To provide context, the history and legal standards, pathophysiology, and clinical diagnostic standards for brain death are reviewed in this paper. Jonas H. Against the stream. Baltimore: The Johns Hopkins University Press; 2006. widely accepted criterion of death case law state statutes and medical opinion backed by clinical studies all support the use of brain death criteria as a means of determining death current state statutes are in need of some uniformity as 12 different statutory approaches to ethical issues in brain death and multiorgan transplantation bernat jl1 Smith M, Vyas H. Management of the potential organ donor. There is substantial confusion among the public about both brain death and organ procurement. Kennedy Inst Ethics J. The dead donor rule: a defense. It might imply to the patient’s family that the brain is not functioning, but the patient is alive. 2010;21(3):243–263. Jahi McMath, a 13-year-old girl, was admitted to Oakland Children’s Hospital in California for a tonsillectomy and adenoidectomy for sleep apnea on December 9, 2013. single institution, Wijdicks et al wrote “The apnea test is a fixture in brain death determination, but there is a perceived Controversies surrounding the concern about the safety of the procedure”.38 However, they validity of neurological criteria wrote, “We may conclude from our study that the apnea test – for death to passively increase [arterial carbon dioxide pressure] – is Although medical practices … Shewmon DA. As Bernat et al wrote, “This criterion [of brain death] is perfectly correlated with the permanent cessation of functioning of the organism as a whole”,61 and as Bernat later emphasized, “With the loss of the critical system [the brain], the organism loses its life-characterizing processes, and entropy (disorder) inevitably increases”.62. Completing the apnea test: decline in complications. This paper analyses the ongoing controversy and evaluates the recent revision of the Swiss Academy of Medical Sciences guidelines for determining death. Though all worldwide legislatures identify brain death with human death explicitly or implicitly, both the public and academic a… The story of brain death begins with changing medical practices in the 1950s and 1960s (see Stevens,6 Jonsen,7 Pernick,8 De Georgia,9 and Belkin10,11 for detailed historical accounts and analyses of the development of the concept of brain death). Miller FG, Truog RD. Death is imbued with social, cultural, and religious meaning. Due to the complexity of these procedures and related ethical-legal aspects, however, there are a lot of doubts and uncertainty about the brain death diagnosis and the maintenance of potential organ donor. It is meant to enable the family to make critical end-of-life decisions, particularly withdrawal of life support system and organ donation, before brain death is diagnosed, as opposed to the current practice of making such decisions after the diagnosis of death. However, high cervical spinal cord injury and endocrine dysfunction can also invalidate the apnea test, and these confounds are not as often considered in the diagnosis, though they can be common in patients with suspected brain death.34 Perhaps more concerning, hypercarbia (which is deliberately induced in the apnea test) is known to increase ICP and therefore can worsen ischemic injury to the brain, potentially contributing to herniation, and thus can be dangerous to a recently injured brain.34–36 “Indeed”, Joffe et al wrote, “it is reasonable to suggest that the apnea test itself can result in failing the apnea test, creating a self-fulfilling prophecy”.34 Finally, although eupneic inspiratory efforts are stimulated by hypercarbia in the setting of normal physiology, in the context of the specific pathophysiology of a cascade of rostral–caudal dysfunction in which the lower medulla will be the final anatomic area to be compromised, the appropriate stimulus would be hypoxia (not hypercarbia), because hypoxia stimulates the lower medulla-mediated gasping reflex.34, Some concerns regarding the safety of the apnea test have been discussed in the literature.37–41 For example, in a review of a large series of brain death determinations at a single institution, Wijdicks et al wrote “The apnea test is a fixture in brain death determination, but there is a perceived concern about the safety of the procedure”.38 However, they wrote, “We may conclude from our study that the apnea test – to passively increase [arterial carbon dioxide pressure] – is a safe and simple procedure”.38 In this study, the safety of the apnea test was operationalized in terms of the absence of major complications such as cardiac arrest or pneumothorax, but did not address the concern that hypercarbia can increase ICP nor that hypoxia rather than hypercarbia is the more appropriate stimulus. 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