No Consensus on Brain Death
A forthcoming article in the journal Neurology provides insight into the complexities of achieving international consensus on brain death.
The article by a team of neurologists and medical researchers from clinics and universities around the US catalogues conceptions of brain death in medical institutions around the world.
The authors found that institutional protocols were absent or poorly understood in a significant number of low-income countries. They also found that “substantial differences in perceptions and practices of brain death exist worldwide” and that “whether a harmonized, uniform standard for brain death worldwide can be achieved remains questionable.”
The study – the first to examine opinions in a broad range of countries – involved an electronic survey which was distributed globally to physicians with expertise in neurocritical care, neurology, or related disciplines who would encounter patients at risk of brain death. Physicians from 91 countries responded.
The results were quite revealing
Doctors around the world leave different periods of time following initial neurologic deterioration before they declare brain death. The most common waiting period is between 6 and 10 hours, but reported results ranged from less than 5 hours to more than 25 hours.
“There were several discrepancies regarding the conduct of apnea testing”, the authors report. Views about the import of ancillary testing (EEGs, Dopler ultrasounds etc.) differed significantly between countries.
In their discussion of the results of the study, the authors flagged a need for greater collaboration between medical institutions from different countries:
“To promulgate a unified stance on brain death, valuable for practitioners everywhere, consensus among leading experts in the field is urgently required…[our] findings underscore the importance of international partnerships between institutions to improve medical education and alleviate critical human resource needs in lower-income settings.”
In a comment on the article, Dr. James Bernat observed that there is significant disagreement on brain death even within the US.
“[There is] a surprising degree of practice variation among hospitals in the United States. In contrast to the international circumstance, in which practice disparities arise more because of legal, cultural, or religious differences, those in the United States result more from the biases and ingrained practices of individual physicians.”
This article is published by Xavier Symons and BioEdge.org under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation. Commercial media must contact us for permission and fees. Some articles on this site are published under different terms.
“Of course, there is no consensus, because “brain death” is NOT true death. I bet they would have no issue determining when someone is truly dead…irreversible cessation of circulatory and respiratory functions. That definition worked fine for us for thousands of years.”
That definition worked fine for us for thousands of years.
Objective: To assess the practices and perceptions of brain death determination worldwide and analyze the extent and nature of variations among countries.
Methods: An electronic survey was distributed globally to physicians with expertise in neurocritical care, neurology, or related disciplines who would encounter patients at risk of brain death.
Results: Most countries (n = 91, response rate 76%) reported a legal provision (n = 63, 70%) and an institutional protocol (n = 70, 77%) for brain death. Institutional protocols were less common in lower-income countries (2/9 of low [22%], 9/18 lower-middle [50%], 22/26 upper-middle [85%], and 37/38 high-income countries [97%], p < 0.001). Countries with an organized transplant network were more likely to have a brain death provision compared with countries without one (53/64 [83%] vs 6/25 [24%], p < 0.001).
Among institutions with a formalized brain death protocol, marked variability occurred in requisite examination findings (n = 37, 53% of respondents deviated from the American Academy of Neurology criteria), apnea testing, necessity and type of ancillary testing (most commonly required test: EEG [n = 37, 53%]), time to declaration, number and qualifications of physicians present, and criteria in children (distinct pediatric criteria: n = 38, 56%).
Conclusions: Substantial differences in perceptions and practices of brain death exist worldwide. The identification of discrepancies, improvement of gaps in medical education, and formalization of protocols in lower-income countries provide first pragmatic steps to reconciling these variations. Whether a harmonized, uniform standard for brain death worldwide can be achieved remains questionable.
- Received September 29, 2014.
- Accepted in final form January 7, 2015.
What if that was your family member and 53% of doctors deviated from the AANC criteria?
Let’s get rid of the legal fiction of brain death.
Last Thursday night on Grey’s Anatomy, Patrick Dempsey’s character, Derek Shepherd, was pronounced brain dead. Now Greys Anatomy for all 10 seasons has been pro-organ donation any chance they got. What was interesting is his wife, Meredith Grey had to make the decision to take him off life support. Her comments were interesting in light of the last 10 years.
Paraphrased: “Ok so now is the time you tell me you waited the number of requisite hours and now you can tell me, he is dead. So you need a bed, and you want me to sign the papers. Now that he is dead, but not really dead. Now I have to decide whether to put him in a long care facility or pull the plug and KILL him.
Did you hear that? Dead but not really dead, pull the plug and kill him?
Start at 1:11 to watch the exchange.