor may affect the outcomes of organ transplantation. The gap between the number of organs harvested and the number of patients awaiting organ transplantation remains high despite continued efforts to increase the number of available organs. Perioperative management of organ donors aims at counteracting the associated unique physiologic derangements and targets optimization of oxygenation of the organs intended for procurement. Optimizing care after death can help ensure the viability of organs and the best outcomes for recipients. As organ donation after cardiac death (DCD) becomes more frequent in the US, anesthesiologists should be aware of the DCD classifications of donors and emerging novel perfusion techniques.
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Affiliation(s)
| | - Apolonia E Abramowicz
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
| | - Peter J Panzica
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
| | - Garret Weber
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
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25
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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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26
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Greer DM. An updated practice guideline for death determination: one giant leap for the field led by Canada. Can J Anaesth 2023; 70:478-482. [PMID: 37131022 DOI: 10.1007/s12630-023-02405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/06/2022] [Accepted: 12/06/2022] [Indexed: 05/04/2023] Open
Affiliation(s)
- David M Greer
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, 85 East Concord Street, Room 1145, Boston, MA, 02118, USA.
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27
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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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28
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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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29
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Gardiner D, Greer DM, Bernat JL, Meade MO, Opdam H, Schwarz SKW. Answering global challenges to the determination of death: consensus-building leadership from Canada. Can J Anaesth 2023; 70:468-477. [PMID: 37131024 DOI: 10.1007/s12630-023-02423-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 01/30/2023] [Accepted: 01/30/2023] [Indexed: 05/04/2023] Open
Affiliation(s)
- Dale Gardiner
- Adult Intensive Care Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- NHS Blood and Transplant, Bristol, UK.
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH, USA
| | - Maureen O Meade
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University Health Sciences Centre, Hamilton, ON, Canada
- Interdepartmental Division of Critical Care, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Helen Opdam
- Department of Intensive Care Medicine, Austin Health, Melbourne, VIC, Australia
- DonateLife, The Australian Organ and Tissue Authority, Canberra, ACT, Australia
| | - Stephan K W Schwarz
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesia, St. Paul's Hospital/Providence Health Care, Vancouver, BC, Canada
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30
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Mazzola MA, Russell JA. Neurology ethics at the end of life. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:235-257. [PMID: 36599511 DOI: 10.1016/b978-0-12-824535-4.00012-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Ethical challenges in medical decision making are commonly encountered by clinicians caring for patients afflicted by neurological injury or disease at the end of life (EOL). In many of these cases, there are conflicting opinions as to what is right and wrong originating from multiple sources. There is a particularly high prevalence of impaired patient judgment and decision-making capacity in this population that may result in a misrepresentation of their premorbid values and goals. Conflict may originate from a discordance between what is legal or from stakeholders who view and value life and existence differently from the patient, at times due to religious or cultural influences. Promotion of life, rather than preservation of existence, is the goal of many patients and the foundation on which palliative care is built. Those who provide EOL care, while being respectful of potential cultural, religious, and legal stakeholder perspectives, must at the same time recognize that these perspectives may conflict with the optimal ethical course to follow. In this chapter, we will attempt to review some of the more notable ethical challenges that may arise in the neurologically afflicted at the EOL. We will identify what we believe to be the most compelling ethical arguments both in support of and opposition to specific EOL issues. At the same time, we will consider how ethical analysis may be influenced by these legal, cultural, and religious considerations that commonly arise.
