Abstract
Purpose
The first criteria for the determination of brain death were developed in 1968 in part to address concerns that had arisen with the retrieval of organs for transplantation. Despite over 30 years of application, some professional and public doubt persists over the validity of the theoretical construct underlying this method of determining death. Our review will address historical perspectives on the development of brain death criteria, and inconsistencies in current clinical criteria.
Method
Narrative review from selected MEDLINE references and other published sources.
Principal findings
The primary construct of the determination of death is that either cardiopulmonary or neurological function irreversibly ceases. However, there is inconsistency in the neurological criteria for death between jurisdictions, between patient populations, and in the use of confirmatory tests. These inconsistencies may cause concern in the public or profession about the validity of the determination of death by neurological criteria.
Conclusions
Organ transplantation is premised on professional and public acceptance that the donor is dead. Given that the criteria for brain death or their application remain variable, we suggest that it is reasonable to consider a national consensus to address these inconsistencies. Alternatively, the standard use of confirmatory radiographie testing prior to the retrieval of organs from donors who meet clinical brain death criteria should be considered to provide conclusive evidence of permanent and irreversible loss of brain function.
Résumé
Objectif
Les premiers critères de mort cérébrale ont été formulés en 1968 pour répondre, en partie, aux inquiétudes soulevées par la recherche d’organes pour les greffes. Maigré 30 ans d’application, un certain doute subsiste chez ies professionnels et le public sur la validité de la notion théorique à l’origine de cette façon de déterminer la mort. Notre revue aborde les perspectives historiques de la formulation des critères de mort cérébrale et des contradictions des critères cliniques actuels.
Méthode
La revue descriptive provient de la consultation de références dans MEDLINE et d’autres sources publiées.
Constatations principales
Le principal concept de la détermination de la mort est l’arrêt irréversible de la fonction cardiopulmonaire ou neurologique. Cependant, il y a des contradictions dans les critères neurologiques de la mort entre les pays, entre les populations de patients et dans l’usage des tests de confirmation. Ces contradictions peuvent inquiéter le public et la profession médicale sur la validité de la détermination de la mort par des critères neurologiques.
Conclusion
La greffe d’organes est fondée sur l’acceptation publique et professionnelle du fait que le donneur soit décédé. Étant donné que les critères de mort cérébrale, ou de leur application, demeurent variables, nous croyons qu’il est raisonnable d’envisager la formation d’un consensus visant à traiter de ces contradictions. Autrement, l’utilisation standard des tests radiographiques confirmatifs, qui précèdent le prélèvement d’organes de donneurs répondant aux critères cliniques de mort cérébrale, devrait être considérée pour fournir la preuve concluante de la perte permanente et irréversible de la fonction cérébrale.
Article PDF
Similar content being viewed by others
References
Rosenbaum S. Ethical conflicts. Anesthesiology 1999; 91: 3–4.
Bernat JL. Ethical and legal aspects of the emergency management of brain death and organ retrieval. Emerg Med Clin North Am 1987; 5: 661–76.
Price D. Contemporary transplantation initiatives: where’s the harm in them? J Law Med Ethics 1996; 24: 139–49.
Bernat JL, Culver CM, Gert B. On the definition and criterion for death. Ann Int Med 1981; 94: 389–94.
Bartlett ET. Differences between death and dying. J Med Ethics 1995; 21: 270–6.
Anonymous. Guidelines for the determination of death. Report of the medical consultants on the diagnosis of death to the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. JAMA 1981; 246: 2184–6.
Mollaret P, Goullon M. Le coma depasse. Rev Neurol 1959; 101: 3–6.
Powner DJ, Ackerman BM, Grenvik A. Medical diagnosis of death in adults: historical contributions to current controversies. Lancet 1996; 348: 1219–23.
Anonymous. A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to examine the definition of brain death. JAMA 1968; 205: 337–40.
Bernat JL. How much of the brain must die in brain death? J Clin Ethics 1992; 3: 21–8.
Anonymous. Guidelines for the diagnosis of brain death. Canadian Neurocritical Care Group. Can J Neurol Sci 1999; 26: 64–6.
Halevy A, Brody B. Brain death: reconciling definitions, criteria, and tests. Ann Int Med 1993; 119: 519–25.
Cranford R. Even the dead are not terminally ill anymore (Editorial). Neurology 1998; 51: 1530–1.
Lamb D. Death, Brain Death, and Ethics. Albany, NY: State University of New York Press; 1985.
Shewmon DA. Chronic “brain death”. Meta-analysis and conceptual consequences. Neurology 1998; 51: 1538–45.
Wijdicks EF, Bernat JL. Chronic “brain death” meta analysis and conceptual consequences (Letter). Neurology 1999; 53: 1370–2.
Lopez-Navidad A. Chronic “brain death” meta analysis and conceptual consequences (Letter). Neurology 1999; 53: 1370–2.
