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Truly Reconciling the Case of Jahi McMath
Abstract
This article clarifies some issues raised by Dr. Ariane Lewis in her recent “Current Opinion/Arguments” article on the case of Jahi McMath. Review of case materials. Jahi’s case most likely represents an instance of global ischemic penumbra (GIP) mimicking brain death (BD), with intracranial blood flow too low to support neuronal function or to be detected by radionuclide scan but sufficient to prevent widespread necrosis. Her MRI scan 9 months after the ischemic insult showed gross preservation of cortical and internal structures, incompatible with there ever having been a period of completely absent blood flow. Regarding Jahi’s alleged intermittent responsiveness, the set of videos, unsystematic as they are, constitutes convincing evidence that her movements in seeming response to command are not of spinal cord origin and are indeed voluntary responses, placing her in the category of minimally conscious state (MCS). In the absence of serial examinations by experts in MCS, the benefit of the doubt should be given. Unfortunately, her death on June 22, 2018, 4½ years after the diagnosis of BD, precludes such examinations. During those 4½ years, Jahi underwent menarche, with three documented menstrual periods, and ongoing pubertal development. Her case is an important example of false-positive diagnosis of BD, demonstrating the inability of current diagnostic standards to distinguish true BD from potentially reversible brain nonfunction due to GIP. The incidence of such mimicry is impossible to determine, because in most cases a BD diagnosis becomes a self-fulfilling prophecy.
... However, argumentative braindead cases have recently raised up new disputes, arguing up-to-date BD criteria by questioning accepted medical standards. [13,[23][24][25][26][27][28][29][30] Three standards of death on neurological grounds have been debated in the last decades: whole brain, brainstem death and higher brain. [3,[31][32][33][34][35][36][37] Higher brain defenders defended the concept of as the "the loss of consciousness", (definition) associated to the permanent destruction of the neocortex (criterion), or "higher brain". ...
... [55][56][57] I have argued that the physio-pathological appraisal of consciousness generation and respiration provides the basis for rejecting Pallis' concept of brainstem death. [31,39,42] Besides, the latency for occurring an asystole after BD declaration, can be by augmented by continuous life support, [4,25,58,59] and in some rare cases [i.e., pregnancy] be prolonged to weeks or months, or extremely to years. [60][61][62] The conceptual and practical difference in BD determination between the USA and UK has been known as the "transatlantic divide". ...
... Then, Jahi McMath was moved to the New Jersey State, where relatives can decide to accept a cardio-respiratory or a neurological standard of death . [24][25][26]30,65,87] In September 2014, I was invited to travel to New Jersey, as an expert advisor, to evaluate ancillary tests prescribed by a US licensed neurologist. ...
Background:
New controversies have raised on brain death (BD) diagnosis when lesions are localized in the posterior fossa.
Objective:
The aim of this study was to discuss the particularities of BD diagnosis in patients with posterior fossa lesions.
Materials and methods:
The author made a systematic review of literature on this topic.
Results and conclusions:
A supratentorial brain lesion usually produces a rostrocaudal transtentorial brain herniation, resulting in forebrain and brainstem loss of function. In secondary brain lesions (i.e., cerebral hypoxia), the brainstem is also affected like the forebrain. Nevertheless, some cases complaining posterior fossa lesions (i.e., basilar artery thrombotic infarcts, or hemorrhages of the brainstem and/or cerebellum) may retain intracranial blood flow and EEG activity. In this article, I discuss that if a posterior fossa lesion does not produce an enormous increment of intracranial pressure, a complete intracranial circulatory arrest does not occur, explaining the preservation of EEG activity, evoked potentials, and autonomic function. I also addressed Jahi McMath, who was declared braindead, but ancillary tests, performed 9 months after initial brain insult, showed conservation of intracranial structures, EEG activity, and autonomic reactivity to "Mother Talks" stimulus, rejecting the diagnosis of BD. Jahi McMath's MRI study demonstrated a huge lesion in the pons. Some authors have argued that in patients with primary brainstem lesions it might be possible to find in some cases partial recovery of consciousness, even fulfilling clinical BD criteria. This was the case in Jahi McMath.
... The Kaplan-Meier survival curve looked similar to that for patients with terminal illnesses that were nevertheless alive. Since that time, more cases have been reported, particularly in pregnant women who had 'chronic BD' for weeks and months until a viable fetus was born [30][31][32]. The longest duration of BD was reported to be 20 years in a boy who suffered BD from meningitis at age 4 years, was sustained at home most of the time with nothing more than ventilation and enteral feeds, and whose heart stopped at age 24 years after which autopsy found no neural elements identifiable intracranially [i.e., he surely had whole-brain death] [33]. ...
... The other identifies the functioning of the whole brain as the hallmark of life because the brain is the regulator of the body's integration. 32 On this view, death is that moment at which the body's physiological system ceases to constitute an integrated whole. Even if life continues in individual cells or organs, life of the organism as a whole requires complex integration, and without the latter, a person cannot properly be regarded as alive. ...
... The recent case of Jahi McMath also suggests that lack of cerebral blood flow on testing may reflect a GIP, meaning, blood flow high enough to prevent brain tissue necrosis but low enough to produce a loss of clinically detectable brain function [32,205]. This GIP may have resulted in lack of detectable brain functions and perfusion that only produced a mimic of BD. ...
Brain death has been accepted worldwide medically and legally as the biological state of death of the organism. Nevertheless, the literature has described persistent problems with this acceptance ever since brain death was described. Many of these problems are not widely known or properly understood by much of the medical community. Here we aim to clarify these issues, based on the two intractable problems in the brain death debates. First, the metaphysical problem: there is no reason that withstands critical scrutiny to believe that BD is the state of biological death of the human organism. Second, the epistemic problem: there is no way currently to diagnose the state of BD, the irreversible loss of all brain functions, using clinical tests and ancillary tests, given potential confounders to testing. We discuss these problems and their main objections and conclude that these problems are intractable in that there has been no acceptable solution offered other than bare assertions of an ‘operational definition’ of death. We present possible ways to move forward that accept both the metaphysical problem - that BD is not biological death of the human organism - and the epistemic problem - that as currently diagnosed, BD is a devastating neurological state where recovery of sentience is very unlikely, but not a confirmed state of irreversible loss of all [critical] brain functions. We argue that the best solution is to abandon the dead donor rule, thus allowing vital organ donation from patients currently diagnosed as BD, assuming appropriate changes are made to the consent process and to laws about killing.
... Shewmon reports several cases of "chronic brain death" where sexual maturation and proportional growth occurred (Shewmon 1998), most recently reporting menarche in Jahi McMath, who was declared dead by neurological criteria but received continued treatment for nearly five years, after a court-mediated compromise between her parents and the hospital (Shewmon 2018a). This is evidence that the hypothalamus and anterior pituitary were regulating pubertal sexual development (Khan 2019;Wood, Lane, and Cheetham 2019). ...
... These cases include contemporaneous preservation of neurological function in the form of hypothalamic osmoregulation and anterior pituitary functions as discussed above (Nygaard, Townsend, and Diamond 1990;Varelas et al. 2011). Importantly, this finding has also occurred in cases unrelated to hypothalamic-pituitary function, including return of spontaneous breathing after diagnosis of brain death supplemented by a non-diffusible nuclear medicine blood flow test (Shewmon 2017); return of breathing, cough and extensor posturing after diagnosis of brain death supplemented by diffusible radionuclide cerebral perfusion SPECT imaging (Latorre, Schmidt, and Greer 2020); and even, though more controversially, transient emergence to the minimally conscious state after neuroimaging with diffusible radionuclide showed absence of brain blood flow (Shewmon 2018a;cf. Lewis 2018). ...
... Famously, Jahi McMath survived almost five years after being declared brain-dead (Shewmon 2018a;cf. Lewis 2018). ...
Some patients who have been diagnosed as “dead by neurologic criteria” continue to exhibit certain brain functions, most commonly, neuroendocrine functions. This preservation of neurologic function after the diagnosis of “brain death” or “brainstem death” is an ongoing source of controversy and concern in the medical, bioethics, and legal literatures. Most obviously, if some brain function persists, then it is not the case that all functions of the entire brain have ceased and hence, declaring such a patient to be “dead” would be a false positive, in any nation with so-called “whole brain death” laws. Furthermore, and perhaps more concerning, the preservation of any brain function necessarily entails the preservation of some amount of brain perfusion, thereby raising the concern as to whether additional areas of neural tissue may remain viable, including areas in the brainstem. These and other considerations cast significant doubt on the reliability of diagnosing either “brain death” or “brainstem death.”
... [1][2][3] Nonetheless, contentious brain-death cases have recently raised new controversies about the diagnosis of BD, widely covered in the US and international press, such as the Jahi McMath case, extensively covered by the press. [4][5][6][7][8][9][10] Jahi McMath meant a terrible tragedy for her and her family. But further than this gloomy story, the case has also raised confusion and challenging qualms about a fundamental query: how we confirm whether a person is dead or alive? ...
... But further than this gloomy story, the case has also raised confusion and challenging qualms about a fundamental query: how we confirm whether a person is dead or alive? 5,[7][8][9][10][11][12] Jahi McMath underwent pharyngeal surgery for obstructive sleep apnea at Oakland Children's Hospital on December 9, 2013. Later that evening, she suffered a massive hemorrhage inside her respiratory ways, leading to a cardiorespiratory arrest. ...
... She continued to grow, began menstrual periods, and was relatively stable except for a few intercurrent hospitalizations. [7][8][9] In September 2014, the author, Dr. Calixto Machado, a Cuban neurologist, was invited to travel to New Jersey, as an expert advisor. Jahi was studied at the Rutgers Hospital. ...