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31
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Marron JM. Pediatric Brain Death Testing Over Parental Objections: Not an Ethically Preferable Option. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:90-93. [PMID: 36595010 PMCID: PMC9813910 DOI: 10.1080/15265161.2022.2146792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- Jonathan M Marron
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School
- Center for Bioethics, Harvard Medical School
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32
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Kitamura E, Lewis A. A thematic analysis of a survey of hospital chaplains on death by neurologic criteria. J Health Care Chaplain 2023; 29:105-113. [PMID: 35189776 DOI: 10.1080/08854726.2022.2040893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
| | - Ariane Lewis
- Departments of Neurology and Neurosurgery, Division of Neurocritical Care, NYU Langone Health, New York, NY, USA
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33
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Wolfe ID. Responding to Parental Objections Over Testing for Death by Neurologic Criteria. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:94-95. [PMID: 36595011 DOI: 10.1080/15265161.2022.2146791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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34
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Morrison WE, Kirschen MP. A Taxonomy of Objections to Brain Death Determination. Neurocrit Care 2022; 37:369-371. [PMID: 35999409 DOI: 10.1007/s12028-022-01580-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/27/2022] [Indexed: 11/28/2022]
Abstract
Family objections to evaluating a patient for death by neurologic criteria, or "brain death," are challenging for the family and the medical team. In this article, we categorize brain death evaluation refusals into a taxonomy: informational objections, emotional objections, and principled objections. We offer suggested approaches for clinicians to respond to refusals on the basis of the category. The category of objection may also be important in considering when accommodation of refusals should be considered. The goal in all such situations is to promote compassionate, ethical, and equitable care for the patient and family.
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Affiliation(s)
- Wynne E Morrison
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Wood 6038, Philadelphia, PA, 19104, USA.
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Wood 6038, Philadelphia, PA, 19104, USA.,Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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35
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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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36
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Krawiec C, Mysore MR, Mathur M, Fang X, Zhou S, Thomas NJ, Nakagawa TA. Impact of the Updated Guideline for Pediatric Brain Death Determination on Current Practice. J Child Neurol 2022; 37:553-561. [PMID: 35603748 PMCID: PMC9177504 DOI: 10.1177/08830738221047668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: A guideline to determine pediatric brain death was updated in 2011. It is unknown how pediatric intensivists have accepted and adopted the revised guideline into clinical practice. Methods: We surveyed US pediatric critical care attending physicians July 2013 to September 2013 and February 2020 to May 2020. Brain death testing practices and utilization of the 2011 pediatric and neonatal brain death guideline were assessed. Results: The 2020 respondents found that the revised pediatric brain death guideline were useful in clinical practice (93.7% vs 83.3%, P = .0484) and provided more consistency and clarity (73.2% vs 63.1%, P = .0462) when compared to 2013 respondents. Conclusion: This study demonstrates that with defined criteria, survey participants reported increased clarity and consistency. Findings from our study indicate that in clinical practice there is no significant deviation from the minimum requirements to determine brain death in children as outlined in the 2011 guideline.
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Affiliation(s)
- Conrad Krawiec
