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Correspondence: When an article is eligible for submission of Correspondence, a link to the response form is available within the full-text article. You must be a current subscriber who has activated the online portion of your subscription in order to send a Correspondence. Any reader can read published Correspondence.
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Correspondence:Correspondence published:
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Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria
- Sung-Tsang Hsieh (25 May 2006)
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Reply from the author
- Eelco F.M Wijdicks (25 May 2006)
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Reply to Letter to the Editor
- Eelco F Wijdicks (20 June 2002)
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Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria
- Calixto Machado (20 June 2002)
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Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria
- Ljiljana Beslac-Bumbasirevic, Dejana Jovanovic and Marko Ercegovac (30 April 2002)
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Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria
- Gustavo Saposnik (30 April 2002)
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Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria
- Claudio Crisci, Fondazione S. Maugeri (30 April 2002)
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Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria
- Jeffrey M Burns, Ivan S. Login (30 April 2002)
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Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria
- Michiko Kimura Bruno, Jun Kimura (30 April 2002)
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Reply to Letters to the Editor
- Eelco F Wijdicks (30 April 2002)
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Sung-Tsang Hsieh, National Taiwan University Hospital, Taipei 7 Chung-Shan South Road, Department of Neurology, Taipei, 100 Taiwan
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sthsieh{at}ntu.edu Sung-Tsang Hsieh
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I recently read the article by Dr. Wijdicks who comprehensively reviewed brain death status and guidelines worldwide. [1] Unfortunately, Table 1A provides mistaken information about the guidelines in Taiwan due to the incorrect extraction of the data from the cited article of Hung and Chen. [2] The following should be corrected: 1. The law regulating Brain Death was passed by Taiwan government in 1987. Thus the Law is present instead of "absent" as summarized in the Table. 2. The number of physicians is two instead of one. 3. The observation time is 12 hours instead of 6 hours. 4. The law requires another 4 hours for defining brain death, and thus a confirmatory test is mandatory. I hope Neurology can provide corrected information to the readers. References 1. Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria. Neurology 2002;58:20-25. 2. Hung TP, Chen ST. Prognosis of deeply comatose patients on ventilators. J Neurol Neurosurg Psychiatry 1995;58:75-80. Disclosure: The author reports no conflicts of interest. |
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Eelco F.M Wijdicks, Mayo Clinic, Neurology, 200 First Street SW, Rochester, MN 55905
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wijde{at}mayo.edu Eelco F.M Wijdicks
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I appreciate the comments by Dr. Hsieh and I apologize if I misread the legal document. The Chinese version of the legal document available to me states that two physicians are needed and in Taiwan an additional 4 hours of observation is needed after the diagnosis of brain death is made. This is in addition to the 12 hours of observation on the ventilator of a patient with a structural brain lesion before the first full brain death examination. In my article [1], I referred to laboratory tests as confirmatory tests and it is my understanding that laboratory tests remain optional and not mandatory. Since my article was published in 2002, I have also noticed--in conversations with physicians from other countries--that there is sometimes confusion between what physicians think they should do and what the law dictates. Disclosure: The author reports no conflicts of interest. |
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Eelco F Wijdicks Mayo Clinic Rochester MN
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wijde{at}mayo.edu Eelco F Wijdicks
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As a consequence of his international meetings in Cuba Dr Machado has stimulated critical thinking about Brain Death and I value his additional comments. It is distressing that a double standard exist in countries that only allow the diagnosis of death by neurologic criteria after consent for organ recovery. |
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Calixto Machado Institute of Neurology and Neurosurgery Ciudad de LA Habana Cuba
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braind{at}infomed.sld.cu Calixto Machado
