Article of the month

 2020 Aug 3.
 doi: 10.1001/jama.2020.11586. Online ahead of print.

Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project

David M Greer 1Sam D Shemie 2 3Ariane Lewis 4Sylvia Torrance 3Panayiotis Varelas 5Fernando D Goldenberg 6James L Bernat 7Michael Souter 8Mehmet Akif Topcuoglu 9Anne W Alexandrov 10Marie Baldisseri 11Thomas Bleck 12Giuseppe Citerio 13Rosanne Dawson 3Arnold Hoppe 14Stephen Jacobe 15Alex Manara 16Thomas A Nakagawa 17Thaddeus Mason Pope 18William Silvester 19David Thomson 20Hussain Al Rahma 21Rafael Badenes 22Andrew J Baker 23Vladimir Cerny 24Cherylee Chang 25Tiffany R Chang 26Elena Gnedovskaya 27Moon-Ku Han 28Stephen Honeybul 29Edgar Jimenez 30Yasuhiro Kuroda 31Gang Liu 32Uzzwal Kumar Mallick 33Victoria Marquevich 34Jorge Mejia-Mantilla 35Michael Piradov 27Sarah Quayyum 36Gentle Sunder Shrestha 37Ying-Ying Su 32Shelly D Timmons 38Jeanne Teitelbaum 39Walter Videtta 40Kapil Zirpe 41Gene Sung 42

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

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

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

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

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

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