Determination of brain death/death by neurologic criteria

David M. Greer, Sam D. Shemie, Ariane Lewis, Sylvia Torrance, Panayiotis Varelas, Fernando D. Goldenberg, James L. Bernat, Michael Souter, Mehmet Akif Topcuoglu, Anne W. Alexandrov, Marie Baldisseri, Thomas Bleck, Giuseppe Citerio, Rosanne Dawson, Arnold Hoppe, Stephen Jacobe, Alex Manara, Thomas A. Nakagawa, Thaddeus Mason Pope, William Silvester, David Thomson, Hussain Al Rahma, Rafael Badenes, Andrew J. Baker, Vladimir Cerny, Cherylee Chang, Tiffany R. Chang, Elena Gnedovskaya, Moon-Ku Han, Stephen Honeybul, Edgar Jimenez, Yasuhiro Kuroda, Gang Liu, Uzzwal Kumar Mallick, Victoria Marquevich, Jorge Mejia-Mantilla, MD, MSc35; Michael Piradov, Sarah Quayyum, Gentle Sunder Shrestha, Ying-ying Su, Shelly D. Timmons, Jeanne Teitelbaum, Walter Videtta, Kapil Zirpe, Gene Sung.  Determination of Brain Death/Death by Neurologic Criteria.  The World Brain Death Project.  JAMA. Published online August 3, 2020. doi:10.1001/jama.2020.11586

Abstract

Importance   There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries.

Objective   To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel.

Process   Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery.

Evidence Synthesis   Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed.

Recommendations   Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability.

Conclusions and Relevance   This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.

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Recommendations Issued for Brain Death/Death by Neurologic Criteria

The World Brain Death Project has released recommendations regarding the minimum clinical criteria needed to determine brain death/death by neurologic criteria (BD/DNC) in various scenarios. 

The recommendations, which were developed by an international, multidisciplinary panel of experts, include: 

A neurologic diagnosis that can cause complete and irreversible loss of all brain function should be established prior to examining a patient for BD/DNC. Clinicians should rule out any conditions that could confound clinical examination and any diseases that may resemble BD/DNC.

A clinical examination demonstrating coma, brainstem areflexia, and apnea can determine BD/DNC, which occurs when:

There are no signs of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation.

Pupils remain fixed in a midsize or dilated position and do not react to light.

There are no corneal, oculocephalic, and oculovestibular reflexes.

No facial movement to noxious stimulation occurs.

The gag reflex does not respond to bilateral posterior pharyngeal stimulation.

The cough reflex does not respond to deep tracheal suctioning.

A brain-mediated motor response to noxious stimulation of the limbs does not occur.

Spontaneous respirations do not occur when apnea test targets reach a pH of less than 7.30 and partial pressure of carbon dioxide of at least 60 mm Hg.

Ancillary testing with blood flow studies or electrophysiologic testing may be considered if the clinical examination is unable to be completed.

Special considerations are required in certain patients, including children, individuals receiving extracorporeal membrane oxygenation, and individuals receiving therapeutic hypothermia.

Other factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability should also be taken into account.

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