G Matis, O Chrysou, D Silva, T Birblis
G Matis, O Chrysou, D Silva, T Birblis. Brain Death: History, Updated Guidelines And Unanswered Questions. The Internet Journal of Neurosurgery. 2012 Volume 8 Number 1.
In 1959, Mollaret & Goulon, two French neurophysiologists, added a new figure of what they called
In 1968, the Harvard Ad Hoc Committee on Brain Death published a report describing the characteristics of a permanently nonfunctioning brain, a condition it referred to as
In 1976, the Conference of Medical Royal Colleges of the United Kingdom described the following criteria:
In 1980, the President’s Commission for the Study of Ethical Problems in Medicine determined brain death as follows:
In 1995, the Quality Standards Subcommittee of the American Academy of Neurology published a report on the practice parameters for determining brain death in adults. It concluded that
In 1999, the Canadian Neurocritical Care Group published its own guidelines for the diagnosis of brain death. According to them, no testing of oculocephalic reflex was needed, the core temperature could be as low as 32.2oC during the apnea test, and the interval between exams as short as 2 hours .
So, many guidelines were issued in the past. But did we achieve a global consensus in diagnostic criteria? According to Wijdicks  no! The author reviewed the guidelines of 80 countries. Legal standards on organ transplantation were found in 55 of 80 countries and practice guidelines for brain death for adults in 88%. He concluded that “
In 2010, 15 years after its first report, the Quality Standards Subcommittee of the American Academy of Neurology issued an evidence-based guideline update . This new report addressed 5 questions:
One year later, 2011, the Society of Critical Care Medicine, Section on Critical Care and Section on Neurology of the American Academy of Pediatrics, and the Child Neurology Society issued an update of the 1987 Task Force recommendations concerning the guidelines for the determination of brain death in infants and children . The recommendations provided are the following:
And which areas should future research concentrate on? For adults, the safety of the apnea test (along with alternative methods of apnea testing) should be assessed. An audit of adequate documentation, and a study of the competence of examiners is also necessary. Details of the neurologic examination may be subjected to an expert panel review, possibly including international organizations .
For children, studies comparing traditional ancillary studies to newer methods to assess cerebral blood flow and neurophysiologic function should be pursued. Hypothermia may alter the natural progression of brain death and its impact should be reviewed. Cooperation with national medical societies to achieve a uniform approach to declaring death that can be incorporated in all hospital policies should be a new goal. Finally, additional studies are required to determine if a single neurologic examination is sufficient for neonates, infants, and children to determine brain death as currently recommended for adults >18 years of age .
OK. Now we have our new updated guidelines. But does really brain death mean that the patient is dead? This must be clarified because it is the declaration of death that permits organ donation/transplantation… Truog & Robinson (2003) among other researchers put into question the so far accepted belief that brain death corresponds to the biological and philosophical understanding of death . For example, many patients diagnosed as brain dead retain function of the posterior pituitary. Additionally, sticking to the current belief would mean that patients in a permanent vegetative state should also be considered dead. Going one step further, the authors proposed that
To end with, guidelines are useful for a uniform declaration of brain death not only in the adult but also in the pediatric patients. Yet, the right question to ask is “is the patient brain dead” or “is the patient dead”? There are no easy answers. A consensus involving physicians, patients and community is imperative and urgently needed. By no means can the answer be separated from the way that our society deals with these matters of life (organ transplantation) and death. Physicians are only responsible for ensuring respect to patients and nonmaleficence. They are surely “