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Dr. Wijdicks published relevant worldwide differences on brain death (BD) determination among countries and states. [1] I have had the personal experience of discovering such differences on BD guidelines by organizing the First, Second and Third International Symposia on Coma and Death, held in Havana in 1992, 1996 and 2000. [2] It is important to notice that although several countries have developed BD guidelines or codes of practice, they are lacking of an ordered formulation of three distinct elements; the definition of death, the anatomic-physiological substratum (criterion), and the tests to prove that the criterion has been satisfied. [3] Hence, although these countries determine death on BD standards, they don't have a clear definition of death on neurological grounds. This issue explains many controversies in the actual discussions on human death. [2, 3] I agree with Dr. Wijdicks that confirmatory tests are not required in many developing countries. [1] Nonetheless, during the Havana Symposia sessions most colleagues from developing countries expressed that they would prefer to include in their BD protocols confirmatory laboratory tests. But if confirmatory laboratory tests were included as mandatory in BD guidelines, and "these technologic devices were not available on a timely basis," [1] the diagnosis of BD would be excluded in many cases. In Cuba, we have defended the use of such confirmatory laboratory tests that could be performed at bedside, as a neurophysiologic test battery, conformed by multimodality evoked potentials (MEP) and electroretinography (ERG), and transcranial Doppler. We have suggested the use a MEP and ERG as robust ancillary tests to shorten the observation time. [2] Another issue to discuss is the legal standards on this issue. Most countries include legal standards to diagnose BD in laws regulating organ transplantation. Although it is impossible to deny the tie relationship between BD and organ transplantation, there is a considerable amount of brain-dead cases not useful as organ donors, whoare usually kept under life support until cardiac arrest occurs. [2, 3, 4] Hence, these patients are diagnosed dead on neurological grounds, only if they are useful as organ donors. [2] Cuba recently passed a law completely separated from any other code related to organ transplantation. [4] Moreover, we included in this legal standard other procedures to diagnose death, based on the absence of cardio-respiratory functions (patients outside the intensive care environment) and cadaver signs (forensic medicine). It doesn't mean that we accept different kinds of death. Absent cardio-respiratory functions can only produce death when ischemia and anoxia are long enough to produce irreversible damage of the brain. [5] References: 1) Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria. Neurology 2002;58:20-25. 2) Machado C. ed. Brain Death (Proceedings of the Second International Symposium on Brain Death). Amsterdam, Elsevier Science, BV, 1995. 3) Bernat JL. A defense of the whole-brain concept of death. Hastings Cent Rep 1998;28:14-23. 4) Edicion Ordinaria del 21 de Septiembre del 2001. 9-21-2001. La Habana, Ministerio de Justicia. Gaceta Oficial de la Republica de Cuba. Resolucion No. 90 de Salud Publica. 5) Machado C. Is the concept of brain death secure? In Zeman A, Emanuel L. eds. Ethical Dilemmas in Neurology, vol. 36. London, W B Saunders Company, 2000:193-212. |
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Ljiljana Beslac-Bumbasirevic Clinical Center of Serbia Yugoslavia, Dejana Jovanovic and Marko Ercegovac
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vbumbasi{at}afrodita.rcub.bg.ac.yu Ljiljana Beslac-Bumbasirevic, et al.
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The concept and clinical criteria of brain death are completely accepted in clinical practice, but there are still some differences concerning legislation of this kind of death. So, in his paper Wijdicks [1] shows that 68% of countries regulated this kind of death by law (86% by guidelines). He also indicates that there is significant difference concerning the time interval in which a patient is being monitored in order to confirm the irreversibility of this condition. This clearly indicates that the concept of irreversibility has not been defined and is therefore subject of many discussions and criticism by the opponents of the brain death concept. [2] Concerning Yugoslavia, the data stated in the paper [1] are not entirely accurate. The first law on organ transplantation was brought in 1980 in the former Yugoslavia, and the most recent in 1996 in Serbia. With this law the Parliament instructed the responsible ministry to adopt legal acts in order to regulate the problem of brain death. This act (1999) regulates medical criteria for diagnosis of brain death; it states that examination is done three times with interval of one hour, and that it is necessary to confirm death by electroencephalography, or by brain stem evoked potentials, or by Transcranial Doppler ultrasonography. [3] Three physicians (neurologist or neurosurgeon, internist