Archives For UDDA

Not All Hospitals Comply With Brain Death Criteria

Not all hospitals in the United States are following guidelines on determining brain death, a new study suggests.


Calendar kept by daughter Lisa SturmThe new study included hospital policies from 492 hospitals or healthcare systems with adequate data for analysis, representing those from all 50 states (some analyses included 491 policies).

Of the total, about a third of policies (33.1%) required specialist expertise in neurology or neurosurgery, but 150 policies had no mention of who could perform the determination. Many policies still allow for more junior physicians to determine brain death, the authors noted.

Unfortunately most hospitals (97.4%) required apnea testing which is the WORST thing to do for a severely injured trauma brain injured patient.

Uniform Determination of Death Act (UDDA)

The Uniform Determination of Death Act (UDDA), drafted in 1980 by the National Conference of Commissioners on Uniform State Laws to provide “comprehensive bases for determining death in all situations,” determined death by the following criteria:

“An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.”

So the UDDA allowed the determination of death to be made in accordance with accepted medical standards, but left it up to each hospital to determine those standards.

I know you’ve heard me talk about if you were injured in Iowa your treatment may be different than IF you were injured in Michigan. If you were taken to the U of M Hospital your care may be different from if you are taken to Beaumont Hospital in the suburbs of Detroit. My point is that it appears and I could certainly be wrong in my intepretation is that the authors are now advocating for more uniform, written standards and protocols in hospitals.

Comments on the article

Here are some of the comments on the original article that I found revealing. (Highlights mine, links mine, no attempt to correct the spelling in their comments)


As an RN who was involved with brain death organ donation in the 1970s, even then I had questions about the diagnosis such as the claim that such patients would die anyway after 2 weeks even with a ventilator but I was assured that greater minds than mine had it all figured out.

I really became alarmed when I saw that pregnant women diagnosed as brain dead were sometimes able to gestate their babies for months and these babies could survive and be healthy. Obviously, the 2 week claim was wrong but I still see it used today.

Later, I served on an ethics committee where one doctor canvassed the brain death criteria in our area, found that the criteria varied wildly but yet suggested that our hospital change its criteria to match the least restrictive one he found so that we could harvest more organs. I protested but was told that I didn’t understand how much these organs meant to the recipients.

I have also even seen a doctor tell a family that their loved one was brain dead even when the could take some breaths without a ventilator and despite apnea being the crucial criteria for brain death. In that case, the goal was not organ harvesting but rather to persuade the family to take the ventilator off a patient with a poor prognosis and give high doses of morphine as “comfort care”.

I am also appalled that this article repeats the claim that “there have been no documented reports of regaining function after a declaration of brain death” despite the recent Zach Dunlap and the current Jahi Mahi cases. These cases and other such cases should be written up for medical journals, not ignored.

Thus, I am not surprised by the problems this article presents. I hope it will lead to unbiased further research even if it results in a reexamination of brain death and even if it means fewer organs for people like my daughter-in-law who needs a kidney transplant. In the meantime, we are hoping for a living donor.


Dr.Kent Lyon 

Unfortunately, federal regulations and financial incentives tend to encourage hospitals to pursue a rushed process of diagnosing brain death and procuring organs, with no incentives to make accurate diagnoses. Thus, Dr. Geer’s effort to “light a fire” is likely to make little headway with disinterested hospitals.  A better approach to organ procurement would be to financially reimburse potential living donors for kidney transplants than to appeal to a professionalism that runs counter to federally constructed financial incentives for procuring cadaveric organs.

Dr. Leon Zacharowicz


Why am I not surprised?


