Death by Brain Criteria

The ability to transplant organs successfully led to the need of criteria for brain death, and national and international definitions have been developed. Many now argue that current criteria are restrictive and should be expanded to include patients who have no reasonable chance of regaining consciousness. y If this change is to be made, a substantial shift in societal thinking about life and death may need to precede it. However, in North America, death by brain criteria is still considered to be irreversible loss of brain function, including that of the brain stem. The single exception to this rule appears to be in the area of osmolar control, and diabetes insipidus is not required for this diagnosis.

At present, most jurisdictions recognize the existence of death by brain criteria, but its precise definition varies with local practice. In general, the first stage in pronouncing death by brain criteria is a permissive diagnosis; that is, there must be a diagnosis adequate to explain death of the brain, including the brain stem. This need not be an etiological diagnosis; for example, a massive intracerebral hemorrhage qualifies as a permissive diagnosis, even if the etiology of the hemorrhage is unknown. This requirement helps exclude cases of hypnosedative overdose, in which the patient may appear dead but still recover. Importantly, this criterion does not require demonstration of an anatomical lesion, and a history of prolonged anoxia, for example, would suffice. One then proceeds to demonstrate that

TABLE 1-6 -- SELECTED ETIOLOGIES ASSOCIATED WITH CHANGES IN LEVEL OF CONSCIOUSNESS

Etiological Category

Developmental

Degenerative and compressive

Storage diseases: Lipidoses, glycogen disorders, and leukoencephalopathies

Amino/organic acidopathies, mitochondrial enzyme defects, and other metabolic errors

Chromosomal abnormalihes and neurocutaneous disorders

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