... For example, in one case an adult exhibited return of cough reflex, intermittent spontaneous breathing, and extensor posturing after diffusible radionuclide cerebral perfusion SPECT imaging showed no intracranial flow (Latorre et al., 2020); in another a young child demonstrated return of spontaneous breathing after non-diffusible nuclear medicine test showed no intracranial blood flow (Shewmon, 2017). Jahi McMath was an adolescent who received continued treatment for more than 4 years after being declared dead by neurologic criteria (Shewmon, 2018). In her case, diffusible radionuclide imaging showed absence of brain blood flow, yet structural imaging 9.5 months after being declared brain dead demonstrated large areas of structurally intact brain tissue, which is inconsistent with the absence of brain blood flow for that period of time (Shewmon, 2018). ...
... Jahi McMath was an adolescent who received continued treatment for more than 4 years after being declared dead by neurologic criteria (Shewmon, 2018). In her case, diffusible radionuclide imaging showed absence of brain blood flow, yet structural imaging 9.5 months after being declared brain dead demonstrated large areas of structurally intact brain tissue, which is inconsistent with the absence of brain blood flow for that period of time (Shewmon, 2018). Furthermore, half of patients declared to be brain dead have preserved osmoregulation (Nair-Collins and Joffe, 2021a). ...
... To the contrary, a previous case suggests the possibility that clinical tests showing loss of certain brain functions such as behavioural motor responsiveness, cranial nerve reflexes, and spontaneous breathing can be associated with preservation of residual conscious awareness and minimally conscious state. 3,4 Neuroimaging has shown diminished but persistent residual intracranial perfusion in patients with a clinical diagnosis of brain death. 5 Reduced perfusion in ischemic penumbra has been associated with reversible loss of brain functions. ...
... Global ischemic penumbra can mimic the clinical neurologic findings in brain death but functional capacity for conscious awareness is preserved. 3,4 Neuroimaging and autopsy confirmation of persistent structural viability and integrity of neural structures constituting the human substrates for external and internal conscious awareness challenges the wisdom of using contemporary clinical tests as the gold standard in brain death diagnosis to determine permanent cessation of capacity for consciousness. 5 Neuroscience has advanced contemporary understanding of external and internal conscious awareness function of the human brain since the conception of brain death 50 years ago. 1 The 2020 World Brain Death Project does not recommend ancillary tests that specifically assess for conscious awareness or provide scientific evidence to refute spontaneous recovery of conscious awareness with time in the severely injured human brain after the clinical diagnosis of brain death. ...
... In contrast, the 2013 UK practice guidelines for prolonged disorders of consciousness have not incorporated new diagnostic and therapeutic modalities in the management of severe brain injuries [19,20]. The scientific reliability of the UK practice guidelines can have profound consequences on clinical decision-making and timing of withdrawal and/or withholding of life-support treatment and other potentially beneficial neurotherapeutic interventions following severe brain injuries [14,15,[20][21][22]. The inclusion of a multimodal approach of functional neuroimaging, neuroelectrophysiological studies, and advanced neuroimaging technology with command-following or naturalistic paradigms can improve the diagnostic accuracy of the UK guidelines for the detection of covert consciousness in prolonged disorders of consciousness [23][24][25]. ...
... Likewise, the 1976 UK Code of practice for the diagnosis and confirmation of death established brain(stem) criteria (coma or behavioral unresponsiveness, brainstem areflexia, and apnea) for the diagnosis of death after severe brain injuries [6]. These clinical diagnostic criteria have remained unchanged in the 2010 updated Code of practice although neuroscience discoveries have refuted the equivalency of the stipulated brain(stem) criteria with death [17,21,22,26]. This is problematic because false positive diagnosis of death has been reported after applying the brain(stem) criteria in children [21,[27][28][29][30][31]. ...
The UK adopted the opt-out system (deemed or presumed consent) in end-of-life organ donation enforceable in May 2020. Presumed consent applies to adults but not children. Transplant advocates have recommended that all children on end-of-life care should be referred for potential organ donation to increase the supply of transplantable organs in the UK. To buttress this objective, a UK survey of parents of deceased children mostly with neurologic disorders secondary to severe brain injuries recommended the integration of routine parental discussion of donation regardless of donation eligibility in end-of-life care. Donation discussions emphasize the utility and suitability of organs in dying children for transplantation to maximize consent rate. To ensure that this recommendation does not harm children and parents, contemporary medical, legal, cultural, and religious challenges to end-of-life organ donation should be disclosed in parental discussion of donation and resolved appropriately. To that effect, it is urged that: (1) practice guidelines for the diagnosis and treatment of neurologic disorders secondary to severe brain injuries in children are updated and aligned with recent advances in neuroscience to eliminate potential errors from premature treatment discontinuation and/or incorrect diagnosis of death by brain(stem) criteria, (2) transparent and non-biased disclosure of all empiric information when discussing donation to ensure informed parental decision-making, and (3) a societal dialogue is conducted on the legal, cultural, and religious consequences of integration of routine donation discussion and referral in end-of-life care of children in the UK.
... Moreover, the distinction between biological and legal definitions should be explored further. The Jahi McMath case, extensively covered by the media in 2013, reflects the uncertainties regarding death, irreversibility and the legal framework [54,55]. Although the State of California issued a death certificate for the 13-year old girl, the family insisted on keeping the brain-dead girl on ventilator support and moved her to the state of New Jersey, where the legislation is different and where religious considerations may prohibit physicians from determining brain death. ...
... Although the State of California issued a death certificate for the 13-year old girl, the family insisted on keeping the brain-dead girl on ventilator support and moved her to the state of New Jersey, where the legislation is different and where religious considerations may prohibit physicians from determining brain death. Cases such as this shed light on the importance of transparency concerning biological and legal definitions, and the hazards of the absence of standardized death determination protocols [54,55]. ...
Background
It is poorly understood how public perception of the difference between brain death and circulatory death may influence attitudes towards organ donation. We investigated the public opinion on brain death versus circulatory death and documented inconsistencies in the legislations of countries with different cultural and socioeconomic backgrounds.
Methods
Using a crowdsourcing approach, we randomized 1072 participants from 30 countries to a case report of organ donation after brain death or to one following circulatory death. Further, we sampled guidelines from 24 countries and 5 continents.
Results
Of all participants, 73% stated they would be willing to donate all organs, while 16% would want to donate some of their organs. To increase the rate of donations, 47% would agree with organ donation without family consent as the default. Exposure to “brain death” was not associated with a lesser likelihood of participants agreeing with organ donation (82.1%) compared to “circulatory death” (81.9%; relative risk 1.02, 95% CI 0.99 to 1.03; p = .11). However, participants exposed to “circulatory death” were more certain that the patient was truly dead (87.9% ± 19.7%) than participants exposed to “brain death” (84.1% ± 22.7%; Cohen's d 0.18; p = 0:004). Sampling of guidelines revealed large differences between countries regarding procedures required to confirm brain death and circulatory death, respectively.
Conclusions
Implementation of organ donation after circulatory death is unlikely to negatively influence the willingness to donate organs, but legislation is still brain death-based in most countries. The time seems ripe to increase the rate of circulatory death-based organ donation.
... [2][3][4][5][6][7][8][9][10][11][12][13] Nonetheless, contentious brain-death cases have recently raised new controversies about the diagnosis of BD, such as the Jahi McMath case, extensively covered by the US and international press. [14][15][16][17][18][19][20][21][22][23][24] . Jahi McMath meant a terrible tragedy for her and her family. ...
... McMath, the family's legal position assured that she was alive because in large part on continued hormonal function manifested by menstruation. 18,[21][22][23] On the contrary, I assured that Jahi McMath was not braindead, because ancillary tests performed 9 months after initial brain insult, showed conservation of intracranial structures, EEG activity, and autonomic reactivity to "Mother Talks" stimulus. I concluded that Jahi McMath represented a new state of disorder of consciousness, non-previously described, that I have termed: "responsive unawake syndrome" (RUS). ...
Abstract
Lewis et al. published an important and timely necessary article about the determination of death by neurological criteria, revising the Uniform Determination of Death.The acceptance of brain death (BD) has been progressively accepted beginning at the late 1950s. Nonetheless, contentious brain-death cases have recently raised new controversies about the diagnosis of BD, such as the Jahi McMath case, extensively covered by the US and international press. Jahi McMath meant a terrible tragedy for her and her family. But further than this gloomy story, the case has also raised confusion and challenging qualms about a fundamental query: how we confirm whether a person is dead or alive? Since 1981, the Uniform Determination of Death Act (UDDA) has served as the legal foundation for the medical practice of determining death. But, although death by neurologic criteria is considered legal death throughout the United States, several recent lawsuits have quizzed the rightfulness the authority of the UDDA to declare death by neurological criteria. This issue explains the importance of Lewis’s et al. paper. In this article I want to present the historical procedure for issuing a law in Cuba for the determination and certification of death. Of course, it is impossible to compare our country with USA. Cuba is a small and developing country, in which a law encompasses a national scenery, in contrast with USA, a multistate nation.
... 13,14 The scientific validity of the practice guidelines can have profound clinical implications on discontinuation of clinically indicated therapeutic interventions including life-support treatment and/or withholding potentially beneficial neurotherapeutic interventions. 8,9,[13][14][15][16] Likewise, the UK code of practice for the diagnosis and confirmation of death was first issued in 1976 and has established the clinical criteria of death after severe brain injuries for organ donation. 17 Since then, neuroscience has refuted the fundamental assumptions underpinning the equation of brain(stem) death criteria with clinical death that is stipulated in the code of practice. ...
... 17 Since then, neuroscience has refuted the fundamental assumptions underpinning the equation of brain(stem) death criteria with clinical death that is stipulated in the code of practice. 15,16,18,19 Furthermore, several paediatric cases of false positive diagnosis of death have been reported after applying the diagnostic criteria of brain(stem) death. 15,[20][21][22][23][24] Faulty determination of death jeopardises trust in clinicians and healthcare providers because it hastily terminates beneficial treatment in a child with the potential to survive. ...