This past summer, my nephew suffered a TBI in a motor vehicle accident.  I received the phone call saying that he was “brain dead,” and his organs were going to be donated, but my sister had requested that he be kept on the ventilator until all family could come to say goodbye.  Through a series of unexpected events, my 8 hour trip turned into a 24 hour trip, and I was the last to arrive at the hospital.  When I arrived, I was told that a possible pupillary response had just been observed by a nurse.  A few hours later, he was re-assessed by the neurologist and a definite pupillary response was present.  When I asked the neurologist about the type and location of the injury, I was told “It doesn’t matter – this is not a survivable injury. The brain is dead.” The trauma specialist told us that it was a diffuse axonal injury to “most of” the left hemisphere, with additional damage from multiple strokes in the right cerebellum. After five days with a Glasgow score of 3, he opened his eyes and looked around.  His GCS increased to 5, then 6. He began breathing on his own.  After weeks in CCU, additional weeks in a neuro step down unit, and more weeks of inpatient TBI therapy, he was able to go home.  It has now been 6 months since his injury.  He is walking, talking, laughing, reading, texting.  His long term memory, personality, and sense of humor are intact.  He’s still working on his short term memory, cognition and vision, with remarkable improvement and strong motivation.  He’s waiting impatiently for snow so he can start cross country skiing.  He will be re-starting college in a few weeks.

Was it a mistake?  Was it a miracle?  A little of each?   I have no idea. The trauma specialist said it is proof that God exists.  I just know that I am profoundly grateful.  And I believe there need to be uniformly followed guidelines for declaring brain death, including multiple assessments with a waiting period between assessments.

Dr. Arthur Drazan

What happened to the proven nuclear medicine brain scan?

Dr. William Goldie

I am concerned  that there is no comment about standards for use of EEG as ancillary  test for determining brain death.  Many well trained specialists who consider themselves experts in brain death will order EEG with no understanding of the necessary standards for using EEG in this setting.  Few hospitals have EEG technicians who are qualified to perform ECS EEG, and few have neurologists available who are qualified to interpret ECS  EEGs.  I would hope that brain death policies include the use of quality EEG to assist with the clinical diagnosis of brain death.

Does Dr. Goldie not know that EEG have not been used since the Minnesota Criteria?

When Harvard first published their criteria in 1968, EEG’s were a part of the evaluation, then in 1971 the Minnesota criteria along and they decided patients didn’t need EEG’s because too many families got upset when they saw brain waves. Then the “Pittsburgh protocol” came along and they began to take organs not from “just” the “brain-dead” patient but from patients after cardiac death. Now in Denver they are waiting 75 sec for a babies heart to stop and then proceeding with organ harvesting.

I believe life and death are NOT human decisions but one that only God can make. He gives life and He takes life away.


Non-Heart Beating Donors

I have written quite extensively on organ donation. Since this blog is a prelude to the book coming out in October I want to write about non heart beating donors. (NHBD)

In April of 1997, Mike Wallace of 60 Minutes did a piece on “Are surgeons taking organs from patients who are not quite dead?” At the end of his piece, Mike Wallace predicted that taking organs from the “not quite dead” or non heart beating donors would go away.

He was wrong.

It has not gone away.

Jamie Caulk in hospitalWhen we were at Vanderbilt, Mike and I were in with Jamie praying over him. I felt someone in the room and opened my eyes and looked at the foot of bed. There she was…an Organ Requester.

What are you doing in here, I asked.

“Well I heard you wanted to donate your son’s organs by having his heart stop beating first.”

No, you heard wrong, I said. I don’t appreciate appreciate you coming in my son’s room and discussing this in front of him, didn’t you see we were praying?” “Now please leave you are not getting one organ from my son.”

Current regulations require hospitals across the United States to notify the Organ Procurement Agencies when a patient is in a coma. If it is a federally funded hospital they can lose their funding if they do not notify them.

The Uniform Anatomical Gift Act (UAGA) assigns explicit priority to the donor’s expressed intent so that consent for organ donation becomes irrevocable and does not require the consent or agreement of any person after the donor’s death.

The donor’s authorization to donate, recorded on an organ donor card, the individual’s driver’s license, or a donor registry, becomes a legally binding advance directive. The UAGA amendment enables OPOs to procure organs without family consent and in certain instances after family refusal to donate.

Organ Procurement Organizations

The OPO at Vanderbilt asked us if they could go ahead and start running tests on Jamie to see if he was suitable for donation.

Andrew-David Caulk My son, Andrew spoke up before any of us could, “No, you are not doing that, you are only hastening my brother’s death, we want him to wake up, you are NOT doing any tests.”

Organ Procurement Organizations have set goals to get your organs, with an average of 75% being the norm.

The Revised UAGA changes the default “non-donation” with “intent to donate” by presuming that a person automatically wants to donate. In the current default option “intent to donate” everything is done medically to ensure the stability of the patient until the OPO’s can determine the medical suitability of the person as a perspective donor.

