Diagnosis of Brain Death 2012 ARORA

Determination of Brain Death

Thomas A. Nakagawa, M.D, FAAP, FCCM Professor of Anesthesiology and Pediatrics Wake Forest University School of Medicine

Pediatric Critical Care Medicine Brenner Children’s Hospital at Wake Forest University Baptist Medical

Center Winston-‐Salem, North Carolina

Objectives n  Review specific recommendations from the AAN

adult brain death guidelines and recommendations from the SCCM/AAP/CNS guidelines for the determination of brain death in infants and children

n  Discuss important issues that can impact the

diagnosis of brain death in adults and children

Characteristics of irreversible coma

A patient in this state appears to be in deep coma. The condition can be satisfactorily diagnosed by points 1,2, and 3 to follow. The electroencephalogram (point 4) provides confirmatory data, and when available it should be utlized.

1.  Unreceptivity and unresponsitivity

2.  No movements or breathing

3.  No reflexes

4.  Flat electroencephalogram

2 Defining Death To embody these conclusions in statutory form the Commission worked with the three organizations which had proposed model legislation on the subject. the American Bar Association, the American Medical Association, and the National Conference of Commissioners on Uniform State Laws. These groups have now endorsed the following statute, in place of their previous proposals: Uniform Determination of Death Act 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. A determination of death must be made in accordance with accepted medical standards. The Commission recommends the adoption of this statute in all jurisdictions in the United States.

Overview of the Report Traditionally, the cessation of heartbeat and of breathing were regarded by the lay and. medical communities alike as the definitive signs of death. The law, through the judgments of courts in deciding individual cases, articulated this general view. In the oft-quoted words of Black's Law Dictionary, the common law mirrored the physician's "definition" of death "as a total stoppage of the circulation of the blood, and a cessation of the animal and vital functions consequent thereon, such as respiration, pulsation, etc."1

Criteria for determining death 162 Defining Death: Appendix F The Criteria for Determination of Death An individual presenting the findings in either section A (cardiopulmonary) or section B (neurologic) is dead. In either section, a diagnosis of death requires that both cessation of functions, as set forth in subsection 1, and irreversibility, as set forth in subsection 2, be demonstrated. A. AN INDIVIDUAL WITH IRREVERSIBLE CESSATION OF CIRCULATORY AND

RESPIRATORY FUNCTIONS IS DEAD. 1. CESSATION IS RECOGNIZED BY AN APPROPRIATE CLINICAL EXAMINATION. 2. IRREVERSIBILITY IS RECOGNIZED BY PERSISTENT CESSATION OF FUNCTIONS DURING AN APPROPRIATE PERIOD OF OBSERVATION AND/OR TRIAL OF THERAPY.

B. AN INDIVIDUAL WITH IRREVERSIBLE CESSATION OF ALL FUNCTIONS OF

THE ENTIRE BRAIN, INCLUDING THE BRAINSTEM, IS DEAD.

Defining Death. A Report on the Medical, Legal and Ethical Issues in the Determination of Death President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research 1981

Criteria for determining death

Defining Death. A Report on the Medical, Legal and Ethical Issues in the Determination of Death President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research 1981

162 Defining Death: Appendix F The Criteria for Determination of Death C. Children The brains of infants and young children have increased

resistance to damage and may recover substantial functions even after exhibiting unresponsiveness on neurological examination for longer periods than do adults. Physicians should be particularly cautious in applying neurologic criteria to determine death in children younger than five years.

A. Etiology and irreversibility of condition B. Absence of brainstem reflexes C. Absence of motor response to pain D. Absence of respiration with PCO2 ≥ 60 mm Hg

Brain death is a clinical diagnosis

IV. Confirmatory laboratory tests (Options) Brain death is a clinical diagnosis. A repeat

clinical evaluation 6 hours later is recommended, but this interval is arbitrary. A confirmatory test is not mandatory but is desirable in patients in whom specific components of clinical testing cannot be reliably performed or evaluated. It should be emphasized that any of the suggested confirmatory tests may produce similar results in patients with catastrophic brain damage who do not (yet) fulfill the clinical criteria of brain death.

Severe brain injury to neurological determination of death:

Canadian forum recommendations

Sam D. Shemie, Christopher Doig, Bernard Dickens, Paul Byrne, Brian Wheelock, Graeme Rocker, Andrew Baker, T. Peter Seland, Cameron Guest, Dan Cass, Rosella Jefferson, Kimberly Young, Jeanne Teitelbaum, on behalf of the Pediatric Reference Group and the Neonatal Reference Group

CMAJ•JAMC March 14, 2006, Vol. 174, No. 6; (suppl):S1–32

Brain arrest: the neurological determination of death and organ donor management in Canada

