New guidelines on brain death diagnosis

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The American Academy of Neurology has issued new national guidelines for determining brain death. These have been updated for the first time in 15 years and the recommendations provide step-by-step instructions to help guide physicians through the complex process of determining brain death in adults

The new guidelines have been published in the 8 June issue of Neurology, the medical journal of the American Academy of Neurology (AAN) and have been developed based on a review of all of the studies on brain death published between 1995 and 2009.

 

Commenting on the importance of the new guidelines, one of the co-authors of the guidelines, Panayiotis N Varelas, director of the Neuro-Intensive Care Service, Henry Ford Department of Neurology and  Neurosurgery, Henry Ford Hospital in Detroit, USA, told NeuroNews: “There are two ways to die in the USA and worldwide: one of them is to become brain dead. These guidelines examine the complex process that leads to the declaration of brain death. They also confirm that after 15 years of new information, no patient who has been declared brain dead survived. Therefore, although this is a complex process, it is also a very reliable one. Lastly, the new guidelines make the process more easily understood for physicians, via answering specific questions and developing a checklist of steps that should be followed.”

 

Varelas also commented on the difference between these guidelines from the previous ones. “These guidelines are more comprehensive than the old ones. They also indicate that a single brain death exam may be sufficient for most cases. They also point at the lack of hard scientific evidence, the reliance on experts’ opinions most of the time and the need for future research in the field.”


The goal of the guidelines is to remove some of the variability among doctors in their procedure for declaring brain death, which previous research has found to be a problem. The authors have pointed out that in order to correctly diagnose brain death, it is essential that clinicians adhere to a uniform framework. The guidelines describe several steps doctors must follow in order to diagnose brain death. They carefully reviewed the best way to demonstrate absence of breathing. The guidelines also conclude that laboratory tests such as an electroencephalogram or cerebral blood flow studies are not always necessary to come to a diagnosis, and make clear that this complex process must be completed by a doctor with considerable skill and experience in diagnosing brain death.


“Many of the details of the clinical neurological examination to determine brain death cannot be established by evidence-based methods. Our goal was to develop a detailed brain death evaluation protocol that would be a useful tool for clinicians,” Varelas said.

 

According to the new guidelines, there are three signs that a person’s brain has permanently stopped functioning. First, the person is comatose, and the cause of the coma is known. Second, all brainstem reflexes have permanently stopped working. Third, breathing has permanently stopped. A ventilator must be used to keep the body functioning.

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