The opt-out system (or presumed consent) for end-of-life organ donation is being widely adopted in the United Kingdom. Since presumed consent for organ donation applies only to adults, commentators have recommended the implementation of routine parental request and integration of organ donation in the end-of-life care of children to increase the donor pool and the supply of transplantable organs. The empirical data for this recommendation originated from a survey of parents of deceased children with severe congenital and acquired brain injuries. The demographics of the surveyed parents were not representative of the diverse ethnic and religious affiliations of British society. Here, it is argued that there are unresolved medical, legal, cultural and religious challenges to the routine integration of end-of-life organ donation that can result in harmful consequences for children and parents. To address these challenges: (1) paediatric practice guidelines should be updated to incorporate new advances in the diagnosis and the treatment of severe brain injuries to eliminate potential clinical errors from premature treatment discontinuation and/or incorrect diagnosis of brain(stem) death and (2) a broad societal debate on the legal, cultural and religious consequences of routine integration of end-of-life organ donation in children.
... Anatomically, there is substantial variability in how the spinal cord receives circulation and our current knowledge challenges the assertion that ligation of aortic arch vessels is sufficient to eliminate perfusion of the entire brain and brainstem, as required by the [Uniform Determination of Death Act]. (OPTN Ethics Committee 2023, 20) Minimal circulation/perfusion that is compatible with function in the brain is not clinically detectable using currently available diagnostic technologies (Coimbra 1999;Shewmon 2018) and has been implicated in some instances of misdiagnosis of brain death (Latorre, Schmidt, and Greer 2020). TA-NRP protocols neither use nor require a clinical brain death exam or clinical measurement of brain perfusion, on the question-begging assumption that the patient has been determined dead by circulatory-respiratory criteria. ...
... However, Jahi McGrath had moved beyond the point of no return and was officially declared dead soon after her transfer to another hospital. [23] This clarification of death as a process helped lawmakers answer a much stronger objection: the objection that it is a doctor's duty to save lives and that a doctor cannot be someone who allows certification of death. The question in cases such as that of Mr. John Doe in this article is whether a person 'is' dead. ...
Objective:
The legal definitions of brain death are tantamount for legal dogmas and sometimes criminal intimidation of the treating doctors. The tests for brain death are only applicable to patients planned for organ transplantation. We intend to discuss the necessity of the "Do Not Resuscitate (DNR)" legislature in cases of brain death patients and applicability of tests for brain death irrespective of the intention for organ donation.
Methods:
A comprehensive review of the literature was performed till May 31, 2020 from the MEDLINE (1966 to July 2019) and Web of Science (1900 to July 2019). Search criteria included all publications with the MESH terms: "Brain Death/legislation and jurisprudence"[Mesh] OR "Brain Death/organization and administration"[Mesh] AND "India" [Mesh]. We also discuss the different opinions and implications of brain death versus brain stem death in India with the senior author (KG) who was responsible for South Asia's first multi-organ transplant after certifying brain death. Additionally, a hypothetical scenario of a DNR case is discussed in the current legal paradigm of India.
Results:
The systematic search yielded only five articles reporting a series of brain stem death cases with an acceptance rate of organ transplant among brain stem deaths being 34.8%. The most common solid organs transplanted were the kidney (73%) and liver (21%). A hypothetical scenario of a DNR and possible legal implications of the same under the current 'Transplantation of Human Organs Act (THOA)' of India remains unclear. A comparison of brain death laws in most Asian countries shows a similar pattern regarding the declaration of brain death and the lack of knowledge or legislature regarding DNR cases.
Conclusion:
After the determination of brain death, discontinuation of organ support requires the consent of the family. The lack of education and the lack of awareness have been major impediments in this medico-legal battle. There is also an urgent need to make laws for cases that do not qualify for brain death. This would help in not only realistic realization but also better triage of the health care resources while legally safeguarding the medical fraternity.
... p0180 We did not review the incidence of all hypothalamicpituitary functions after a diagnosis of brain death. It is worth noting that there are rare reports of "chronic brain death" where the patient had undergone puberty and proportional growth after the diagnosis of brain death (Shewmon, 1998(Shewmon, , 2018. Given that the hypothalamus (via gonadotropin-releasing hormone and growth hormone-releasing hormone) and anterior pituitary (via luteinizing hormone, follicle-stimulating hormone, and growth hormone) are required for pubertal development and proportional growth (Khan, 2019;Wood et al., 2019), this can be considered further evidence that at least some patients diagnosed as brain dead have remaining neuroendocrine functions. ...
Some patients who have been diagnosed as “dead by neurologic criteria” continue to exhibit certain brain functions, most commonly, neuroendocrine functions. In this chapter, we review the pathophysiology of brain death that can lead either to neuroendocrine failure or to preserved neuroendocrine functioning. We review the evidence on continued hypothalamic functioning in patients who have been declared “brain dead,” examine potential mechanisms that would explain these findings, and discuss how these findings create additional confounds for brain death testing. We conclude by reviewing the evidence for the management of hypothalamic–pituitary failure in the setting of brain death and organ transplantation.
... They believe that the accepted criteria for diagnosing brain death do not establish that all biological functioning driven by the brain has irreversibility ceased, as some functions can remain intact for years following a brain death diagnosis (48). For example, some patients declared brain dead can still regulate free water balance via neurohormonal secretion by the hypothalamus, menstruate, and even support gestation of a fetus to term (42,49,50). To circumvent this challenge, some propose relaxing the whole brain criterion to include only those functions essential to the brain as a whole, though acknowledge that defining such essential functions may be difficult (43,51). ...
In the five decades since its inception, brain death has become an accepted medical and legal concept throughout most of the world. There was initial reluctance to apply brain death criteria to children as they are believed more likely to regain neurologic function following injury. In spite of early trepidation, criteria for pediatric brain death certification were first proposed in 1987 by a multidisciplinary committee comprised of experts in the medical and legal communities. Protocols have since been developed to standardize brain death determination, but there remains substantial variability in practice throughout the world. In addition, brain death remains a topic of considerable ethical, philosophical, and legal controversy, and is often misrepresented in the media. In the present article, we discuss the history of brain death and the guidelines for its determination. We provide an overview of past and present challenges to its concept and diagnosis from biophilosophical, ethical and legal perspectives, and highlight differences between adult and pediatric brain death determination. We conclude by anticipating future directions for brain death as related to the emergence of new technologies. It is our position that providers should endorse the criteria for brain death diagnosis in children as proposed by the Society of Critical Care Medicine (SCCM), American Academy of Pediatrics (AAP), and Child Neurology Society (CNS), in order to prevent controversy and subjectivity surrounding what constitutes life versus death.
... 4, p. 8, table 3). The Project asserted that documented movements by Jahi McMath (a 13-year-old girl declared brain dead in California following surgery in 2013, who later had video evidence of intermittent nonmyoclonus, nonclonus, nonspasmodic, nonrhythmic movements in response to commands) 6 were due to "misinterpretation of complex spinal-mediated movements" (supp. 5, p. 20). ...
The World Brain Death Project clarified many aspects of the diagnosis of brain death/death by neurologic criteria. Clearer descriptions than previously published were presented concerning the etiology, prerequisites, minimum clinical criteria, apnea testing targets, and indications for ancillary testing. Nevertheless, there remained many epistemic and metaphysical assertions that were either false, ad hoc, or confused. Epistemically, the project was not successful in explaining away remaining brain functions, complex reflexes as "spinal," the risk and lack of utility of the apnea test, the ignored and often present confounders of central endocrine dysfunction and high-cervical-spinal-cord injury, the limitations of ancillary tests, or the cases of reversibility of some findings of brain death/death by neurologic criteria. Metaphysically, the World Brain Death Project variously suggested different concepts of death that were not supported with argument. Concepts offered included simply restating the criterion of brain death/death by neurologic criteria; personhood, without recognizing it is a higher-brain concept; and emergent functions of the organism as a whole, without specifying what these might be, if not biologic anti-entropic integration that actually remains after brain death/death by neurologic criteria. The World Brain Death Project only offered confused metaphysical discussion, and gave no reason why the state they described as brain death/death by neurologic criteria should be considered death itself. The main epistemic and metaphysical problems with brain death/death by neurologic criteria remain untouched by the World Brain Death Project.
... 51 Heart rate variability to external stimuli was demonstrated in the case of Jahi McMath and, although she satisfied the AAN brain death criteria, Shewmon recently postulated that she was in a minimally conscious state. 47 Neuroimaging studies have indicated functional interactions between the autonomic nervous system and the higher brain structures that mediate attention and conscious processes and that heart rate variability can be useful clinically to assess the capacity for conscious awareness and residual responsiveness in disorders of consciousness. 52 ...
Background
There remains a lack of awareness around the American Academy of Neurology (AAN) procedural criteria for brain death and the surrounding controversies, leading to significant practice variability. This survey study assessed for existing knowledge and attitude among healthcare professionals regarding procedural criteria and potential change after an educational intervention.
Methods
Healthcare professionals with increased exposure to brain injury at Mayo Clinic hospitals in Arizona and Florida were invited to complete an online survey consisting of 2 iterations of a 14-item questionnaire, taken before and after a 30-minute video educational intervention. The questionnaire gathered participants’ opinion of (1) their knowledge of the AAN procedural criteria, (2) whether these criteria determine complete, irreversible cessation of brain function, and (3) on what concept of death they base the equivalence of brain death to biological death.
