Death by Neurologic Criteria

by Mark Hughes, MD, MA

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    00:01 The last kind of neurologic insult I want to talk about is death by neurologic criteria.

    00:07 So this was previously known as brain death.

    00:10 The difficulty with calling it Brain death is that it sort of differentiates, well, some people will interpret that as well, the brain is dead, but the rest of the body is alive.

    00:20 When this has been worked out and intubated, over the past 30 years or so, it's an idea that the person has died.

    00:30 It's just that neurologic criteria being used to determine death, rather than, what the historic pattern has been was cardiopulmonary death.

    00:41 So here, because person hood has been lost, because the overall integrative functions of the brain are no longer working.

    00:50 The person has died and we call this death by neurologic criteria.

    00:56 So there has to be absence or complete, you know, cessation, and has to be irreversible, of both cerebral and brainstem function.

    01:05 So they're going to be various tests that are going to be done to demonstrate that there is no cerebral or brainstem functioning.

    01:13 The person when they're in this condition, are going to have an irreversible coma.

    01:18 And it has to be the result of some known central nervous system catastrophe.

    01:23 So whether it's been trauma, whether it's been a massive stroke, whether it's been, you know, they had a cardiac arrest, and didn't get any oxygen up to their brain for a long period of time, any kind of insult like that, that you know has resulted in irreversible coma.

    01:43 Next, you have to make sure that there are no other complicating medical conditions that might be bearing on whether or not they've got neurologic function.

    01:53 So, are there any toxins in their system that might be affecting brain function? Is the body so cold, that it can't function.

    02:02 And if you warm the body up, some neurologic function might come back.

    02:08 So you need to know are there electrolyte abnormalities that need to be corrected.

    02:13 Various things, make sure that there are no other complicating medical condition, you've excluded those and that it's because of the brain injury, that there's this irreversible coma and loss of cerebral and brainstem function.

    02:27 So you're going to need to do tests to show that there's an absence of brain originating motor responses.

    02:33 So some of the things of the stimuli that might give to see if there's going to be a motor response, and there's no response by the body to those things.

    02:43 Because there's loss of brainstem function, you also have to demonstrate that there's no respiratory drive.

    02:48 So there's going to be no spontaneous breaths.

    02:51 If the person is on a ventilator, they don't breathe over the ventilator.

    02:55 If you turn off the ventilator and let their oxygen level drop in their carbon dioxide level rise, that there's no evidence that that stimulates the person to the body to start breathing.

    03:08 And then lastly, you do various neurologic tests to show that there's an absence of brainstem reflexes.

    03:14 So these are typically done by these testings for brain death or death by neurologic criteria are done by neurologists, neurosurgeons, intensivist, that have very specific skill set of how to diagnose definitely neurologic criteria.

    03:33 The reason that this has become important over the past few decades is because patients that are declared dead by neurologic criteria can be organ donors.

    03:43 So there's the opportunity if they are now deceased, that they might be able to donate their organs or their family donate their organs on their path for use in transplantation.

    03:56 So this is just one instance of the clinicians role of determining death, and then deciding what happens to the person's body after their death.

    04:07 So it's important to be aware of these neurologic conditions because they do bear on decision making with families.

    04:13 For instance, in persistent vegetative state, there may be questions of whether or not to provide artificial nutrition and hydration and minimally conscious state.

    04:23 There may be patients that say, if I really have minimal awareness of my environment, I may not want to be kept alive in that situation.

    04:30 And for death by neurologic criteria.

    04:32 That's really a decision that, the clinicians have to come to, do the appropriate testing, and then share that information, the diagnosis of death with the family.

    04:43 All very challenging situations, bears on our clinical acumen or clinical judgment, but it does speak to clinical ethics as well.

    About the Lecture

    The lecture Death by Neurologic Criteria by Mark Hughes, MD, MA is from the course Ethical Considerations in Palliative Care.

    Included Quiz Questions

    1. Irreversible cessation of cerebral and brainstem function
    2. Exclusion of other complicating medical conditions
    3. No brain-originating motor responses
    4. Unknown central nervous system trauma
    5. Respiratory drive without spontaneous breaths
    1. No response to sternal rub
    2. No brain-originating motor responses
    3. No respiratory drive
    4. No spontaneous breaths
    5. No brainstem reflexes

    Author of lecture Death by Neurologic Criteria

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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