- Penn State Children’s Hospital, Pediatric Critical Care Medicine, Department of Pediatrics, 500 University Drive, Hershey, PA, USA
| | - Mohan R. Mysore
- Pediatric Critical Care, Boys Town National Research Hospital, Boys Town, NE, USA
| | - Mudit Mathur
- Pediatric Critical Care, Southern California Permanente Medical Group, Kaiser Permanente School of Medicine, Pasadena, CA, USA
| | - Xinying Fang
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Shouhao Zhou
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Neal J. Thomas
- Penn State Children’s Hospital, Pediatric Critical Care Medicine, Department of Pediatrics, 500 University Drive, Hershey, PA, USA,Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Thomas A. Nakagawa
- Department of Pediatrics, Division of Critical Care Medicine, University of Florida College of Medicine. Jacksonville, FL, USA
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37
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Pope TM. COUNTERPOINT: Whether Informed Consent Should Be Obtained for Apnea Testing in the Determination of Death by Neurologic Criteria? No. Chest 2022; 161:1145-1147. [PMID: 35526888 DOI: 10.1016/j.chest.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/30/2021] [Indexed: 10/18/2022] Open
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38
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Shewmon DA. Rebuttal From Dr Shewmon. Chest 2022; 161:1147-1148. [PMID: 35526889 DOI: 10.1016/j.chest.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 11/30/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- D Alan Shewmon
- Departments of Pediatrics and Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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39
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Gagnon DJ, Ryzhov SV, May MA, Riker RR, Geller B, May TL, Bockian S, deKay JT, Eldridge A, Van der Kloot T, Lerwick P, Lord C, Lucas FL, Mailloux P, McCrum B, Searight M, Wirth J, Zuckerman J, Sawyer D, Seder DB. Ceftriaxone to PRevent pneumOnia and inflammaTion aftEr Cardiac arresT (PROTECT): study protocol for a randomized, placebo-controlled trial. Trials 2022; 23:197. [PMID: 35246202 PMCID: PMC8895836 DOI: 10.1186/s13063-022-06127-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 02/23/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Pneumonia is the most common infection after out-of-hospital cardiac arrest (OHCA) occurring in up to 65% of patients who remain comatose after return of spontaneous circulation. Preventing infection after OHCA may (1) reduce exposure to broad-spectrum antibiotics, (2) prevent hemodynamic derangements due to local and systemic inflammation, and (3) prevent infection-associated morbidity and mortality. METHODS The ceftriaxone to PRevent pneumOnia and inflammaTion aftEr Cardiac arrest (PROTECT) trial is a randomized, placebo-controlled, single-center, quadruple-blind (patient, treatment team, research team, outcome assessors), non-commercial, superiority trial to be conducted at Maine Medical Center in Portland, Maine, USA. Ceftriaxone 2 g intravenously every 12 h for 3 days will be compared with matching placebo. The primary efficacy outcome is incidence of early-onset pneumonia occurring < 4 days after mechanical ventilation initiation. Concurrently, T cell-mediated inflammation bacterial resistomes will be examined. Safety outcomes include incidence of type-one immediate-type hypersensitivity reactions, gallbladder injury, and Clostridioides difficile-associated diarrhea. The trial will enroll 120 subjects over approximately 3 to 4 years. DISCUSSION The PROTECT trial is novel in its (1) inclusion of OHCA survivors regardless of initial heart rhythm, (2) use of a low-risk antibiotic available in the USA that has not previously been tested after OHCA, (3) inclusion of anti-inflammatory effects of ceftriaxone as a novel mechanism for improved clinical outcomes, and (4) complete metagenomic assessment of bacterial resistomes pre- and post-ceftriaxone prophylaxis. The long-term goal is to develop a definitive phase III trial powered for mortality or functional outcome. TRIAL REGISTRATION ClinicalTrials.gov NCT04999592 . Registered on August 10, 2021.
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Affiliation(s)
- David J Gagnon
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA.
- Maine Medical Center Research Institute, Scarborough, ME, USA.
- Tufts University School of Medicine, Boston, MA, USA.