Results
Of the 928 people contacted, a total of 118 and 62 participants completed the pre-intervention and post-intervention questionnaire, respectively. The results show broad, unchanging support for the concept of brain death (86.8%) and that current criteria constitute best practice. While 64.9% agree further that the loss of consciousness and spontaneous breathing is sufficient for death, contradictorily, 37.6% believe the loss of additional integrated bodily functions such as fighting infection is necessary for death. A plurality trusts these criteria to demonstrate loss of brain function that is irreversible (67.6%) and complete (43.6%) at baseline, but there is significantly less agreement on both at post-intervention.
Conclusion
Although there is consistent support that AAN procedural criteria are best for clinical practice, results show a tenuous belief that these criteria determine irreversible and complete loss of all brain function. Despite support for the concept of brain death first developed by the President’s Council, participants demonstrate confusion over whether the loss of consciousness and spontaneous breath are truly sufficient for death.
... 11 It has been suggested that the standard brain death tests performed were not sensitive enough to detect the patient's low brain blood flow. 12 Such a case draws attention to the UDDA's intentional abstention from prescribing standards for death examination, which enables the standard for cessation of function to remain up-to-date as medical technology advances. 13 If our current medical standards do not accurately predict when a person has lost all brain function, then perhaps they need to be updated. ...
Death's legal definition must be responsive to advances in technology, and it must delineate between life and death. But where to draw the line is difficult to determine. Death's current legal definition requires irreversible cessation of cardiorespiratory function or irreversible cessation of all brain function. But technology can often restore some brain functions without restoring consciousness, so brain death is often diagnosed without the irreversibility requirement being met. This article argues that the law should be updated to require permanent cessation, not irreversible cessation and that medicine should be transparent about what permanent means.
... 8,9 Where prolonged physiological support is undertaken after breath death, circulatory survival can persist for months, or even years, as in the well-known case of Jahi McMath. 10 The most comprehensive study of foetal delivery following MPS-BD was published in 2010. A team from Heidelberg, Germany, analysed 30 cases, reporting successful foetal delivery and neonatal survival in 63%. ...
Increasingly, reports are emerging of maternal physiological support after brain death in pregnant women declared brain dead long before the gestational age of foetal viability. While these ‘miracle babies’ often receive significant media attention – such as the recent case of Catarina Sequeira – it is difficult to estimate the probability of a live birth in such circumstances given a clear publication bias in favour of reporting good outcomes. In a number of highly publicised cases, continuation of maternal physiological support after brain death has been attempted against the express wishes of the patient's family in jurisdictions where a foetal right to life is given weight in law. The legal issues around discontinuation of maternal physiological support after brain death have not yet been assessed by a UK court. The scenario is easily envisioned, however, where conflict emerges as to the appropriateness of such support. While there is no statutory definition of death in the UK, the courts have accepted brain-dead patients as legally dead upon completion of brainstem testing. However, as UK law grants few explicit legal rights to a foetus, it is unclear as to how conflicts are to be resolved. This article is not intended as a systematic review of the medical or legal academic literature, nor as a review of the clinical management of the pregnant brain-dead patient; rather, it aims to summarise the evidence base for maternal physiological support after brain death and the relevant case law. Using a recent case as an example, this article will outline the legal approach to death in the UK, contrast the status in law of a brain-dead mother and her foetus, and advance an argument of the circumstances in which maternal physiological support after brain death may be ethically justifiable. The authors hope this will assist the UK intensivist in the complex decision-making such cases demand.
... However, quarrelsome brain-dead cases have lately raised up new debates, disputing current BD criteria by enquiring accepted medical standards. [12][13][14][15][16][17]. ...
Brain death (BD) concept has been increasingly widely accepted beginning since the late 1950s, but several controversies have appeared when intracranial pathology is localized to the posterior fossa. In the presence of a primary supratentorial brain lesion, a severe forebrain lesion is combined with either the subsequent gradual loss of brainstem function, due to rostrocaudal transtentorial brain herniation. In secondary brain lesions (i.e., cerebral hypoxia), the brainstem is also affected like the forebrain. However, a minority of patients with a primary infratentorial brain lesion (i.e., basilar artery thrombosis or brainstem or cerebellar bleeds) may retain cerebral blood flow and EEG activity. In this article I discuss that if a brainstem lesion does not provoke a massive increase of intracranial pressure there may be no complete cerebral circulatory arrest, explaining the preservation of EEG activity, evoked potentials, and autonomic function. I also discuss the case of Jahi McMath who was declared brain-dead, but ancillary tests, performed 9 months after initial brain insult, showed conservation of intracranial structures, EEG activity, and autonomic reactivity to “Mother Talks” stimulus, rejecting the diagnosis of BD. Jahi McMath’s MRI study demonstrated a huge lesion in the pons. Some authors have argued that in patients with primary brainstem lesions it might be possible to find a in some cases partial recover of consciousness, even fulfilling clinical BD criteria. This was the case in Jahi McMath. Further research and discussion are necessary about the use of ancillary tests in BD diagnosis in primary posterior fossa lesions.
The concept of brain death was introduced in the late 1960s and continues to develop. The article presents a brief history of the evolution of the idea of death by neurologic criteria. The concept is accepted worldwide, but there is still considerable variability in brain death determination protocols. New treatments for critical patients change the preconditions for brain death testing. The refinement of diagnostic techniques improves the capabilities of confirmatory tests. Controversial cases of determination of brain death cause public resonance and justified criticism of opponents of the concept. All these factors lead to review of some concept statements, terminology and update diagnostic protocols. In 2020, an international expert working group presented the minimum clinical standards for determination of brain death/death by neurologic criteria with guidance for various clinical circumstances. Some countries have already started to implement international recommendations and revise national diagnostic protocols. The extensive debate accompanying this process is an important contribution to the improvement of the concept of brain death.
The evolutionary emergence of consciousness is a research topic that has been attracting increasing attention in recent years. In a brief span of time, the debate surrounding various models in this area is driving the development of an increasingly specific research agenda. In this article, we examine the main available models of emergence. All the models we discuss assume, with varying degrees of caution, that consciousness emerged through convergent evolution in three distinct phyla within the animal kingdom. Nevertheless, they provide a unified account that aims to comprehensively cover all independent tokens of emergence. After analyzing the suitability of this unifying strategy through the lens of contemporary evolutionary theory, we recommend adopting a token-by-token, phylum-by-phylum approach. At this point, we emphasize the advantage of accumulated comparative knowledge regarding vertebrate evolution, advocating for an interoceptive view of the emergence of consciousness in vertebrates.
Purpose of review
The adoption of brain death played a crucial role in the development of organ transplantation, but the concept has become increasingly controversial. This essay will explore the current state of the controversy and its implications for the field.
Recent developments
The brain death debate, long limited to the bioethics community, has in recent years burst into the public consciousness following several high-profile cases. This has culminated in the reevaluation of the Uniform Determination of Death Act (UDDA), which is in the process of being updated. Any change to the UDDA has the potential to significantly impact the availability of organs.
Summary
The current update to the UDDA introduces an element of uncertainty, one the brain death debate had not previously had.
This Element considers current legal, ethical, metaphysical, and medical controversies concerning brain death. It examines the implicit metaphysical and moral commitments and dualism implied by neurological criteria for death. When these commitments and worldview are not shared by patients and surrogates, they give rise to distrust in healthcare providers and systems, and to injustice, particularly when medicolegal definitions of death are coercively imposed on those who reject them. Ethical obligations to respect persons and patient autonomy, promote patient-centered care, foster and maintain trust, and respond to the demands of justice provide compelling ethical reasons for recognizing reasonable objections. Each section illustrates how seemingly academic debates about brain death have real, on-the-ground implications for patients and their families.
In 2017, Michael Nair-Collins formulated his Transitivity Argument which claimed that brain-dead patients are alive according to a concept that defines death in terms of the loss of moral status. This article challenges Nair-Collins’ view in three steps. First, I elaborate on the concept of moral status, claiming that to understand this notion appropriately, one must grasp the distinction between direct and indirect duties. Second, I argue that his understanding of moral status implicit in the Transitivity Argument is faulty since it is not based on a distinction between direct and indirect duties. Third, I show how this flaw in Nair-Collins’ argument is grounded in the more general problems between preference utilitarianism and desire fulfillment theory. Finally, I present the constructivist theory of moral status and the associated moral concept of death and explain how this concept challenges the Transitivity Argument. According to my view, brain death constitutes a valid criterion of death since brain death is incompatible with the preserved capacity to have affective attitudes and to value anything.
Transplant surgeons in the USA have begun performing a novel organ procurement protocol in the setting of circulatory death. Unlike traditional donation after circulatory death (DCD) protocols, in situ normothermic perfusion DCD involves reperfusing organs, including the heart, while still contained in the donor body. Some commentators, including the American College of Physicians, have claimed that in situ reperfusion after circulatory death violates the widely accepted Dead Donor Rule (DDR) and conclude that in situ reperfusion is ethically impermissible. In this paper I argue that, in terms of respecting the DDR, in situ reperfusion cardiac transplantation does not differ from traditional DCD cardiac transplantation. I do this by introducing and defending a refined conception of circulatory death, namely vegetative state function permanentism . I also argue against the controversial brain occlusion feature of the in situ reperfusion DCD protocol, on the basis that it is ethically unnecessary and generates the problematic appearance of ethical dubiousness.
The mainstream concept of death-the biological one-identifies death with the cessation of an organism. In this article, I challenge the mainstream position, showing that there is no single well-established concept of an organism and no universal concept of death in biological terms. Moreover, some of the biological views on death, if applied in the context of bedside decisions, might imply unacceptable consequences. I argue the moral concept of death-one similar to that of Robert Veatch-overcomes such difficulties. The moral view identifies death with the irreversible cessation of a patient's moral status, that is, a state when she can no longer be harmed or wronged. The death of a patient takes place when she is no longer capable of regaining her consciousness. In this regard, the proposal elaborated herein resembles that of Veatch yet differs from Veatch's original project since it is universal. In essence, it is applicable in the case of other living beings such as animals and plants, provided that they have some moral status.