Crisci C. Chronic “brain death” meta analysis and conceptual consequences (Letter). Neurology 1999; 53: 1370–2.
Lang CJ. Chronic “brain death” meta analysis and conceptual consequences (Letter). Neurology 1999; 53: 1370–2.
Anonymous. An appraisal of the criteria of cerebral death. A summary statement. JAMA 1977; 237: 982–6.
Grigg MM, Kelly MA, Celesia GG, Ghobrial MW, Ross ER. Electroencephalographic activity after brain death. Arch Neurol 1987; 44: 948–54.
Kaukinen S, Makela K, Hakkinen VIC, Martikainen K. Significance of electrical brain activity in brain-stem death. Intensive Care Med 1995; 21: 76–8.
Wijdicks EF. Brain death worldwide. Accepted fact but no global consensus in diagnostic criteria. Neurology 2002; 58: 20–5.
Anonymous. Practice parameters for determining brain death in adults (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1995; 45: 1012–4.
Wijdicks EF. The diagnosis of brain death. N Engl J Med 2001; 344: 1215–21.
Anonymous. Criteria for the diagnosis of brain stem death. Review by a working group convened by the Royal College of Physicians and endorsed by the Conference of Medical Royal Colleges and their Faculties in the United Kingdom. J R Coll Physicians Lond 1995; 29: 381–2.
Takeuchi K. Evolution of criteria for determination of brain death in Japan. Acta Neurochir 1990; 105: 82–4.
Wijdicks EF. Determining brain death in adults. Neurology 1995; 45: 1003–11.
Youngner SJ, Landefeld CS, Coulton CJ, Juknialis BW, Leary M. ‘Brain death’ and organ retrieval. A cross-sectional survey of knowledge and concepts among health professionals. JAMA 1989; 261: 2205–10.
Young P, Matta B. Anaesthesia for organ donation in the brainstem dead-why bother? (Editorial). Anaesthesia 2000; 55: 105–6.
Turner M. The implications of anaesthetising the brainstem dead: 2 (Letter). Anaesthesia 2000; 55: 695–6.
Poulton B, Garfield M. The implications of anaesthetising the brainstem dead: 1 (Letter). Anaesthesia 2000; 55: 695–6.
Coad N, Byrne A. Guillain-Barre syndrome mimicking brainstem death. Anaesthesia 1990; 45: 456–7.
Chandler JM, Brilli RJ. Brainstem encephalitis imitating brain death. Crit Care Med 1991; 19: 977–9.
Bakshi N, Maselli RA, Gospe SM Jr, Ellis WG, McDonald C, Mandler RN. Fulminant demyelinating neuropathy mimicking cerebral death. Muscle Nerve 1997; 20: 1595–7.
Hughes R, McGuire G. Neurologic disease and the determination of brain death. The importance of a diagnosis. Crit Care Med 1997; 25: 1923–4.
Hassan T, Mumford C. Guillain-Barre syndrome mistaken for brain stem death. Postgrad Med J 1991; 67: 280–1.
Ragosta K. Miller Fisher syndrome, a brainstem encephalitis, mimics brain death. Clin Pediatr 1993; 32: 685–7.
Ringel RA, Riggs JE, Brick JF. Reversible coma with prolonged absence of pupillary and brainstem reflexes: an unusual response to a hypoxic-ischemic event in MS. Neurology 1988; 38: 1275–8.
Okamoto K, Sugimoto T. Return of spontaneous respiration in an infant who fulfilled current criteria to determine brain death. Pediatrics 1995; 96: 513–5.
Van Norman GA. A matter of life and death. What every anesthesiologist should know about the medical, legal, and ethical aspects of declaring brain death. Anesthesiology 1999; 91: 275–87.
Sanner M. A comparison of public attitudes toward autopsy, organ donation, and anatomic dissection. A Swedish survey. JAMA 1994; 271: 284–8.
Shemie S, Doig C, Belitsky P. Advancing toward a modern death: the path from severe brain injury to neurological determination of death. CMAJ 2003; 168: 993–5.
de la Riva A, Gonzalez FM, Llamas-Elvira JM, et al. Diagnosis of brain death: superiority of perfusion studies with99Tcm-HMPAO over conventional radionuclide cerebral angiography. Br J Radiol 1992; 65: 289–94.
Nau R, Prange HW, Klingelhofer J, et al. Results of four technical investigations in fifty clinically brain dead patients. Intensive Care Med 1992; 18: 82–8.
Dossetor JB. Death provides renewed life for some, but ethical hazards for transplant teams (Editorial). Can Med Assoc J 1999; 160: 1590–1.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Doig, C.J., Burgess, E. Brain death: resolving inconsistencies in the ethical declaration of death. Can J Anaesth 50, 725–731 (2003). https://doi.org/10.1007/BF03018718
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF03018718