and anesthesiologist) do the examination. Apnea is confirmed by the lack of spontaneous breathing three minutes after the respirator is turned off. The minister of health brought this and several earlier laws (1980, 1981, 1990, 1991). However, there is no law in Yugoslavia equalizing the concept of brain death with the traditional concept of cardiorespiratory death. In December 2000, the symposium on brain death was held at School of Medicine University of Belgrade. It is interesting that clinicians concluded that it was necessary to equate this concept of death with the traditional one, and not to recognize it only in the case of the potential organ donors, but the forensic medicine experts disagreed and thought that the nation wide debate should decide on these issues. At the request of medical profession, the Serbian Orthodox Church discussed the problem of transplantation (from alive person or dead body) and it stated that it has no reason to be against these procedures on condition that they are performed based on the modern scientific achievements and in honest and Christian way. References: 1. Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria. Neurology 2002; 58:20-25. 2. DuBois J. Non-heart-beating organ donation: A defense of the required determination of death. J Law Med Ethics 1999; 27:126-136. 3. Medical criteria on brain death for organ donors (Minister of Health). Sluzbeni Glasnik RS. 1999; 34:557. |
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Gustavo Saposnik Garrahan Hospital Buenos Aires Argentina
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gsaposnik{at}yahoo.com Gustavo Saposnik
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I read with great interest the excelent review of Wijdicks [1]. He summarized how the diagnosis of brain death (BD) is made in different countries, with a special reference to the apnea test (AT). The way the diagnosis of Brain death is made varies worldwide, the data are dispersed, and consequently, the information on the legal requirements or guidelines is difficult to obtain. Two major problems can be detected: a) the legal criteria can be modified from one year to another and the changes are not readily published in medical journals, thus limiting communication to the medical community, b) Clinical criteria o guidelines for the diagnosis of BD lack in several countries. One of the major concerns relates to the AT, an essential procedure to be performed according to the available criteria. The most widely used are the AAN guidelines [2], with or without the CO2 augmentation technique.
I would like to put forward some remarks. Table 1 shows that AT in Argentina is performed with "disconnection from ventilator" and not with PCO2 criteria [1]. The author quoted past regulations from 1977. Currently, the BD diagnosis follows a protocol similar to the AAN guidelines. It was reviewed and modified on March 20th, 1998 (Act 24.193). The AT is also performed following the recommendations of the AAN and our legal requirements. If respiratory movements are absent and the arterial pCO2 is >60 mmHg (or there is a 20 mmHg increase from normal pCO2 baseline) the apnea test result is positive (i.e., it supports the diagnosis of BD)[2]. As Wijdicks mentioned, the apnea test is an essential procedure to establish this diagnosis. However, only a few studies with a small number of patients have been performed to standardize this method. Pitfalls in performing the apnea test can be encountered in clinical practice.[3, 4,5] Any complication during this procedure may limit organ perfusion, the diagnosis of BD, and, subsequently, organ procurement for transplantation. Significant clinical complications can be found in one third of potential donors during or immediately after the AT [4]. The most frequent complications are acidosis and hypoxemia. Both are worsened by arterial hypotension. Since this prodedure is not innocuous, the AT should be performed according to the AAN recommendations in order to avoid clinical complications.[2,5] Prospective studies may help to establish risk factors for complications during this practice. Finally, I believe that an international consensus meeting with representatives from countries with an interest in this issue may help to solve several of the current controversies in brain death. References: 1- Wijdicks EFM. Brain Death worldwide. Neurology 2002; 58: 20-25. 2- Practice parameters for determining brain death in adults (summary statement). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1995;45:1012-1014. 3- Gad-Bar J, Yaron-Bar L, Zeev Z. Tension pneumothorax during apnea testing for the determination of brain death. Anesthesiology 1998; 89: 1250-1251. 4- Marks SJ, Zisfein J. Apneic oxygenation in apnea test for brain death. A controlled trial. Arch Neurol. 1990;47: 1066-1068. 5- Goudreau JL, Wijdicks EFM, Emery SF. Complications during apnea testing in the diagnosis of brain death: predisposing factors. Neurology 2000; 55: 1045-1048. |
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Claudio Crisci Telese Terme (Bn) Italy, Fondazione S. Maugeri
Send Correspondence to journal:
ccrisci{at}fsm.it Claudio Crisci, et al.