Crit Care Med 2011;29:2139-2156

Pediatrics 2011;128:e720-e740

National and International Endorsements Adult Pediatric

Society of Critical Care Medicine

§  American Academy of Neurology

§  Child Neurology Society

§  Neurocritical Care Society

§  American College of Radiology

§  The Radiologic Society of North America

§  American Academy of Pediatrics

§  Child Neurology Society

§  American Association of Critical Care Nurses

§  National Association of Pediatric Nurse Practitioners

§  Society for Pediatric Anesthesia

§  Society of Pediatric Neuroradiology

§  World Federation of Pediatric Intensive and Critical Care Societies

§  *American Academy of Neurology affirms the value of the manuscript

The adult and pediatric brain death guidelines emphasize the important point that brain death is a

clinical diagnosis based on the absence of neurologic function with a known irreversible

cause of coma

Clinical examination criteria to determine brain death

Wijdicks EFM. The diagnosis of brain death. N Engl J Med 2001;344:1215-1221

Clinical neurologic examination and apnea testing are the cornerstone of brain death determination.

n  Deep, unresponsive coma n  Absent respiratory effort

(apnea) n  Loss of all motor responses,

excluding spinal reflexes n  Loss of all brain stem

reflexes, including n  Absent gag reflex n  Absent cough reflex n  Absent corneal reflex n  Absent oculocephalic and

oculovestibular reflexes n  Fixed and dilated pupils

Determination of brain death §  Brain death can be determined in infants > 37 weeks gestational age to adults § Specified the age of pediatric and adult patients   Acknowledged special sub groups of pediatric patients   Pediatric trauma patients

The committee recognizes differences in age criteria for pediatric trauma patients(37 weeks gestational age to 18 years of age)

  Special Considerations for Term Newborns (37 weeks Gestation) to 30 Days of Age

No recommendations were made for neonates < 37 weeks gestation because of insufficient data

§  Testing for brain death must occur with appropriate physiologic parameters

n  The patient should not be hypotensive (based on age) n  The patient should not be hypothermic n  Sedatives, analgesics or neuromuscular blocking agents

should not have been recently administered n  Conditions capable of imitating brain death must be ruled

out n  Severe metabolic disturbances including electrolyte and

glucose abnormalities capable of causing a potentially reversible coma

n  Clinically significant drug intoxications including alcohol, barbiturates, opiates, and sedative agents n  Low to mid therapeutic levels of anticonvulsants, sedatives, and

analgesic agents should not preclude the clinical diagnosis

Additional parameters to determine absence of neurologic function

•  This update sought to use evidence-‐based methods to answer 5 ques8ons historically related to varia8ons in brain death determina8on to promote uniformity in diagnosis –  Are there pa8ents who fulfill the clinical criteria of brain death who recover brain func8on? (Level U)

–  What is an adequate observa8on period to ensure that cessa8on of neurologic func8on is permanent? (Level U)

–  Are complex motor movements that falsely suggest retained brain func8on some8mes observed in brain death? (Level C)

–  What is the compara8ve safety of techniques for determining apnea? (Level U)

–  Are there new ancillary test that accurately iden8fy pa8ents with brain death? (Level U)

Evidence based medicine guidelines •  EBM ranks evidence based on the effectiveness of treatment or

interventions –  Level 1: Evidence obtained from at least one properly designed randomized controlled trial –  Level 11-‐1: Evidence obtained from well-‐designed controlled trials without randomization –  Level 11-‐2: Evidence obtained from well-‐designed cohort or case-‐controlled analytic studies

preferably from more that one center or research group –  Level 11-‐3: Evidence obtained from multiple time series with or without the intervention.

Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

–  Level 111: Opinions of respected authorities, based on clinical experience, descriptive studies, or report of expert committee.

•  Levels of evidence (Oxford Centre for Evidence-‐based Medicine) –  Level A: Consistent randomised controlled clinical trial, cohort study, all or none clinical

decision rule validated in different populations –  Level B: Consistent retrospective cohort, exploratory cohort, ecologic study, outcomes

research, case-‐controlled study, or extrapolations from level A studies –  Level C: Case-‐series study or extrapolations from level B studies –  Level D: Expert opinion without explicit critical appraisal, or based on physiology, bench

research or first principles

§  6 specific recommendations were made §  Determination of brain death in term newborns, infants,

and children is a clinical diagnosis   Insufficient data in the literature to make recommendations for

preterm infants < 37 weeks gestational age

§  Hypotension, hypothermia, and metabolic disturbances should be treated and corrected and medications that can interfere with the neurologic examination and apnea testing should be discontinued allowing for adequate clearance before proceeding with these evaluations

§  Two examinations, including apnea testing with each examination separated by an observation period, are require

•  An observation period of 24 hours for term newborns (37 weeks gestational age) to 30 days of age and 12 hours for infants and children (> 30 days to 18 years) is recommended.

§  Apnea testing to support the diagnosis of brain death must be performed safely

§  Ancillary studies are not required to establish brain death and are not a substitute for the neurologic examination

§  Death is declared when these criteria are fulfilled

Grading of Recommendations, Assessment, Development and Evaluation (GRADE)

GRADE is a recently developed standardized methodologic consensus-based approach used to make recommendations for the updated guidelines GRADE allows panels to evaluate evidence and opinions and make recommendations using 5 domains to judge the balance between the desirable and undesirable effects of an intervention. A GRADE score was produced by each committee member for the strength of evidence linked to a specific recommendation Based upon these scores, specific recommendations were made based upon available literature at the time of publication

•  Ques%on: Are there pa8ents who fulfill the clinical criteria of brain death who recover brain func8on? – Conclusion:

•  In adults, recovery of neurologic func8on has not been reported aIer the clinical diagnosis of brain death has been established using the criteria in the 1995 AAN prac8ce parameter

Crit Care Med 2011;39:1538-1542

Guidelines for the determination of brain death in infants and children

§  Cerebral protective therapies such as hypothermia may alter the natural progression of brain death and their impact should be reviewed as more information becomes available. The clinician caring for critically ill infants and children should be aware of the potential impact of new therapeutic modalities on the diagnosis of brain death.

