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Multiprofessional Critical Care Review: Adult 2024 ...
6: Death by Neurologic Criteria (Andrew M. Nadiech ...
6: Death by Neurologic Criteria (Andrew M. Nadiech, MD, MS)
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Video Transcription
Hello, and welcome to today's course. This lecture is on death by neurological criteria with me, Andrew Dadek. As disclosures, I do have some grant funding from Health and Human Services. The term brain death has often been used colloquially since we started talking about death by neurological criteria in the 1960s. However, brain death may give a sense of differing meaning to some families. Because brain modifies death, maybe the patient isn't completely dead and implies that the injury might somehow be survivable. Most intensivists and neurologists now use the term death by neurological criteria, making it clear that the patient has, in fact, legally died, but that the criteria are neurological ones, not necessarily cardiovascular ones. You should be familiar with the terms donation after determination of death by neurological criteria and donation after determination of circulatory death, often in non-perfusing rhythm. The history of the neurological criteria for death comes out of the need for organs during organ transplantation, and the original documentation is quite clear about this. Many of the ethical problems associated hinge on the appropriate definition, and so keeping the definition of death by neurological criteria clear is crucial to be up front, to be ethical, and to be sure that everyone is aware of the process. There is variability in the practices for declaring death by neurological criteria throughout the United States. Most places require appropriate medical staff to do so, some require a nervous system specialist like a neurologist or a neurosurgeon, or some with additional qualification like an intensivist who's had additional training in the examination. A variety of protocols show what is required to do the determination. Established cause, absence of potentially confounding drugs, absence of hypertension are commonly used criteria. These have been recently codified in new criteria for the determination of neurological death, which we'll describe. You must never get the diagnosis of death by neurological criteria wrong, because if you do, someone will say you hastened the death of a patient who could have recovered if you had taken your time to do so. Death by neurological criteria excludes minimally conscious state and excludes potential recovery. The determination of neurological death by neurological criteria is irreversible. This is a typical one of a number of press releases of a lawsuit of parents of an 18-year-old, say doctors intentionally hustled up the determination of neurological death in order to get his organs. Whether this is true or not in this case is not for discussion today, but simply to show that it must always be crystal clear and wherever possible, the patient's family should agree. In the examination for death by neurological criteria, we perform an examination that is typically reflexes that do not require active participation from the patient. You'll note this is essentially a brainstem exam, pupils, corneals, facial pain, the doll's eye response, colds, calorics, a gag, a cough, and central motor responses to pain as opposed to peripheral. Thank you. It's important to be clear and consistent that there is nothing to hide in the evaluation of death by neurological criteria. This is a standard part of medical care. In a randomized controlled trial, families were assigned to an intervention group to be present during the evaluation or absent. Baseline understanding of death by neurological criteria was similar between the two groups. In the intervention group that was present, scores increased, and they were more likely to have perfect post-intervention understanding scores of the process for death by neurological criteria. The impact of the event and general health were not different at follow-up. This goes along with the idea that we want to be open and honest with families when we are doing death by neurological criteria evaluations, and if anything, it will help patients' families understand what's happened. Recently, the criteria for death by neurologic criteria have been updated. New updates include, there must be a mechanism for brain death. There is an odd case report of a patient that had a paralytic drip mistakenly unlabeled in the operating room and appeared to be brain death until it wore off, but with no criteria for brain death was not so declared. And a very severe case of the Miller-Fisher variant of Guillain-Barre involving cranial nerves where the patient had a brain death exam, but no good reason for brain death. The new criteria ensure there must be a good reason for brain death, such as an intracranial catastrophe, herniation, or hemorrhage. Updates include observing the patient for 24 hours after hypoxia ischemia, say after cardiac arrest, and rewarming to 36 centigrade if that has in fact occurred. There must be, quote, unquote, sufficient time for other conditions to be evaluated, not clearly specified. The brain injury must be judged to be permanent, systolic pressure should be at least 100, or for patients on ECMO, the mean arterial pressure at least 75. There should be therapeutic levels, perhaps negative toxurine if clinically indicated, and if phenobarbital has been used, a phenobarbital level less than five. The ancillary tests have also recently been changed. You only need ancillary tests if you cannot do the exam and an apnea challenge. In most hospital policies, and hospital policies govern the criteria for neurological death, an examination, a good reason, and the apnea challenge are all that is required. If you cannot complete these for some reason, say the patient has acute respiratory distress syndrome and would not tolerate an apnea challenge, then you must do an ancillary test. In the past, electroencephalography, evoked potentials, CT angio and MR angio have been acceptable. However, the new 2023 revision excludes these and now restricts ancillary tests, mostly to blood vessel imaging studies that show lack of blood flow into the brain. Digital subtraction angiography showing no intracranial flow, transcranial Doppler showing a water hammer pulse, no auto-regulation, and no consistent forward flow, and radionuclide scanning showing no intracranial flow are all acceptable ancillary tests. EEG, MR angio, and CT angio are no longer considered acceptable ancillary tests. No lecture would be clear or complete without mentioning the extraordinary case of John a 13-year-old girl in California who had a cardiac arrest during a tonsillectomy. She was pronounced brain dead after meeting the appropriate criteria by competent neurologists and having an isoelectric EEG. Because of the extraordinary case, the family received an exemption from the traditional death by neurologic criteria in California and transferred the patient to New Jersey. There she was supported for another four and a half years until she died of another apparent cardiac arrest. Her MRI is on the right side of the screen, and there were some intact brain stem structures even though the patient met the criteria for death by neurologic criteria with a lack of brain stem reflexes at the time of the evaluation. Death by neurologic criteria means a permanent loss of brain function or an irreversible neurological catastrophe and an apnea challenge showing no spontaneous respiratory effort in a hemodynamically stable patient. It does not mean the loss of every neuron. It does not mean the loss of spinal cord reflexes, and it does not mean there is no nervous system tissue left. Be very open and honest with families about the potential for the diagnosis, how it is arrived, and perhaps consider inviting them to watch the evaluation. Be sure the communications are predictable and clear for this very sensitive case of intensive care medicine.
Video Summary
The lecture focuses on death by neurological criteria, emphasizing the usage of clear terminology to indicate legal death based on neurological, not cardiovascular criteria. Various protocols and criteria are established to ensure accurate determination, avoiding ethical dilemmas. A comprehensive examination, ancillary tests if necessary, and patient observation are key components. Recent updates stress the importance of a valid reason for brain death, specific hemodynamic parameters, and limited ancillary test options. The impact on families during the evaluation process is highlighted, promoting transparency and understanding. The case study of a teenage girl with a unique exemption from traditional criteria underscores the complexity and importance of clear communication in such situations.
Keywords
brain death
neurological criteria
death determination
organ transplantation
healthcare practitioners
ancillary tests
education and training
legal death
protocols
ethics
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