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Wijdicks review [1] on brain death certainly has the merit of trying to assess the actual situation on this difficult issue, and to point out the importance of a correct diagnosis of brain death, since some experts still doubt that brain death is equal to death, with really disturbing consequences [2] and confusion. Unfortunately this survey looses much of its value to me, since I found that the Italian situation reported in the table is completely wrong, as it refers to the old Italian law of 1975! A new law on Brain Death was formulated in 1993 [3] and completed in 1994 [4]; the National Law on Organ Donation was formulated in 1999. [5] In all these laws it is clearly stated that brain death must be declared by an "ad hoc" team of three physicians (not one as in the table): one forensic medicine specialist, one anesthesiologist and one board-certified neurophysiologist or one board-certified neurologist with special training in clinical neurophysiology. The observation time ranges from 6 to 24 hours depending on the age of the subject: 6 h for an adult, 12 h for a child under 5 years, 24 h for a child under 1 year, during which EEG, specific neurologic examination and apnea test are performed. Having been part of these teams for several years, I know that it is impossible in this way to declare anyone dead by mistake; actually it may be possible the opposite: to declare that someone may still be alive! Moreover, Italian law specifies that no member of the "ad hoc" team can be also in the transplant team and vice versa, to ensure the total autonomy of decisions. Italy has done a great effort in the last years to extend correct information on brain death and its diagnosis to improve organ donation and the results are really rewarding. I understand that Wijdicks survey is just an attempt to stimulate a worldwide consensus on standardization of procedures. However if Italian situation (easy to verify on Internet: see www.parlamento.it) is wrongly reported, I wonder in how many other countries there is a different reality from that one on the table. A more thorough, careful and updated evaluation of the real legal standards and practice guidelines would be probably necessary to have a clear and realistic picture of the worldwide situation and would lead to different comments and suggestions. References: (1)Wijdicks EFM: Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria. Neurology 2002; 58:20-25. (2) Shewmon DA. Chronic "brain death": Meta-analysis and conceptual consequences. Neurology 1998;51;1538-1545. (3) Legge 29 dicembre 1993, n.578: "Norme per l'accertamento e la certificazione di morte" (4) Ministero della Sanita' - Decreto 22 agosto 1994, n. 582: "Regolamento recante le modalita' per l'accertamento e la certificazione di morte". (5) Legge 1° aprile 1999, n. 91 "Disposizioni in materia di prelievi e di trapianti di organi e di tessuti". |
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Jeffrey M Burns University of Virginia Health Services, Ivan S. Login
Send Correspondence to journal:
jburns{at}virginia.edu Jeffrey M Burns, et al.
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While evaluating a hypothermic comatose patient recently we were surprised to learn of an inconsistency in the minimum body temperature requirements in the AAN practice guideline for brain death. The document proposes three cardinal criteria for brain death: 1) coma, 2) absent brainstem reflexes and 3) apnea which are assessed if the minimum core temperature is at least 32°C. The guideline, however, recommends the appropriate administration of the apnea test meet a minimum core temperature of 36.5°C. We would be interested in the views of your learned readership on this inconsistency. How did it evolve and why is it justified? We wonder if setting the minimum core temperature to one value or the other throughout the entire assessment would be a more logical and consistent alternative to avoid confusion in this medically and ethically challenging realm. Reference: 1) Wijdicks EFM. Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria. Neurology 2002;58:20-25. 2) Wijdicks EFM. Determining brain death in adults. Neurology 1995;45:1003-1011. |
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Michiko Kimura Bruno Weill-Cornell Medical Center New York Presbyterian Hospital, Jun Kimura
Send Correspondence to journal:
MichikoBruno{at}msn.com Michiko Kimura Bruno, et al.
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We read with interest the recent article by Wijdicks [1] and the accompanying editorial [2] comparing brain death criteria worldwide. The article implies a universal acceptance of this concept although methodological details may vary. This inference prompted our response to elaborate on a complex medical practice in Japan as it relates to the diagnosis of brain death. The author cites Law No. 104, passed in 1997 as "Organ Transplantation Law", as the Japanese criteria. This brain death criteria, however, applies only to organ transplantation candidates, and not uniformly as legal death for everyone. [3] To be eligible, the patients must carry a specific "donor" card expressing their wishes to donate their organs, and the family must also concur. The stringent requirement set out in stature 104 has limited the number of declared brain death to fewer than 20 cases since 1997 when the law was established. Physicians may perform examination to evaluate non- organ donor candidates, and the family may request the withdrawal of care based on this information. The majority of patients, however, adhere to the concept of cardiac death, which remains the legal criteria of the land. Thus, they remain on a ventilator to receive