Clinicians’ Confusion over Brain Death Criteria Persists
In medical school, Krishanu Chatterjee, MD, was taught as a statement of biological fact that a positive result on the American Academy of Neurology (AAN) protocol for determining brain death (which assesses for irreversible coma, absent brainstem reflexes, and absent drive to breathe) meant that a person had passed away.
Chatterjee, currently a psychiatry resident at the University of Illinois Chicago, later became aware some prominent physicians and ethicists have disputed this criteria. “At the same time, I found myself at an institution, the Mayo Clinic, where there are voiceful proponents on both sides of the debate,” Chatterjee says.
Chatterjee and colleagues surveyed 118 healthcare professionals at Mayo Clinic hospitals in Arizona and Florida.1 They asked about clinicians’ knowledge of and attitudes on the AAN procedural criteria. Specifically, participants were asked whether the criteria determine complete and irreversible cessation of brain function, and on what concept of death they base the equivalence of brain death to biological death.
Participants completed a 30-minute video educational intervention, after which 62 participants completed the same questionnaire again. Both times, 86% supported the concept of brain death, and agreed current criteria constituted best practice. “Our main conclusion was that a strong and persistent consensus that a positive result on the AAN protocol is equivalent to brain death truly exists. However, our results reveal how tenuous and contradictory this consensus is, even among our highly trained and knowledgeable participants,” Chatterjee says.
Nearly 65% of participants agreed irreversible loss of consciousness and spontaneous breathing is sufficient for death. However, 37.6% stated, in apparent contradiction to this, that the loss of additional bodily functions, such as fighting infection, also is necessary for death. “Despite the conclusiveness with which the concept of brain death is taught in the medical curriculum, an overwhelming number of participants ask for further discussion,” Chatterjee says.
The determination of brain death by the AAN protocol is the accepted standard of care. “Thus, in the hospital setting, it is first and foremost the clinician’s responsibility to ensure that the AAN protocol is followed correctly,” Chatterjee stresses. “Then, and in conjunction with ethicists on staff, the clinician must accurately and honestly convey the limits of this determination of brain death.”
The process should allow room for religious objection to the concept of brain death if state law permits. The study’s findings, says Chatterjee, “underscore the need for transparency in what the medical community in the current era can and cannot declare as fact, and the need to consider the values and beliefs of individual families while being honest in terms of prognosis.”
However, highly publicized cases illustrate the breakdown in trust that can arise from lack of clarity on this issue.2 As for ethicists, one important goal is to ensure their institutional protocol aligns with the currently accepted medical standards for determination of death by neurologic criteria.3,4 “There are inconsistencies between these standards and institutional protocols and clinical practice,” says Ariane Lewis, MD, FNCS, director of neurocritical care at NYU Langone Medical Center.
This is problematic for several reasons. Inconsistencies can erode both clinician and public trust in the determination of death by neurologic criteria. Inconsistencies also can cause false-positive determinations in which a patient is incorrectly determined to be dead. To avoid these issues, Lewis suggests ethicists advocate for ensuring clinicians involved in the determination of death by neurologic criteria are equipped with appropriate expertise. “One means to facilitate education about death by neurologic criteria is through the Neurocritical Care Society’s educational module on determination of death by neurologic criteria,” Lewis notes.
Any determination of death requires criteria by which it is measured, says John Meinert, PhD, director of ethics at Mercy Fort Smith (AR). If clinicians are uncertain whether a particular patient meets the criteria, it could lead to mistakes concerning the determination of death. “This is a big ethical problem because our responsibilities to patients who are alive and those who are dead differ significantly,” Meinert says.
Ethicists, although not experts in clinical determinations of death, says Meinert, “can help contextualize the determination of death within a wider philosophy of medicine, and connect it to other ethical issues, such as organ donation.”
REFERENCES
- Chatterjee K, Rady MY, Verheijde JL, Butterfield RJ. A framework for revisiting brain death: Evaluating awareness and attitudes toward the neuroscientific and ethical debate around the American Academy of Neurology brain death criteria. J Intensive Care Med 2021;36:1149-1166.
- Shewmon DA, Salamon N. The extraordinary case of Jahi McMath. Perspect Biol Med 2021;64:457-478.
- Wijdicks EF, Varelas PN, Gronseth GS, et al. Evidence-based guideline update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2010;74:1911-1918.
- Nakagawa TA, Ashwal S, Mathur M, et al. Guidelines for the determination of brain death in infants and children: An update of the 1987 task force recommendations. Crit Care Med 2011;39:2139-2155.
There are inconsistencies between standards and institutional protocols and clinical practice. Inconsistencies can erode clinician and public trust in the determination of death by neurologic criteria. Inconsistencies also can cause false-positive determinations in which a patient is incorrectly determined to be dead. Ethicists should advocate for ensuring clinicians involved in the determination of death by neurologic criteria are equipped with appropriate expertise.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.