Ethical challenges in medical decision making are commonly encountered by clinicians caring for patients afflicted by neurological injury or disease at the end of life (EOL). In many of these cases, there are conflicting opinions as to what is right and wrong originating from multiple sources. There is a particularly high prevalence of impaired patient judgment and decision-making capacity in this population that may result in a misrepresentation of their premorbid values and goals. Conflict may originate from a discordance between what is legal or from stakeholders who view and value life and existence differently from the patient, at times due to religious or cultural influences. Promotion of life, rather than preservation of existence, is the goal of many patients and the foundation on which palliative care is built. Those who provide EOL care, while being respectful of potential cultural, religious, and legal stakeholder perspectives, must at the same time recognize that these perspectives may conflict with the optimal ethical course to follow. In this chapter, we will attempt to review some of the more notable ethical challenges that may arise in the neurologically afflicted at the EOL. We will identify what we believe to be the most compelling ethical arguments both in support of and opposition to specific EOL issues. At the same time, we will consider how ethical analysis may be influenced by these legal, cultural, and religious considerations that commonly arise.
The persistence of some degree of hypothalamic function is common in patients who meet all other preconditions to test for the determination of death by neurologic criteria with approximately 50% of such patients not developing diabetes insipidus. This may be difficult to reconcile with the whole-brain criterion for death that requires the loss of all functions of the entire brain including the brainstem. The determination of death must also be made in accordance with accepted medical standards. In most countries, these standards are not set in legislation, but are developed by appropriate professional bodies. Professional standards worldwide and international consensus statements accept that the absence of diabetes insipidus is compatible with a determination of death by neurologic criteria. This mismatch in legal and clinical requirements will continue to raise philosophical, legal, professional, and ethical arguments until the mismatch is resolved. Meanwhile, it remains true that no patient who meets the conditions for determination of death by neurologic criteria ever regains consciousness or breathes independently again, irrespective of the presence or absence of neuroendocrine function.
This chapter examines concepts and criteria of death and the coherence of their associations. Concepts of death fall into two broad categories: non-ontological and ontological. Non-ontological concepts include death as a cluster kind and death as a process; the corresponding criteria are stipulative, based on pragmatic concerns. Ontological concepts are essentially either psychological (cessation of “personhood,” equated with capacity for thinking and self-awareness) or biological (cessation of the human organism). The psychological concept corresponds to a “higher brain” criterion, namely irreversible, permanent nonfunction (destruction) of bilateral thalami (the sufficiency of neocortical destruction alone being uncertain); anatomically broader criteria are sufficient but not necessary. The biological concept corresponds to a criterion of irreversible, permanent cessation of circulation of oxygenated blood (irreversible cessation of brain function being necessary but not sufficient). Irreversible apneic unconsciousness is best understood not as a concept of death but as a stipulative criterion. Concepts of life and death and their corresponding criteria derive from fundamental worldviews, on which there has been no consensus for over two millennia, nor is there likely ever to be. Respect for deeply held fundamental worldviews requires allowance for personal specification of circulatory or brain-based criteria.
Irreversible loss of all functions of the entire brain must be confirmed in order to determine death by neurologic criteria (i.e. brain death). However, in many cases the accepted medical standards for determination of death by neurologic criteria cannot absolutely confirm either irreversibility or the loss of all functions of the entire brain. One way to reconcile this discrepancy is to require the absence of brain circulation to determine death by neurologic criteria. Prolonged absent brain circulation guarantees neuronal death, and is thus the only way to assure both irreversibility and loss of all functions of the entire brain. In this chapter, I discuss how the accepted medical standards for determination of death by neurologic criteria fail to determine death by neurologic criteria. I then discuss several benefits that will emerge if these accepted medical standards are amended to require the absence of brain circulation: (1) more accurate determination of loss of all functions of the entire brain, (2) more accurate determination of irreversibility, and (3) improved congruity with the determination of death by circulatory-respiratory criteria.
The steps to determine death by neurologic criteria are straightforward and methodical. Despite this precision, there is a surprising amount of variability in determination of death by neurologic criteria both intra- and internationally. Although some degree of variability is acceptable, clinicians should embrace stringent minimum standards to ensure that determination of death by neurologic criteria is done responsibly and accurately 100% of the time, so that there are no false-positive determinations of death. Variability can take the form of philosophical differences, as in the “whole brain” vs. “brainstem” formulations of death by neurologic criteria, or in specific medical areas, such as who can determine death by neurologic criteria, how clinical testing is performed (including apnea testing), when to get ancillary testing and which test to perform, as well as how to accommodate families who are unaccepting of death determined by neurologic criteria. In this chapter, we discuss the different areas of variability in death by neurologic criteria and steps that are being taken to reduce this variability to help ensure the profession’s and the public’s trust in the concept and determination process.
Capítulo 9. Bioética, muerte y derechos humanos, pp 217.
This article examines an Australian campaign to increase organ and tissue donation for transplantation. It analyses the use of the gift rhetoric to promote community awareness and resources, target migrant groups, and recruit cultural and religious leaders to endorse organ and tissue donation as an altruistic act. In unpacking this ‘gift of life’ approach to organ donation, it explores the convergence of medical and religious bodies and pushes beyond uniform determinations of death to reveal how multiple deaths transpire in organ donation. Drawing on recent advances in the anthropology of becoming as a critical lens to examine death and organ donation, it examines how the ‘unfinishedness’ of donor bodies produces new possibilities for understanding donation. This article thus attends to the situated, layered and contradictory sensibilities that open up multiple and malleable understandings of the donation of body parts.
Jahi McMath was diagnosed brain dead on 12/12/2013 in strict accordance with both the pediatric and adult Guidelines, reinforced by 4 isoelectric electroencephalograms and a radionuclide scan showing intracranial circulatory arrest. Her magnetic resonance imaging scan 9 1/2 months later surprisingly showed gross integrity of cortex, basal ganglia, thalamus, and upper brainstem. The greatest damage was in the white matter, which was extensively demyelinated and cystic, and in the lower brainstem, most likely from partial herniation that resolved. The apparent integrity of gray matter and the ascending reticular activating system may have provided a potential structural basis for the reemergence of some limited brain functions, while the white matter and lower brainstem lesions would have caused severe motor disability, brainstem areflexia and apnea. The findings indicate that there could never have been a period of sustained intracranial circulatory arrest. Rather, at the time of brain death diagnosis, low blood flow below the detection threshold of the radionuclide scan was sufficient to maintain widespread neuronal viability, though insufficient to support synaptic function. Her case represents the first indirect confirmation of the reality and clinical relevance of global ischemic penumbra, hypothesized in 1999 as a generally unacknowledged and possibly common brain death mimic.
In this paper, I review the case of Jahi McMath, who was diagnosed with brain death (BD). Nonetheless, ancillary tests performed nine months after the initial brain insult showed conservation of intracranial structures, EEG activity, and autonomic reactivity to the “Mother Talks” stimulus. She was clinically in an unarousable and unresponsive state, without evidence of self-awareness or awareness of the environment. However, the total absence of brainstem reflexes and partial responsiveness rejected the possibility of a coma. Jahi did not have uws because she was not in a wakefulness state and showed partial responsiveness. She could not be classified as a LIS patient either because LIS patients are wakeful and aware, and although quadriplegic, they fully or partially preserve brainstem reflexes, vertical eye movements or blinking, and respire on their own. She was not in an MCS because she did not preserve arousal and preserved awareness only partially. The CRS-R resulted in a very low score, incompatible with MCS patients. mcs patients fully or partially preserve brainstem reflexes and usually breathe on their own. MCS has always been described as a transitional state between a coma and UWS but never reported in a patient with all clinical BD findings. This case does not contradict the concept of BD but brings again the need to use ancillary tests in BD up for discussion. I concluded that Jahi represented a new disorder of consciousness, non-previously described, which I have termed “reponsive unawakefulness syndrome” (RUS).
Discrepancies between the Uniform Determination of Death Act (UDDA) and the adult and pediatric diagnostic guidelines for brain death (BD) (the “Guidelines”) have motivated proposals to revise the UDDA. A revision proposed by Lewis, Bonnie and Pope (the RUDDA), has received particular attention, the three novelties of which would be: (1) to specify the Guidelines as the legally recognized “medical standard,” (2) to exclude hypothalamic function from the category of “brain function,” and (3) to authorize physicians to conduct an apnea test without consent and even over a proxy’s objection. One hundred seven experts in medicine, bioethics, philosophy, and law, spanning a wide variety of perspectives, have come together in agreement that while the UDDA needs revision, the RUDDA is not the way to do it. Specifically, (1) the Guidelines have a non-negligible risk of false-positive error, (2) hypothalamic function is more relevant to the organism as a whole than any brainstem reflex, and (3) the apnea test carries a risk of precipitating BD in a non-BD patient, provides no benefit to the patient, does not reliably accomplish its intended purpose, and is not even absolutely necessary for diagnosing BD according to the internal logic of the Guidelines; it should at the very least require informed consent, as do many procedures that are much more beneficial and less risky. Finally, objections to a neurologic criterion of death are not based only on religious belief or ignorance. People have a right to not have a concept of death that experts vigorously debate imposed upon them against their judgment and conscience; any revision of the UDDA should therefore contain an opt-out clause for those who accept only a circulatory-respiratory criterion.
Double Effect Donation claims it is permissible for a person meeting brain death criteria to donate vital organs, even though such a person may be alive. The reason this act is permissible is that it does not aim at one’s own death but rather at saving the lives of others and because saving the lives of others constitutes a proportionately serious reason for engaging in a behavior in which one foresees one’s death as the outcome. Double Effect Donation, we argue, opens a novel position in debates surrounding brain death and organ donation and does so without compromising the sacredness and fundamental equality of human life.
