Brain Death Guidelines Revised

A new practice guideline updated clinicians on how they should determine death by neurologic criteria -- also known as brain death -- in adults and children.

The consensus guidance, published in Neurology, was developed jointly by the American Academy of Neurology (AAN), the American Academy of Pediatrics (AAP), the Child Neurology Society (CNS), and the Society of Critical Care Medicine (SCCM). It updates the 2010 adult and the 2011 pediatric guidelines.

"The new guideline is the first to combine guidance for adult and pediatric patients," co-author David Greer, MD, MA, of Boston University and Boston Medical Center, told MedPage Today.

"Most aspects of brain death/death by neurologic criteria are shared between adults and pediatrics, but there are physiological reasons why children are different that need to be recognized, including their blood pressures that vary by age, as well as the skull bones not being fused until 1 to 2 years of age," Greer said. "Those differences are very specifically called out."

"The new guideline also provides guidance for specific areas not addressed by prior guidelines, such as in the setting of hypothermia, ECMO [extracorporeal membrane oxygenation], or pregnancy," he added.

Brain death occurs in patients who have sustained catastrophic brain injury with no evidence of function of the brain as a whole, a state that must be permanent. The process of determining brain death begins with the presumption that the patient does not meet death by neurologic criteria, which must then be disproved.

"Brain death is different from comatose and vegetative states," Greer emphasized. "People do not recover from brain death. Brain death is legal death."

The new guidance is consistent with the Uniform Determination of Death Act (UDDA). "It interprets the phrase 'all functions of the entire brain' as permanent loss of function of the brain as a whole, including the brainstem, resulting in (1) coma, (2) brainstem areflexia, and (3) apnea in the setting of an adequate stimulus," co-author Ariane Lewis, MD, of NYU Langone Medical Center in New York City, told MedPage Today.

The UDDA may be revised soon, however: in 2021, the Uniform Law Commission, which advises states about determination of death laws, created a committee to update the 40-year-old UDDA. Several groups have proposed changes, including ways to clarify death by neurologic criteria. In July, Neurology published a series of articles outlining the most important brain death controversies the Uniform Law Commission faces.

The new guideline from the AAN, AAP, CNS, and SCCM includes 85 recommendations that cover:

• General principles for brain death evaluations
• Qualifications to perform brain death evaluations
• Prerequisites for brain death determination
• Components of the brain death neurologic examination
• Apnea testing and ancillary tests as part of the brain death evaluation
• Special considerations for determining brain death including time of death and discontinuation of organ support, evaluating brain death when a patient is pregnant, preservation of neuroendocrine function, evaluating patients with primary posterior fossa injury, and obtaining consent for a brain death evaluation

It also addresses organ donation, stipulating that to avoid conflicts of interest, any clinician involved with surgical recovery of organs for transplantation must not be involved with the brain death evaluation.

Currently, brain death determination policies vary in hospitals across the U.S. and worldwide, Lewis observed. "This guideline provides a highly rigorous and structured approach to brain death evaluation and determination," she said.

"Clinicians should review the new guideline carefully and ensure their hospital brain death/death by neurologic criteria guidelines are updated to reflect the changes from the old guidelines in order to prevent inaccurate determinations of death," Lewis added.

Experts from all four medical societies developed the new recommendations. Because high-quality evidence on the topic was lacking, the guideline committee used an evidence-informed formal consensus process.

"The American Academy of Pediatrics appreciates the development of this consensus guideline, which took many hours of careful and evidence-based consideration," co-author Sonia Partap, MD, of Stanford University in California, said in a statement.

"Any child's death is never short of devastating," Partap added. "Pediatricians share a special relationship and trust with their patients and this guideline is to ensure we help families walk through the most difficult circumstances."

As part of the guideline, a digital application to lead clinicians through the brain death determination process will be available on AAN.com.

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