| | - Sergey V Ryzhov
- Maine Medical Center Research Institute, Scarborough, ME, USA
| | - Meghan A May
- University of New England College of Osteopathic Medicine, Biddeford, ME, USA
| | - Richard R Riker
- Tufts University School of Medicine, Boston, MA, USA
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Bram Geller
- Tufts University School of Medicine, Boston, MA, USA
- Maine Medical Partners, MaineHealth Cardiology, Scarborough, ME, USA
| | - Teresa L May
- Maine Medical Center Research Institute, Scarborough, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Sarah Bockian
- Maine Medical Center Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | - Joanne T deKay
- Maine Medical Center Research Institute, Scarborough, ME, USA
| | - Ashley Eldridge
- Maine Medical Center Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | | | - Patricia Lerwick
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Christine Lord
- Maine Medical Center Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | - F Lee Lucas
- Maine Medical Center Research Institute, Scarborough, ME, USA
| | - Patrick Mailloux
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | - Barbara McCrum
- Maine Medical Center Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | - Meghan Searight
- Maine Medical Center Neuroscience Institute, Maine Medical Center, Portland, ME, USA
| | - Joel Wirth
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
| | | | - Douglas Sawyer
- Maine Medical Center Research Institute, Scarborough, ME, USA
- Maine Medical Partners, MaineHealth Cardiology, Scarborough, ME, USA
| | - David B Seder
- Maine Medical Center Research Institute, Scarborough, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
- Department of Critical Care Services, Maine Medical Center, Portland, ME, USA
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40
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The Uniform Determination of Death Act is Being Revised. Neurocrit Care 2022; 36:335-338. [DOI: 10.1007/s12028-021-01439-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022]
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McEvoy MJ, Scott MJ, Sawyer KE. Requests for Accommodation in Brain Death Cases: Emerging Role for Pediatric Palliative Care. J Pain Symptom Manage 2021; 62:1319-1324. [PMID: 33933614 DOI: 10.1016/j.jpainsymman.2021.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
Death by neurologic criteria is a diagnosis that has presented complexities since its inception and pediatric cases are no exception. While rare, families may request accommodation to deviate from the traditionally defined diagnostic pathway based on their beliefs, mistrust of the diagnosis, or other complex reasons. Palliative care consultation offers a unique clinical perspective to complement the work of intensivists to support families through the diagnosis and possible resolution around accommodation requests. With misinformation and high-profile cases widely visible to the public through the media, these requests require a thoughtful and informed clinical approach by all members of the interdisciplinary clinical team. Common themes in many of these cases are trauma, bias and their impact on caregivers. We use a case-based approach to explore these complexities and clinical tools.
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Affiliation(s)
| | - Maya J Scott
- Seattle Children's Hospital, Seattle, Washington, USA
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Chen PM, Trando A, LaBuzetta JN. Simulation-Based Training Improves Fellows' Competence in Brain Death Discussion and Declaration. Neurologist 2021; 27:6-10. [PMID: 34842565 DOI: 10.1097/nrl.0000000000000354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite well-defined American Academy of Neurology guidelines for death by whole brain criteria (brain death), there is marked variability in national practice, which some have attributed to lack of formal education. Further, communication with surrogates and families about brain death is integral to brain death declaration. As such, we developed a targeted brain death curriculum combining didactics and simulation-based education to improve examination and subsequent communication skills with families. METHODS Multidisciplinary critical care fellows participated in (1) didactic and case-based curriculum, (2) brain death simulated examination (SimMan3G mannequin), and (3) a standardized family scenario with delivery of a brain death diagnosis to a surrogate "family member". Fellows completed a precurriculum and postcurriculum multiple choice knowledge test and survey (Likert 1 to 10 scale) evaluating measures regarding diagnosis and communication of brain death. t Test and 2-tailed Wilcoxon signed rank test were used for statistical analysis (P<0.05). RESULTS Thirteen critical care fellows participated in the curriculum. Most fellows [80% (N=12)] had only participated in 0 to 5 brain death declarations before this intervention. There was significant improvement across all measures: self-rated knowledge (P=0.004), perceived knowledge relative to peers (P=0.002), confidence (P=0.001), and comfort (P=0.001) with performing a brain death exam, and comfort with family discussion (P=0.01). Objective test scores improved from 56 to 73% after simulation (P=0.004). All fellows found the curriculum beneficial. CONCLUSION Trainees may lack sufficient exposure to brain death education. Didactics with simulation-based education can improve objective knowledge and subjective measures of comfort with brain death declaration and surrogate communication.