However, under mandated consent the OPO’s would not have to even ask or request permission because the removal of organs would be compulsory.

Mandatory consent overrides the health care directive that many wise people have written for their end of life care.

One of the critical issue’s with the non heart beating donor is by waiting 2-5 minutes (depending on which hospital you are in and what their protocol is) overrides the “dead donor rule”. I have posted here that by pronouncing death it rules out that the harvesting of the organs causes the death of the person.

NHBD is a donor whose death is defined by “irreversible cessation of circulatory and respiratory functions” as opposed to “irreversible cessation of all functions of the entire brain, including the brainstem” (Uniform Determination of Death Act, 12 Uniform Laws Annotated 320.

If you believe as I and many other’s do that a brain dead person, is not truly dead, you will still be approached to consider your loved one being a non-heart beating donor.

What to do when you are approached about donation by cardiac death

Prior to donation, the patient will be given heparin and phentolamine (Regitine), they are taken off life support, the heart will stop for 2-5 minutes, or they will check your pulse for just a very few seconds and pronounce you dead.  You will be resuscitated, put back on life support and the harvesting will begin.

My recommendation is:

1) Do not allow heparin or phentolamine drugs. Heparin and phentolamine would NOT be drugs given to a patient care unless they were considering organ donation. In certain patients under certain circumstances, these drugs may actively hasten death. They are only used to enhance organ quality.

2) Understand that non-beating heart donation is a way to increase organ donation’s.  By removing you from life support before you have died  and for some reason can not be called brain dead.

3) Do not let them start to take blood and tissue samples.

4) Do not let them cannulate. This is a when they insert a tube into the artery in the femoral artery and femoral vein prior to withdrawal of life support. Cannulation is done so that organs can cooled and preserved to improve transplant outcomes.

5) Non-heart beating donation is a fall back to get organs when they can’t proclaim brain death.

Journal of Hospital Medicine written by Mohamed Y. Rady, MD, PhD, and Joseph L Verheijde, PhD, MBA and Joan McGregor, PhD. 2007; 2(5):324-334. 

Read more at Non-Heart-Beating Organ Transplantation: Medical and Ethical Issues in Procurement

Is it cruel to question organ donation?

Steve Salerno wrote a piece for Playboy Magazine called, “The Heart Stopping Truth about Organ Donation”, in October 2002. No, I don’t read Playboy I’ve just read the article online.  I’m glad there was an article in Playboy, because wherever the TRUTH can be exposed about the lie of brain death being true death the better.

Mr. Salerno states that,  “According to the Centers for Disease Control, the mortality rate due to injury among men 18 to 35 years old is about twice that of the national average.” In other words, organ-procurement organizations (OPOs) are “waiting for you to do something stupid. In fact, they’re counting on it.”

The stats are on their side.

PlayboyIf you fall within that age range, you’re about four times more likely to meet a sudden end than your wife or girlfriend of an equivalent age is. Bottom line: If you’re the typical reader of Playboy magazine, you’re a prize candidate for organ donation. (Yes, glad Steve Salerno said it)

One popular belief peddled by the transplantation community is that brain death is as much a bedrock medical concept as conventional cardiac death. By those terms, a brain-dead patient is dead. Period.

In fact, brain death is an expedient “medical fiction,” to use Stuart Youngner’s phrase, invented to enable physicians to declare patients dead in a timely fashion and in a controlled environment.

“Anesthesiologist Philip Keep told the BBC that ‘nurses get really upset. You stick the knife in [into a patient whose organs are being removed], and the pulse and blood pressure shoot up.’ In an effort to squelch such disturbing manifestations, many British hospitals administer anesthesia prior to harvest. As Dr. Keep noted (without apparent irony), ‘If you don’t give anything at all, the patient will start moving and wriggling around and it’s impossible to do the operation.”

The Rules Have Been Written

The Dead Donor Rule

The Uniform Definition of Death Act

The Uniform Anatomical Gift Act

All of these laws are written to harvest your organs when you are pronounced brain dead. Though it’s not the kind of thing the medical establishment is eager to publicize, there has long been an arbitrariness to policies governing clinical determinations of death. “

Years ago one hospital, The Cleveland Clinic, wanted to implement a new standard that would declare a person dead with a five or seven-minute absence of a pulse,” says Carmen Marino, a former prosecutor for Ohio’s Cuyahoga County and one of a number of law-enforcement officials who have challenged the medical community’s willingness to alter current definitions of death.