Summary
Recent cases and discussion have raised questions about whether brain death criteria successfully capture natural death. These questions are especially troubling since vital organs are often retrieved from individuals declared dead by brain death criteria. We therefore seem to be left with a choice: either salvage brain death criteria or else abandon current organ donation practices. In this article, we present a different way forward. In particular, we defend a view we call Double Effect Donation, according to which it is permissible for a person meeting brain death criteria to donate vital organs, even though such a person may be alive. Double Effect Donation, we argue, is not merely compatible with but grows out of a view that acknowledges the sacredness and fundamental equality of human life.
Spinal automatisms and reflexes, peripheral neurogenic and myogenic reactions are common in patients with irreversible brain death. They are therefore compatible and are even understood by experienced investigators as confirmation of irreversible brain death. This article provides an overview of the phenomenology of irreversible brain death and discusses it from a neuropathological perspective. Furthermore, irreversible brain death is described in order to distinguish it from pathological movements and motor reactions in comatose patients or patients with disturbed consciousness due to severe brain disorders.
In this paper, I reviewed the case of Jahi McMath who was diagnosed as being in brain death (BD). Nonetheless, ancillary tests, performed 9 months after initial brain insult, showed conservation of intracranial structures, EEG activity, and autonomic reactivity to “Mother Talks” stimulus. She was clinically in a state of unarousable and unresponsiveness, without evidence of awareness of self or environment, but full absence of brainstem reflexes, and partial responsiveness rejected the possibility of being in coma. Jahi was not a UWS, because she was not in a wakefulness state, and showed partial responsiveness. LIS patients are wakeful and aware, and although these cases are quadriplegic, they fully or partially preserve brainstem reflexes, vertical eye movements, and/or blinking, and respire by their own, rejecting the possibility of classifying her as a LIS patient. She was not a MCS because she did not preserve arousal, and only partially preserved awareness. The CRS-R resulted in a very low score, not corresponding with MCS patients. MCS patients fully or partially preserve brainstem reflexes, and usually breathe by their own. MCS has been always described as a transitional state between coma, UWS, but MCS has never been reported in a patient who has all clinical BD findings. This case doesn’t contradict the concept of BD, but brings again to discussion the needs of using ancillary tests in BD. I concluded that Jahi represented a new state of disorder of consciousness, non-previously described, that I have termed: “responsive unawake syndrome” (RUS).
In light of the current medical evidence, physicians and ethicists no longer have the moral certainty that Pope John Paul II deemed vital for vital organ transplantation. The current medical evidence suggests that some brain-dead patients do seem to exhibit signs of global integration. This article will analyze the interpretations of this evidence, both from ethicists for and against the neurological criteria. Even the strongest arguments in favor of the neurological criteria in light of the new evidence fail to prove that the patient with total brain failure (TBF) has died. Furthermore, the recent Jahi McMath case demonstrates a new and alarming reality that there is no way in practice to distinguish global ischemic penumbra from TBF. In the absence of the moral certainty required by Pope John Paul II, it is clear that the Catholic Church should immediately call for a halt on vital organ transplantation.
Summary
This article analyzes the current medical evidence about brain death and argues that we have lost the moral certainty that Pope John Paul II deemed necessary for vital organ transplantation.
Commentary: False Positives in the Diagnosis of Brain Death - Volume 28 Special Issue - MICHAEL NAIR-COLLINS, FRANKLIN G. MILLER
Disturbing cases continue to be published of patients declared brain dead who later were found to have a few intact brain functions. We address the reasons for the mismatch between the whole-brain criterion and brain death tests, and suggest solutions. Many of the cases result from diagnostic errors in brain death determination. Others probably result from a tiny amount of residual blood flow to the brain despite intracranial circulatory arrest. Strategies to lessen the mismatch include improving brain death determination training for physicians, mandating a test showing complete intracranial circulatory arrest, or revising the whole-brain criterion.
Death can be defined as the permanent cessation of the organism as a whole. Although the organism as a whole is a century-old concept, it remains better intuited than analyzed. Recent concepts in theoretical biology including hierarchies of organization, emergent functions, and mereology have informed the idea that the organism as a whole is the organism’s critical emergent functions. Because the brain conducts the critical emergent functions including conscious awareness and control of respiration and circulation, the cessation of brain functions is death of the organism. A newer concept, the brain as a whole, may offer a superior criterion of death to the whole-brain criterion, because it more closely matches accepted clinical brain death tests and confirms the cessation of the organism’s emergent functions. Although the concepts of organism as a whole and brain as a whole remain vague and in need of rigorous biophilosophical analysis, their future precision will be restricted by the categorical limitations intrinsic to theoretical biological models.
The whole-brain criterion of death provides that a person who has irreversibly lost all clinical functions of the brain is dead. Bedside brain death (BD) tests permit physicians to determine BD by showing that the whole-brain criterion of death has been fulfilled. In a nonsystematic literature review, we identified and analyzed case reports of a mismatch between the whole-brain criterion of death and bedside BD tests. We found examples of patients diagnosed as BD who showed (1) neurologic signs compatible with retained brain functions, (2) neurologic signs of uncertain origin, and (3) an inconsistency between standard BD tests and ancillary tests for BD. Two actions can resolve the mismatch between the whole-brain criterion of death and BD tests: (1) loosen the whole-brain criterion of death by requiring only the irreversible cessation of relevant brain functions and (2) tighten BD tests by requiring an ancillary test proving the cessation of intracranial blood flow. Because no one knows the precise brain functions whose loss is necessary to fulfill the whole-brain criterion of death, we advocate tightening BD tests by requiring the absence of intracranial blood flow.
We compare and discuss three cases including: a clearly brain-dead patient, a vegetative state/unresponsive wakefulness syndrome (VS/UWS) patient and a patient diagnosed as brain-dead (BD) demonstrating some but not all clinical features of a BD state. Two of the patients demonstrated clear presentation allowing for an effective determination of state of death or consciousness. One patient, in comparison to the other two, presented with a complete absence of brainstem reflexes, absence of spontaneous driving to breath, and required permanent mechanical ventilation. Nonetheless, preservation of intracranial structures, remaining brain function in both brainstem and cerebral hemispheres was evidenced in the third case similar to the reported VS/UWS patient. Moreover, autonomic reactivity to mother's voice stimulation precluded the diagnosis of a BD in the latter case. This third patient was not comatose. The clinical examination demonstrated complete absence of brainstem reflexes, and no spontaneous driving to breath. This patient did not appear to be a VS/UWS, as she had not shown intermittent wakefulness with measurable sleep-wake cycles, and variably
preserved cranial nerve reflexes. Therefore, the possibility of a responsive wakefulness state-minimally conscious state (MCS), or MCS emergence state was also excluded. This third patient in contradistinction to the other two demonstrates features similar to BD states, without being brain-dead,
comatose, or VS/UWS or MCS states, and therefore rests somewhere on the spectrum of clinical consciousness. The importance of this paper is in that it highlights some of the difficulties in the clinical classification of states of consciousness, when the evaluation is categorized, showing that one of the patients presented rests somewhere else on the spectrum of clinical consciousness.
We compare and discuss three cases including: a clearly brain-dead patient, a vegetative state/unresponsive wakefulness syndrome (VS/UWS) patient and a patient diagnosed as brain-dead (BD) demonstrating some but not all clinical features of a BD state. Two of the patients demonstrated clear presentation allowing for an effective determination of state of death or consciousness. One patient, in comparison to the other two, presented with a complete absence of brainstem reflexes, absence of spontaneous driving to breath, and required permanent mechanical ventilation. Nonetheless, preservation of intracranial structures, remaining brain function in both brainstem and cerebral hemispheres was evidenced in the third case similar to the reported VS/UWS patient. Moreover, autonomic reactivity to mother's voice stimulation precluded the diagnosis of a BD in the latter case. This third patient was not comatose. The clinical examination demonstrated complete absence of brainstem reflexes, and no spontaneous driving to breath. This patient did not appear to be a VS/UWS, as she had not shown intermittent wakefulness with measurable sleep-wake cycles, and variably preserved cranial nerve reflexes. Therefore, the possibility of a responsive wakefulness state-minimally conscious state (MCS), or MCS emergence state was also excluded. This third patient in contradistinction to the other two demonstrates features similar to BD states, without being brain-dead, comatose, or VS/UWS or MCS states, and therefore rests somewhere on the spectrum of clinical consciousness. The importance of this paper is in that it highlights some of the difficulties in the clinical classification of states of consciousness, when the evaluation is categorized, showing that one of the patients presented rests somewhere else on the spectrum of clinical consciousness. Keywords: Brain death (BD); persistent vegetative state, unresponsive wakefulness syndrome (PVS/UWS), minimally conscious state (MCS), EEG, magnetic resonance imaging (MRI), autonomic nervous system (ANS), heart rate variability (HRV).
The Uniform Determination of Death Act (UDDA) states that an individual is dead when “all functions of the entire brain” have ceased irreversibly. However, it has been questioned whether some functions of the hypothalamus, particularly osmoregulation, can continue after the clinical diagnosis of brain death (BD). In order to learn whether parts of the hypothalamus can continue to function after the diagnosis of BD, we performed 2 separate systematic searches of the MEDLINE database, corresponding to the functions of the posterior and anterior pituitary. No meta-analysis is possible due to nonuniformity in the clinical literature. However, some modest generalizations can reasonably be drawn from a narrative review and from anatomic considerations that explain why these findings should be expected. We found evidence suggesting the preservation of hypothalamic function, including secretion of hypophysiotropic hormones, responsiveness to anterior pituitary stimulation, and osmoregulation, in a substantial proportion of patients declared dead by neurological criteria. We discuss several possible explanations for these findings. We conclude by suggesting that additional clinical research with strict inclusion criteria is necessary and further that a more nuanced and forthright public dialogue is needed, particularly since standard diagnostic practices and the UDDA may not be entirely in accord.