ICU care even after a brain death status is established. Death occurs more as a social than individual event in the east-Asian culture, which evolved from family- oriented agrarian society4. Here, the body has an equally important recognition as the soul, unlike the western philosophy of separating the two. This, in part, accounts for the general tendency not to accept death of beloved one unless the heart stops and the body turns cold. An unfortunate early experience also hindered the progress in disseminating the concept of brain death among the Japanese lay public. In 1968, the first attempted case of cardiac transplantation came under heavy attack for inadequate documentation of brain death of the donor, triggering considerable criticism against the new venture. [4] The untoward publicity has resulted in distrust of the medical practice, leading to the introduction of the law [3] to authorize the diagnosis of brain death only for the purpose of organ transplantation. The legislators and medical community are contemplating how to resolve this peculiar state of double standard. In the mean time, controversies continue, posing a number of still unresolved issues medically and philosophically. References: 1. Wijdicks EFM: Brain death worldwide: Accepted fact but no global consensus in diagnostic criteria. Neurology 2002;58:20-25. 2. Swash M, Beresford R.: Brain Death: Still-unresolved issues worldwide. Neurology 2002; 58:9-10. 3. Japan Law #. 104 of 16 July 1997 on organ transplantation. Int Dig Health Legis 1988;48:484-487. 4. Kimura R: Organ transplantation and brain death in Japan. Cultural, legal and bioethical background. Ann Transplant 1998;3:55-58. |
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Eelco F Wijdicks Mayo Clinic Rochester MN
Send Correspondence to journal:
wijde{at}mayo.edu Eelco F Wijdicks
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Drs Burns and Login-among others who have contacted me since the publication of the AAN practice parameters in 1995- point out a possible discrepancy in the temperature limit. Although explained in the text, it obviously is not sufficiently transparent. The core temperature of 32 degrees is a prerequisite for the clinical examination; the core temperature of 36.5 degrees is a prerequisite for the apnea test (see page 1006, section III). It is briefly touched upon in the background document (page1004, last paragraph). Hypothermia may promote hypocarbia and thus is expected to prolong the time to reach the PaCO2 target. Correction to normothermia is part of the overall measure (preoxygenation, correction of blood pressure and volume status) to stabilize the patient before performing the apnea test. Drs Bruno and Kimuro provide a very important additional insight in the difficult situation in Japan. There is little general knowledge in the world of these pressing problems in Japan and how it all came to be after the murder charge of the first Japanese-US trained transplant surgeon. Thanks to Professor Takeshita, I had the opportunity to become familiar with some of its complexity [1] A piercing insight can also be found in a scholarly work by the western anthropologist Margaret Lock.[2] I appreciate Dr. Crisci's comments about the Italian law in organ transplantation. Many of these recent law amendments apply to details of proper organ disposition. In my interpretation of the translation of the document, I could not clearly extrapolate that all three physicians with different expertise (including the "forensic medicine specialist")actually do the neurologic examination and I remain uncertain whether this is mandated practice. Moreover I am unaware of data that suggest multiple examinations this is a necessary safeguard against errors. The time of observation and confirmatory tests in my document applies to adults, but a separate study in children and neonates throughout the world would be of interest. I appreciate Dr Saposnik addition to the information he provided me earlier for the table. I would beam pleased if the apnea test will be performed using the AAN practice guideline.However the I.N.C.U.C.A.I. allows 10 minutes of disconnection as a method of apnea testing if bloodgasses are not available. I appreciate the information provided by Basilica- Bumbasirevic et al. about the regulations and guidelines in Serbia. Three examinations every hour by three physicians limited to three specialties is quite complicated. Again it confirms the impression -I was left with after this worldwide survey -that not much consensus exist to come to the diagnosis. The admirable position of the Serbian Orthodox church echoes the position taken by most clergy. I appreciate these additional details and the numerous e -mails I received.I also became aware that Mexico has changed the time of observation and the sultanate of Oman requires 2 neurologists(separately or together) and the observation may be as long as 24 hours.More details have been forthcoming and the differences are even more striking. In my view, a layered examination by an international task force could prove useful and I will press on to achieve that. It may lead to a white paper.This does not mean every country has to accept it face value.Far from it,but when given the option between a simple set of rules while maintaining academic precision and a complicated,costly, all encompassing protocol the choice should be clear. References: 1. Wijdicks (Editor)Brain Death Lippincott, Williams and Wilkins 2001. 2.Lock M The problem of brain death Japanes disputes about bodies and modernity p239-256 In Definition of Death Contemporary Controversies Youngner SJ,Arnold RB,SchapiroR JOHNS HOPKINS UNIVERSITY PRESS BALTIMORE 2000. |
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