Inconsistency between the circulatory and the brain criteria of death in the Uniform Determination of Death Act

The Uniform Determination of Death Act (UDDA) provides that “an individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.” We show that the UDDA contains two conflicting interpretations of the phrase “cessation of functions”. By one interpretation, what matters for the determination of death is the cessation of spontaneous functions only, regardless of their generation by artificial means. By the other, what matters is the cessation of both spontaneous and artificially supported functions. Because each UDDA criterion uses a different interpretation, the law is conceptually inconsistent. A single consistent interpretation would lead to the conclusion that conscious individuals whose respiratory and circulatory functions are artificially supported are actually dead, or that individuals whose brain is entirely and irreversibly destroyed may be alive. We explore solutions to mitigate the inconsistency.

The Determination of Death under Polish Law in Comparative, Historical and Medical Perspective

It has been recently adopted under Polish law that the determinant of death is both the brain death criterion, tantamount to the permanent and irreversible cessation of its function, and the equally valid circulatory criterion. This means that the determination of brain death is not indispensable to pronounce a person dead, because the irreversible cessation of circulation is sufficient in this respect. The purpose of this article is to present current developments in Polish law against the comparative, historical and medical background.

Pathophysiological Changes and Systemic Inflammation in Brain Dead Organ Donors: Effect on Graft Quality

Transplantation is the definitive treatment of end-stage organ disease. As the shortage of suitable organs poses its main limitation, the active management of potential organ donors becomes increasingly more important. The majority of solid organs are still obtained from donors after confirmed brain death. Brain death is the complete and irreversible cessation of all brain functions, and triggers a variety of severe pathophysiological changes in cardiovascular, hormonal and metabolic status that can result in organ damage. Moreover, brain death is associated with massive inflammatory response with a cytokine storm and complement activation that increases graft immunogenicity and adversely affects graft survival. Organs from brain-dead donors are more prone to graft dysfunction and rejection when compared to organs obtained from living donors. Brain death is thus believed to be an important risk factor influencing the quality of organs before procurement.

How should we use imaging in the determination of brainstem death?

Brainstem death is defined as the “irreversible cessation of brainstem function”, either due to primary intracranial events or extracranial factors such as hypoxia. The importance of accurate and timely diagnosis of brainstem death in critical care should not be understated, as it allows the withdrawal of treatment when it is no longer deemed to beneficial. Additionally, it may facilitate the process of organ donation. Overall, the diagnosis of brainstem death has four common principles across the world: (1) neurological criteria based on clinical assessment; (2) evidence of irreversible brain damage from known aetiology; (3) demonstrating an absence of a reversible cause; and (4) the use of ancillary studies. The latter in particular has been a controversial issue, with much debate continuing on how imaging should be used. We discuss three key questions surrounding the role of imaging in the diagnosis of brainstem death as well as important issues the radiology community should consider.

EVOLUTION OF DIAGNOSTIC TECHNIQUES OF DEATH: AYURVEDA PERSPECTIVE AND MODERN TRENDS IN INDIA

Background: Death is the permanent and irreversible cessation of the tripod of life, viz. the brain, the heart and the lungs. However, there exist philosophical, religious and cultural differences in the concept of death. The diagnosis of death has medical and legal implications which have come a long way over the years and in the regions. Method: The references available regarding the diagnostic techniques for declaring death in classical text were studied and compared with the available information in the contemporary medical literatures and published articles. Result: A number of Ayurveda literatures such as Charaka Samhita, Sushruta Samhita, Astangahrdayam, Vishavaidyasarasamuchhaya, Vishavaidya jyotsnika etc. written in different era by authors from different region have put forward their techniques for diagnosing death which are mostly similar, simple and gross. With the advent of technology and the development of Modern medical sciences, the clincians in India have been following the western system mostly the one practiced in United Kingdom for diagnosing death. The focus has shifted the cardio-respiratory cessation to brain-stem death due to the development of artificial ventilator system and scope for organ transplantation. However, there is need for universal guidelines and much progress have been made regarding the same. Some of the governing laws in this regard in India are Transplantation of Organ Act (THO Act 1994, 2011, 2014) and THO Rules 1995. Conclusion: Ayurveda criteria also focused on declaring death based on the cessation of the function of the three vital organs, although using different sets of techniques. Better, more specific and accurate techniques have evolved over the years.

Inconsistencies Between the Criterion and Tests for Brain Death

The whole-brain criterion of death provides that a person who has irreversibly lost all clinical functions of the brain is dead. Bedside brain death (BD) tests permit physicians to determine BD by showing that the whole-brain criterion of death has been fulfilled. In a nonsystematic literature review, we identified and analyzed case reports of a mismatch between the whole-brain criterion of death and bedside BD tests. We found examples of patients diagnosed as BD who showed (1) neurologic signs compatible with retained brain functions, (2) neurologic signs of uncertain origin, and (3) an inconsistency between standard BD tests and ancillary tests for BD. Two actions can resolve the mismatch between the whole-brain criterion of death and BD tests: (1) loosen the whole-brain criterion of death by requiring only the irreversible cessation of relevant brain functions and (2) tighten BD tests by requiring an ancillary test proving the cessation of intracranial blood flow. Because no one knows the precise brain functions whose loss is necessary to fulfill the whole-brain criterion of death, we advocate tightening BD tests by requiring the absence of intracranial blood flow.

Death, Brain Death, and the Limits of Science: Why the Whole-Brain Concept of Death is a Flawed Public Policy

The 1981 Uniform Determination of Death Act (UDDA) states:An individual that has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.The “whole-brain concept of death,” appealed to in the UDDA, has been roundly criticized for many years. However, despite a great deal of legitimate criticism in academic circles no real clinical or legislative changes have come about. At least one reason for this inertia is aptly stated by James Bernat, one of the principal and founding proponents of the brain death doctrine: “In the real world of public policy on biological issues, we must frequently make compromises or approximations to achieve acceptable practices and laws.” While acknowledging that the brain death doctrine is not flawless and that he and other proponents have been unable to address all valid criticisms, Bernat nonetheless maintains that the brain death doctrine is optimal public policy.

Brain death and the vegetative state

Death can be defined as the irreversible loss of the capacity for consciousness and brain stem function, combined with irreversible loss of the capacity to breathe. The irreversible cessation of brainstem function, whether caused by a primary intracranial catastrophe (e.g. trauma, haemorrhage) or the result of extracranial cranial events (e.g hypoxia), will result in the same clinical state, hence brain stem death is the same as death of the patient....

Brainstem death and organ donation

Brain death in the United States of America is defined as the ‘irreversible cessation of all functions of the entire brain, including the brainstem … that are clinically ascertainable’; in the United Kingdom the definition focuses on brainstem function. Half of those who fulfil the necessary clinical criteria will have a cardiac arrest despite intensive treatment within 24 h, and this happens to almost all within 72 h....