The data reviewed here suggest the possibility that a global reduction of blood supply to the whole brain or solely to the infratentorial structures down to the range of ischemic penumbra for several hours or a few days may lead to misdiagnosis of irreversible brain or brain stem damage in a subset of deeply comatose patients with cephalic areflexia. The following proposals are advanced: 1) the lack of any set of clinically detectable brain functions does not provide a safe diagnosis of brain or brain stem death; 2) apnea testing may induce irreversible brain damage and should be abandoned; 3) moderate hypothermia, antipyresis, prevention of arterial hypotension, and occasionally intra-arterial thrombolysis may contribute to good recovery of a possibly large subset of cases of brain injury currently regarded as irreversible; 4) confirmatory tests for brain death should not replace or delay the administration of potentially effective therapeutic measures; 5) in order to validate confirmatory tests, further research is needed to relate their results to specific levels of blood supply to the brain. The current criteria for the diagnosis of brain death should be revised.
Background:
The case of Jahi McMath has captured the attention of the public, healthcare professionals, and ethicists. Jahi was declared brain dead in late 2013, but her family transferred her to New Jersey to continue organ support. A lengthy legal battle has been ongoing since then. Jahi's family and two neurologists, Drs. Calixto Machado and Alan Shewmon, believe that she is not brain dead. Her family and Dr. Shewmon think that she is capable of following commands, thus making her minimally conscious.
Methods:
Review of case materials.
Results and conclusion:
Because brain death is an irreversible coma, one of three conclusions must be drawn: 1) Jahi was never dead; 2) Jahi met the criteria for brain death, but she isn't dead now; or 3) Jahi's movements are not purposeful responses, and she has been brain dead since 2013. The possibility that a person who was declared brain dead is now following commands threatens to erode the notion that brain death should be considered legal death. The discordant ideas that Jahi is brain dead and is following commands can only be reconciled if a formal evaluation for determination of death is repeated by reputable examiners.
In early 2017, Nevada amended its Uniform Determination of Death Act (UDDA), in order to clarify the neurologic criteria for the determination of death. The amendments stipulate that a determination of death is a clinical decision that does not require familial consent and that the appropriate standard for determining neurologic death is the American Academy of Neurology’s (AAN) guidelines. Once a physician makes such a determination of death, the Nevada amendments require the withdrawal of life-sustaining treatment within twenty-four hours with limited exceptions. Neurologists have generally supported Nevada’s amendments for clarifying the diagnostic standard and limiting the ability of family members to challenge it. However, it is more appropriate to view the Nevada amendments with concern. Even though the primary purpose of the UDDA is to ensure that all functions of a person’s entire brain have ceased, the AAN guidelines do not accurately assess this. In addition, by characterizing the determination of death as solely a clinical decision, the Nevada legislature has improperly ignored the doctrine of informed consent, as well as the beliefs of particular faiths and cultures that reject brain death. Rather than resolving controversies regarding brain death determinations, the Nevada amendments may instead instigate numerous constitutional challenges.
In response to a number of recent lawsuits related to brain death determination, the American Academy of Neurology Ethics, Law, and Humanities Committee convened a multisociety quality improvement summit in October 2016 to address, and potentially correct, aspects of brain death determination within the purview of medical practice that may have contributed to these lawsuits. This article, which has been endorsed by multiple societies that are stakeholders in brain death determination, summarizes the discussion at this summit, wherein we (1) reaffirmed the validity of determination of death by neurologic criteria and the use of the American Academy of Neurology practice guideline to determine brain death in adults; (2) discussed the development of systems to ensure that brain death determination is consistent and accurate; (3) reviewed strategies to respond to objections to determination of death by neurologic criteria; and (4) outlined goals to improve public trust in brain death determination.
A 2-year-old boy with severe head trauma was diagnosed brain dead according to the 2011 Pediatric Guidelines. Computed tomographic (CT) scan showed massive cerebral edema with herniation. Intracranial pressures were extremely high, with cerebral perfusion pressures around 0 for several hours. An apnea test was initially contraindicated; later, one had to be terminated due to oxygen desaturation when the Pco2 had risen to 57.9 mm Hg. An electroencephalogram (EEG) was probably isoelectric but formally interpreted as equivocal. Tc-99m diethylene-triamine-pentaacetate (DTPA) scintigraphy showed no intracranial blood flow, so brain death was declared. Parents declined organ donation. A few minutes after withdrawal of support, the boy began to breathe spontaneously, so the ventilator was immediately reconnected and the death declaration rescinded. Two hours later, life support was again removed, this time for prognostic reasons; he did not breathe, and death was declared on circulatory-respiratory grounds. Implications regarding the specificity of the guidelines are discussed.
The definition and criterion of death have been rendered ambiguous by developments in organ support technology, particularly the positive-pressure ventilator and vasopressor medications, that uncouple the unitary loss of vital functions in death and create cases in which the brain has been destroyed while circulation and ventilation can be supported. Developing a biophilosophic analysis of the meaning of death before physicians can declare it requires four sequential steps: (1) agreement on the paradigm conditions that frame the analysis and clarify the task; (2) identifying the definition of death, which makes explicit the meaning of death that is accepted in our consensual usage of the term but that has become obscured by technology; (3) identifying the criterion of death that shows that the definition has been fulfilled, and that can be incorporated into a death statute; and (4) devising bedside tests of death for physicians to perform to satisfy the criterion. Although there is a strong consensus on death determination medical standards in countries around the world that has been enshrined into laws, and accepted by most societies and religions, there remains an active dispute among scholars on the precise definition and criterion of death.
1. Postmortem examinations were made on 240 of the 459 cases succumbing 52 percent of the deaths in the Collaborative Study on Cerebral Survival; the central nervous system was examined in 226 cases.
2. The autopsy was performed on an average of 15.3 hours after death.
3. The mean weight of the brains was 1450 +/- 196 grams; the mean weight of the brains of patients on whom resuscitation was stopped, presumably on the basis of "cerebral death," was greater than that of the patients succumbing to cardiac failure. There was a tendency for the brain to increase in weight about 24 hours after the initiation of resuscitative measures. At that time, swelling, discoloration, softening, congestion, and brain herniations also became more prominent.
4. On the basis of a survey of American neuropathologists and the data from this study, the entity commonly termed "respirator brain" may be confirmed.
This is a dynamic process that is complicated by concurrent postmortem changes. The respirator brain requires time approximately 24 hours for maturation; many patients die a cardiac death during the metamorphosis. If the patient survives for 3 to 4 days, the percentage dying with typical respirator brains is less, and more patients have electroencephalograms with biological activity.
(C) 1975 American Association of Neuropathologists, Inc
To review and revise the 1987 pediatric brain death guidelines.
Relevant literature was reviewed. Recommendations were developed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system.
(1) Determination of brain death in term newborns, infants, and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma. Because of insufficient data in the literature, recommendations for preterm infants <37 weeks gestational age are not included in these guidelines. (2) Hypotension, hypothermia, and metabolic disturbances should be treated and corrected, and medications that can interfere with the neurologic examination and apnea testing should be discontinued allowing for adequate clearance before proceeding with these evaluations. (3) Two examinations including apnea testing with each examination separated by an observation period are required. Examinations should be performed by different attending physicians. Apnea testing may be performed by the same physician. An observation period of 24 hours for term newborns (37 weeks gestational age) to 30 days of age and 12 hours for infants and children (>30 days to 18 years) is recommended. The first examination determines the child has met the accepted neurologic examination criteria for brain death. The second examination confirms brain death based on an unchanged and irreversible condition. Assessment of neurologic function after cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for 24 hours or longer if there are concerns or inconsistencies in the examination. (4) Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial PaCO(2) 20mmHg above the baseline and ≥60mmHg with no respiratory effort during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed. (5) Ancillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination. Ancillary studies may be used to assist the clinician in making the diagnosis of brain death (a) when components of the examination or apnea testing cannot be completed safely due to the underlying medical condition of the patient; (b) if there is uncertainty about the results of the neurologic examination; (c) if a medication effect may be present; or (d) to reduce the interexamination observation period. When ancillary studies are used, a second clinical examination and apnea test should be performed, and components that can be completed must remain consistent with brain death. In this instance, the observation interval may be shortened, and the second neurologic examination and apnea test (or all components that are able to be completed safely) can be performed at any time thereafter. (6) Death is declared when these above criteria are fulfilled.
To elucidate the time course of neuronal cell death after the clinical criteria for brain death are met, the authors reviewed serial changes of serum neuron-specific enolase levels in 3 children (age range, 3-15 years) clinically diagnosed as brain dead due to cardiopulmonary arrest. All patients survived for more than 2 months after brain death. Children with brain death had higher peak neuron-specific enolase values (1069-2849 ng/mL) than did 3 control children (256-1800 ng/mL) who did not become brain dead but had poor neurological outcome (1 death, 2 vegetative state) after cardiopulmonary arrest. A major finding is that children with brain death showed persistent elevation of neuron-specific enolase at 4 weeks (>400 ng/mL) and 8 weeks (>50 ng/mL) after cardiopulmonary arrest, in comparison with 2 surviving patients without brain death (<50 ng/mL at 4 weeks). This prolonged elevation of neuron-specific enolase suggests that total brain necrosis might not be present at the time of clinical diagnosis of brain death.