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Affiliation(s)
- Patrick M Chen
- Department of Neurosciences, Division of Neurocritical Care, University of California, San Diego, CA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aaron Trando
- Department of Neurosciences, Division of Neurocritical Care, University of California, San Diego, CA
| | - Jamie Nicole LaBuzetta
- Department of Neurosciences, Division of Neurocritical Care, University of California, San Diego, CA
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Sawyer KE, Kraft SA, Wightman AG, Clark JD. Pediatric Death by Neurologic Criteria: The Ever-Changing Landscape and the Expanding Role of Palliative Care Professionals. J Pain Symptom Manage 2021; 62:1079-1085. [PMID: 33984463 DOI: 10.1016/j.jpainsymman.2021.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/18/2022]
Abstract
Pediatric palliative care providers are especially suited to support families and medical teams facing a potential diagnosis of brain death, or death by neurologic criteria (DNC), when a child suffers a devastating brain injury. To support pediatric palliative care providers' effectiveness in this role, this article elucidates the clinical determination of DNC and the evolution of the ethical and legal controversies surrounding DNC. Conceptual definitions of death used in the context of DNC have been and continue to be debated amongst academicians, and children's families often have their own concept of death. Increasingly, families have brought legal cases challenging the definition of death, arguing for a right to refuse examination to diagnose DNC, and/or voicing religious objections. We describe these conceptual definitions and legal challenges then explore some potential reasons why families may dispute a determination of DNC. We conclude that working with patients, families, and healthcare providers facing DNC carries inherent and unique challenges suited to intervention by interdisciplinary palliative care teams.
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Affiliation(s)
| | - Stephanie A Kraft
- University of Washington School of Medicine, Seattle Children's Research Institute Seattle, Washington, 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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Neuroprognostication after Cardiac Arrest: Who Recovers? Who Progresses to Brain Death? Semin Neurol 2021; 41:606-618. [PMID: 34619784 DOI: 10.1055/s-0041-1733789] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Approximately 15% of deaths in developed nations are due to sudden cardiac arrest, making it the most common cause of death worldwide. Though high-quality cardiopulmonary resuscitation has improved overall survival rates, the majority of survivors remain comatose after return of spontaneous circulation secondary to hypoxic ischemic injury. Since the advent of targeted temperature management, neurologic recovery has improved substantially, but the majority of patients are left with neurologic deficits ranging from minor cognitive impairment to persistent coma. Of those who survive cardiac arrest, but die during their hospitalization, some progress to brain death and others die after withdrawal of life-sustaining treatment due to anticipated poor neurologic prognosis. Here, we discuss considerations neurologists must make when asked, "Given their recent cardiac arrest, how much neurologic improvement do we expect for this patient?"
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Fainberg N, Mataya L, Kirschen M, Morrison W. Pediatric brain death certification: a narrative review. Transl Pediatr 2021; 10:2738-2748. [PMID: 34765497 PMCID: PMC8578760 DOI: 10.21037/tp-20-350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/05/2021] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Nina Fainberg
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leslie Mataya
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew Kirschen
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
| | - Wynne Morrison
- Division of Pediatric Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, USA
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Mataya L, Ross LF, Ghavam A, Paquette ET. Pediatric Intensivist and Pediatric Neurologist Perspectives and Practices on Death by Neurologic Criteria. THE JOURNAL OF CLINICAL ETHICS 2021. [DOI: 10.1086/jce2021323195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Smok D, Prager KM. The ethics of neurologically complicated pregnancies. HANDBOOK OF CLINICAL NEUROLOGY 2021; 171:227-242. [PMID: 32736753 DOI: 10.1016/b978-0-444-64239-4.00013-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Bioethical conflicts in pregnancy are distinguished from those in other areas of medicine due to competing interests between mother and fetus because of their shared biology. Historically, prior to the advent of fetal therapy and advances in medical technology, the maternal-fetal complex was considered to be a single entity. With advances in medicine, treatment options can now be directed at both the mother and the fetus, and a duality has evolved in the maternal-fetal unit. Thus at some point during pregnancy, two individuals rather than just one are the responsibility of the physician. In determining how to properly care for the pregnant woman with a neurologic condition, therapeutic choices must take into consideration the impact a treatment will have on both the mother and the fetus. Since what benefits one may harm the other, tension results from the need to choose. This chapter will highlight ethical conflicts arising at the interface of obstetrics and neurology. We will delve into situations where difficult reproductive and therapeutic decisions must be made in pregnant women with intellectual disabilities, stroke, brain tumors, and epilepsy. The complexity of brain death in pregnancy will be analyzed, acknowledging the influence of politics, law, and religion that bears on ethical decision-making. In approaching ethical dilemmas encountered in pregnancies complicated by neurologic conditions, frameworks based on principles, virtues, care, and feminist ethics, and case precedents will be applied to facilitate ethically appropriate shared decision-making. We hope that this chapter will provide valuable guidance for providers caring for this complex obstetric population.
