AAN Panel Reaffirms Brain-Death Criteria
An expert panel of the American Academy of Neurology (AAN), the flagship organization of US neurologists, confirms the 1995 criteria for establishing brain death and has little to add on the basis of the interim literature. The panel’s assessment is available in the latest issue of Neurology.
Among the findings:
- There have been no published reports of neurologic recovery once brain death has been diagnosed by using the 1995 criteria.
- There is insufficient evidence to define a minimal observation period for diagnosing brain death, once brain function has ceased.
- Complex, spontaneous movements, like facial myokymia, and ventilator triggering can be seen in brain death.
- The various tests for determining apnea have not been compared—so one test has not been shown to be preferable.
- Data supporting the use of newer ancillary tests, like MR angiography, to confirm brain death are not sufficiently compelling.
The steps to determining brain death include the prerequisites (eg, excluding the use of CNS depressants and neuromuscular blockers, establishing a normal core body temperature and blood pressure), the clinical evaluation (eg, documenting a lack of responsiveness, assessing brainstem reflexes, performing an apnea test), and ancillary tests (eg, performing an EEG or imaging study). A useful appendix checklist is provided in the article.
In addition, the AAN web site provides a Q&A with one of the panel members, Eelco Wijdicks of the Mayo Clinic, regarding the reassessment of brain-death criteria. In addition to discussing clinical and other parameters, Dr. Wijdicks provides all-important guidance for communicating the diagnosis of brain death to the victim’s family. (In my experience, a particularly difficult concept for many family members to understand is the idea that brain death equals death, both functionally and legally. Conveying this information firmly and compassionately can be a challenge.)
After the diagnosis of brain death is made, the attending physician should meet with the family, accompanied by nursing staff and, often, hospital clergy. Considerable time for conversation and a quiet place to sit are needed. The family members are told that their loved one has passed on and that the medical staff deeply regrets the loss. The family members will have ample time to say their good-byes. The medical staff will be available for support. The family, however, will have to make a decision about possible organ donation and is invited to speak with an organ donation agency. The medical staff is keeping the rest of the organs working with medication and the mechanical ventilator, and if there is no wish for organ donation, the staff will stop the ventilator and other treatments.