The determination of brain death is based on a comprehensive clinical assessment. A confirmatory test-at least, in adult patients in the United States-is not mandatory, but it typically is used as a safeguard or added when findings on clinical examination are unwontedly incomplete. In other countries, confirmatory tests are mandatory; in many, they are optional. These tests can be divided into those that test the brain's electrical function and those that test cerebral blood flow. A false-positive result (i.e., the test result suggests brain death, but clinically the patient does not meet the criteria) is not common but has been described for tests frequently used to determine brain death. A false-negative result (i.e., the test result suggests intact brain function, but clinically the patient meets the criteria) in one test may result in more confirmatory tests and no resolution when the test results diverge. Also, pathologic studies have shown that considerable areas of viable brain tissue may remain in patients who meet the clinical criteria of brain death, a fact that makes these tests less diagnostic. Confirmatory tests are residua from earlier days of refining comatose states. A comprehensive clinical examination, when performed by skilled examiners, should have perfect diagnostic accuracy.
To provide an update of the 1995 American Academy of Neurology guideline with regard to the following questions: Are there patients who fulfill the clinical criteria of brain death who recover neurologic function? What is an adequate observation period to ensure that cessation of neurologic function is permanent? Are complex motor movements that falsely suggest retained brain function sometimes observed in brain death? What is the comparative safety of techniques for determining apnea? Are there new ancillary tests that accurately identify patients with brain death?
A systematic literature search was conducted and included a review of MEDLINE and EMBASE from January 1996 to May 2009. Studies were limited to adults.
In adults, there are no published reports of recovery of neurologic function after a diagnosis of brain death using the criteria reviewed in the 1995 American Academy of Neurology practice parameter. Complex-spontaneous motor movements and false-positive triggering of the ventilator may occur in patients who are brain dead. There is insufficient evidence to determine the minimally acceptable observation period to ensure that neurologic functions have ceased irreversibly. Apneic oxygenation diffusion to determine apnea is safe, but there is insufficient evidence to determine the comparative safety of techniques used for apnea testing. There is insufficient evidence to determine if newer ancillary tests accurately confirm the cessation of function of the entire brain.
A spectrum of descriptive definitions of death has been formulated based on a variety of observations using currently available clinical methods. These definitions vary widely in objectivity and some fail to distinguish the inevitability of death or irreversible coma from the fact of death. A hopeless prognosis may be an adequate criterion for termination of artificial resuscitation, but the bioethical issue involved is one of “passive” euthanasia and not brain death. A hopeless prognosis without a pronouncement of death itself would seem inadequate grounds to remove viable organs for transplantation.
When organ donation is contemplated, the declaration of death as a past event must be based on cerebral rather than on cardiovascular criteria. At this point in the history of the art and science of medicine, the highest degree of assurance that the brain is dead may be achieved in the shortest possible time, only by using multiple independently measured variables including clinical criteria, electrophysiologic criteria (the EEG), and assessment of cerebral circulation determined either directly or indirectly. As science and technology improve, the degree of objectivity and facility in obtaining objective criteria will also improve.
The permanent cessation of functioning of the organism as a whole is the definition underlying the traditional understanding of death. We suggest the total and irreversible loss of functioning of the whole brain as the sole criterion of death; this has always been an implicit criterion of death. If artificial ventilation is present, only completely validated brain dysfunction tests should be used to show that this criterion of death is satisfied. In most cases without artificial ventilation, permanent loss of cardiopulmonary function is sufficient. We propose a statutory definition of death based on the criterion of total and irreversible cessation of whole brain functions but allowing physicians to declare death according to their customary practices in most cases.
One rationale for equating "brain death" (BD) with death is that it reduces the body to a mere collection of organs, as evidenced by purported imminence of asystole despite maximal therapy. To test this hypothesis, cases of prolonged survival were collected and examined for factors influencing survival capacity.
Formal diagnosis of BD with survival of 1 week or longer. More than 12,200 sources yielded approximately 175 cases meeting selection criteria; 56 had sufficient information for meta-analysis. Diagnosis was judged reliable if standard criteria were described or physicians made formal declarations. Data were analyzed by means of Kaplan-Meier curves, with treatment withdrawals as "censored" data, compared by log-rank test.
Survival probability over time decreased exponentially in two phases, with initial half-life of 2 to 3 months, followed at 1 year by slow decline to more than 14 years. Survival capacity correlated inversely with age. Independently, primary brain pathology was associated with longer survival than were multisystem etiologies. Initial hemodynamic instability tended to resolve gradually; some patients were successfully discharged on ventilators to nursing facilities or even to their homes.
The tendency to asystole in BD can be transient and is attributable more to systemic factors than to absence of brain function per se. If BD is to be equated with death, it must be on some basis more plausible than loss of somatic integrative unity.
The mainstream rationale for equating "brain death" (BD) with death is that the brain confers integrative unity upon the body, transforming it from a mere collection of organs and tissues to an "organism as a whole." In support of this conclusion, the impressive list of the brain's myriad integrative functions is often cited. Upon closer examination, and after operational definition of terms, however, one discovers that most integrative functions of the brain are actually not somatically integrating, and, conversely, most integrative functions of the body are not brain-mediated. With respect to organism-level vitality, the brain's role is more modulatory than constitutive, enhancing the quality and survival potential of a presupposedly living organism. Integrative unity of a complex organism is an inherently nonlocalizable, holistic feature involving the mutual interaction among all the parts, not a top-down coordination imposed by one part upon a passive multiplicity of other parts. Loss of somatic integrative unity is not a physiologically tenable rationale for equating BD with death of the organism as a whole.
To establish consensus recommendations among health care specialties for defining and establishing diagnostic criteria for the minimally conscious state (MCS).
There is a subgroup of patients with severe alteration in consciousness who do not meet diagnostic criteria for coma or the vegetative state (VS). These patients demonstrate inconsistent but discernible evidence of consciousness. It is important to distinguish patients in MCS from those in coma and VS because preliminary findings suggest that there are meaningful differences in outcome.
An evidence-based literature review of disorders of consciousness was completed to define MCS, develop diagnostic criteria for entry into MCS, and identify markers for emergence to higher levels of cognitive function.
There were insufficient data to establish evidence-based guidelines for diagnosis, prognosis, and management of MCS. Therefore, a consensus-based case definition with behaviorally referenced diagnostic criteria was formulated to facilitate future empirical investigation.
MCS is characterized by inconsistent but clearly discernible behavioral evidence of consciousness and can be distinguished from coma and VS by documenting the presence of specific behavioral features not found in either of these conditions. Patients may evolve to MCS from coma or VS after acute brain injury. MCS may also result from degenerative or congenital nervous system disorders. This condition is often transient but may also exist as a permanent outcome. Defining MCS should promote further research on its epidemiology, neuropathology, natural history, and management.
Disorders of consciousness continue to be the subject of hot debate in healthcare settings, research consortiums, bioethics departments and media forums. There are no standards of care to guide assessment and treatment decisions resulting in wide disparities in daily practice. In response to this problem, expert panels in neurology and neurorehabilitation were convened and charged with developing consensus-based definitions and diagnostic criteria for disorders of consciousness. The Multi-Society Task Force Report on the persistent vegetative state and the Aspen Workgroup statement on the minimally conscious state represent two such initiatives. This paper summarizes the practice recommendations proposed by these groups and discusses their implications for existing and future interventions.
Autopsy studies in patients who have been declared brain dead are rare. Total brain necrosis ("respirator brain") has been a common finding in the distant past. The time to brain fixation has been shortened as a result of timely organ transplant protocols, therefore the neuropathologic findings may be different than previously described.
We reviewed macroscopic and microscopic brain pathology for ischemic neuronal damage in 41 patients who fulfilled the clinical criteria of brain death. Hematoxylin and eosin stained brain tissue slides were retrieved and available wet tissue was additionally stained to complete a series of samples of the hemispheres, brainstem, and cerebellum for each patient. Neuronal ischemic change was semiquantitatively graded for severity (mild 0 to 5%, moderate >5 to 75%, and severe >75%).
After the clinical diagnosis of brain death and terminal cardiac arrest, 12 brains were fixated in less than 12 hours and 29 brains were fixated between 12 and 36 hours. The frontal lobe, temporal lobe, parietal lobe, occipital lobe, and basal ganglia showed moderate to severe ischemic change in 53 to 68% of the cases. Moderate to severe neuronal ischemic change was found in the thalamus in 34%, midbrain in 37%, pons in 41%, medulla in 40%, and cerebellum in 52% of the cases.
No distinctive neuropathologic features were apparent in our series of patients with brain death. Neuronal ischemic changes were frequently profound, but mild changes were present in a third of the examined hemispheres and in half of the brainstems. Respirator brain with extensive ischemic neuronal loss and tissue fragmentation was not observed. Neuropathologic examination is therefore not diagnostic of brain death.
FCCM in support of defendants’ motion for summary adjudication of plaintiff Jahi McMath’s first cause of action for personal injuries
- T A Nakagawa
- Declaration
- A Thomas
- M D Nakagawa
- Faap
Nakagawa TA. Declaration of Thomas A. Nakagawa, M.D., FAAP, FCCM
in support of defendants' motion for summary adjudication of plaintiff
Jahi McMath's first cause of action for personal injuries. Superior Court of
California, Alameda County, R-1838158; 2017.
Reconstructing medical ethics at the end of life
- F G Miller
- R D Truog
- FG Miller
Miller FG, Truog RD. Death, dying, and organ transplantation. Reconstructing medical ethics at the end of life. New York: Oxford University
Press; 2012.
Jahi McMath, whose 2013 declaration of brain death sparked a legal fight to keep her on life support, dies
- A Tchekmedyian
Tchekmedyian A. 'A girl with a brain injury. ' Jahi McMath, whose 2013 declaration of brain death sparked a legal fight to keep her on life support,
dies. Los Angeles Times, 2018; B1-B2.
A girl with a brain injury.’ Jahi McMath, whose 2013 declaration of brain death sparked a legal fight to keep her on life support, dies
- A Tchekmedyian
Refinements in the definition and criterion of death
- JL Bernat
- SJ Youngner
- RM Arnold
- R Schapiro