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Affiliation(s)
- Dorothy Smok
- Department of Obstetrics Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States.
| | - Kenneth M Prager
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, United States
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Francoeur C, Weiss MJ, MacDonald JM, Press C, Greer DM, Berg RA, Topjian AA, Morrison W, Kirschen MP. Variability in Pediatric Brain Death Determination Protocols in the United States. Neurology 2021; 97:e310-e319. [PMID: 34050004 DOI: 10.1212/wnl.0000000000012225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/14/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To determine the variability in pediatric death by neurologic criteria (DNC) protocols between US pediatric institutions and compared to the 2011 DNC guidelines. METHODS In this cross-sectional study of DNC protocols obtained from pediatric institutions in the United States via regional organ procurement organizations, protocols were evaluated across 5 domains: general DNC procedures, prerequisites, neurologic examination, apnea testing, and ancillary testing. Descriptive statistics compared protocols to each other and the 2011 guidelines. RESULTS A total of 130 protocols were analyzed with 118 dated after publication of the 2011 guidelines. Of those 118 protocols, identification of a mechanism of irreversible brain injury was required in 97%, while 67% required an observation period after acute brain injury before DNC evaluation. Most protocols required guideline-based prerequisites such as exclusion of hypotension (94%), hypothermia (97%), and metabolic derangements (92%). On neurologic examination, 91% required a lack of responsiveness, 93% no response to noxious stimuli, and 99% loss of brainstem reflexes. A total of 84% of protocols required the guideline-recommended 2 apnea tests. CO2 targets were consistent with guidelines in 64%. Contrary to guidelines, 15% required ancillary testing for all patients and 15% permitted ancillary studies that are not validated in pediatrics. CONCLUSION Variability exists between pediatric institutional DNC protocols in all domains of DNC determination, especially with respect to apnea and ancillary testing. Better alignment of DNC protocols with national guidelines may improve the consistency and accuracy of DNC determination.
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Affiliation(s)
- Conall Francoeur
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Matthew J Weiss
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Jennifer M MacDonald
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Craig Press
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - David M Greer
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Robert A Berg
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Alexis A Topjian
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Wynne Morrison
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Matthew P Kirschen
- From Université Laval Research Center (C.F., M.J.W.), CHU de Québec Université Laval, Canada; Division of Pediatric Critical Care Medicine (J.M.M.), Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus; Department of Pediatrics (C.P.), Section of Neurology, University of Colorado, Denver; Department of Neurology (D.M.G.), Boston University, MA; and Departments of Anesthesiology and Critical Care Medicine (R.A.B., A.A.T., W.M., M.P.K.), Pediatrics (R.A.B., A.A.T., W.M., M.P.K.), and Neurology (M.P.K.), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania.
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50
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Miller FG, Nair-Collins M, Truog RD. It Is Time to Abandon the Dogma That Brain Death Is Biological Death. Hastings Cent Rep 2021; 51:18-21. [PMID: 34255368 DOI: 10.1002/hast.1268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Drawing on a recent case report of a pregnant, brain-dead woman who gave birth to a healthy child after over seven months of intensive care treatment, this essay rejects the established doctrine in medicine that brain death constitutes the biological death of the human being. The essay describes three policy options with respect to determination of death and vital organ transplantation in the case of patients who are irreversibly comatose but remain biologically alive.
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