“The organs that are most susceptible to blood deprivation after death are the heart and the liver. The liver transplant doctors said, “That’s too long. If we wait five or seven minutes, we’re not going to have a useful organ anymore. Let’s make it two minutes. And that was that.”

As a result, concludes Marino, “You go without a pulse for two minutes in some hospitals, you’re dead. They take your organs. In other places, at two minutes, they’re still trying to revive you.”

The reason for hushing up such facts is simple, says Stuart Youngner, director of the Center for Biomedical Ethics at Case Western Reserve University. “The OPOs are afraid that if we have these discussions publicly, it will slow down donations dramatically.”

Cynics look back on the Harvard milestone as a case in which a far-reaching medical judgment was made largely, if not purely, for non medical reasons.

Stuart Youngner is blunt: “The thrust of the Harvard decision was, ‘Let’s call them dead so we can’t be accused of killing them when we take their organs.”

New Guidelines for pronouncing death after cardiac death Well regardless of Marino’s ability to stop the Cleveland temporarily eventually every hospital adopted a 2 minute rule, and now there are even shorter guidelines.

During transfer the patient is supported on a ventilator, the ventilator is turned off, the patients heart stops, death is pronounced, then the heart is  started again, then your organs are harvested.

The heart is the last to go and at that point you are dead like most people think of death.

The legitimacy of “brain death,” “cardiac death,” and even “circulatory death” – which can be declared only 75 seconds after circulatory arrest – as actual death has been an ongoing debate in public commentary on organ donation.

Many experts assert that doctors familiar with organ donation are aware that the terms, intended to delineate a threshold of probable death, is different from actual bodily death, rendering highly uncertain the moral status of organ donation.

Is it cruel to question organ donation? 

Uniform Determination of Death Act (UDDA)

George Bush was the current President of the United States when he commissioned the  study of defining a uniform law on death.

At the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research they recommended and concluded that, in light of the ever-increasing powers of biomedical science and practice, a statue is needed to provide a clear and socially accepted basis for making determinations of death.

The commission, composed of ten men recommend the adoption of such a statute by the Congress for areas coming under federal jurisdiction and by all states as a means of achieving uniform law on defining death throughout the Nation.

The Uniform Determination of Death Act says, An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.

Surgery No person authorized by law to determine death, who makes such a determination in accordance with the Act, should, or will be, liable for damages in any civil action or subject to prosecution in any criminal proceeding for his acts or the acts of others based on that determination. 

Note: “This act is silent on acceptable diagnostic tests and medical procedures.… The medical profession remains free to formulate acceptable medical practices and to use new biomedical knowledge, diagnostic tests and equipment.”

Different Medical Standards

Each state has passed the UDDA and it is left to each doctor or hospital to determine the “acceptable medical standards”. One hospital could require one test, another hospital two doctors, some hospitals a nurse (Michigan). Some require an Apnea test, others two Apnea tests.

Depending on where you end up in a Trauma Center or hospital your “legal death” could be determined by different standards.

Life Processes in those pronounced “Brain Dead”

Regardless of the UDDA which defined death in the United States Dr. Alan D Shewmon has compiled a list of life processes that brain-dead patients continues to exhibit: 

  • Cellular wastes continue to be eliminated, detoxified, and recycled.
  • Body temperature is maintained, though at a lower than normal temperature and with the help of blankets.
  • Wounds heal.
  • Infections are fought by the body.
  • Infections produce fever.
  • Organs and tissues continue to function.
  • Brain-dead pregnant women can gestate a fetus.
  • Brain-dead children mature sexually and grow proportionately.

The other valid argument for Dr. Shewmon’s 150 cases is that in science, all you need is one case to falsify a theory.  Teresi, Dick (2012-03-13). The Undead: Organ Harvesting, the Ice-Water Test, Beating Heart Cadavers–How Medicine Is Blurring the Line Between Life and Death

If brain death is true death, then even one case (Dr. Shewmon has 150) destroys that theory.

Flickr Photo credit