IV. Confirmatory laboratory tests (Options) Brain death is a clinical diagnosis. A repeat clinical evaluation 6 hours later is recommended, but this interval is arbitrary. A confirmatory test is not mandatory but is desirable in patients in whom specific components of clinical testing cannot be reliably performed or evaluated. It should be emphasized that any of the suggested confirmatory tests may produce similar results in patients with catastrophic brain damage who do not (yet) fulfill the clinical criteria of brain death.

•  Ques%on: What is an adequate observa8on period to ensure that cessa8on of neurologic func8on is permanent? –  There are no detailed studies on serial examina8ons in adults who have been declared brain dead

–  Conclusion: •  There is insufficient evidence to determine the minimally acceptable observa8on period to ensure that neurologic func8ons have ceased irreversibly.

•  Prac8cal (Non-‐evidenced based) guidance for determina8on of brain death

•  “Many of the details of the clinical neurologic examina6on to determine brain death cannot be established by evidence-‐based methods. The detailed brain death evalua6on protocol that follows is intended as a useful tool for clinicians. It must be emphasized that this guidance is opinion-‐based. Alterna6ve protocols may be equally informa6ve”

•  Perform 1 neurologic examina%on (sufficient to pronounce brain death in most US states) •  “If a certain period of 6me has passed since the onset of the brain insult to exclude the possibility of recovery (in prac6ce, usually several hours), 1 neurologic examina/on should be sufficient to pronounce brain death. However, some US state statutes require 2 examina/ons.”


§  Recommendation 3   Two examinations, including apnea testing with each examination separated by an observation period, are required. Examinations should be performed by different attending physicians. Apnea testing may be performed by the same physician.

 Observation period   24 hours for term newborns (37 weeks gestational age) to 30 days of age

  12 hours for infants and children (> 30 days to 18 years)

Criticisms of the revised pediatric brain death guidelines

§  Observation periods between examinations §  2 examinations to determine brain death §  2 separate attending physicians are needed to

declare death §  Recommendation for an arterial line

Why two examinations separated by an observation period for children?

75,976 adults 11,020 children 1,264 children < 1 year of age

OPTN data 2/2012

The importance of two examinations separated by an observation period

n  The first examination determines the patient meets criteria for brain death. The second examination confirms that the patient’s neurologic status remains consistent with the diagnosis of brain death throughout the observation period

n  Fulfills criteria for irreversibility from the President’s commission n  The Criteria for Determination of Death

A diagnosis of death requires that both cessation of functions, as set forth in subsection 1, and irreversibility, as set forth in subsection 2, be demonstrated. 1. CESSATION IS RECOGNIZED BY AN APPROPRIATE CLINICAL EXAMINATION. 2. IRREVERSIBILITY IS RECOGNIZED BY PERSISTENT CESSATION OF FUNCTIONS DURING AN APPROPRIATE PERIOD OF OBSERVATION AND/OR TRIAL OF THERAPY.


§  Recommendations   Examinations should be performed by different attending physicians   The guidelines list appropriately trained individuals who should be competent to perform the neurologic examination

  State and local guidelines will determine whether physicians trained in the neurosciences are required to perform at least one of the examinations.

  Apnea testing must be performed in conjunction with each neurologic examination

  Apnea testing should be performed by the physician managing the ventilator (Apnea testing can be performed by the same physician)


§  Recommendation 3   Assessment of neurologic function after cardiopulmonary resuscitation or other severe acute brain injuries should be deferred for ≥ 24 hours if there are concerns or inconsistencies in the examination

1,229 adult and 82 pediatric patients were studied over a 2.5 year period Mean brain death interval between the 2 examination was 19.2 hours Hospitals with fewer beds had longer intervals between testing Consent for organ donation decreased from 57% to 45% as the brain death declaration interval increased Refusal of organ donation increased from 23% to 36% as the brain death interval increased 166 patient (12%) sustained a cardiac arrest between the 2 examinations or after the second examination

We demonstrated a significant delay in the diagnosis of brain death as a result of a second examination resulting in negative consequences of organ donation and procurement of organs. The mean observation period between the 2 brain death examinations was substantially longer than the 6 hours proposed in the New York State Guidelines. In several patients, a second brain death examination was performed more than 1 ½ to 2 days after the first examination. Regrettably, 116 patients sustained a cardiac arrest while awaiting a second brain death examination, and an additional 50 patients arrested after the second brain death examination following the brain death interval. Cardiac arrest was a direct result of the requirement of a second clinical examination and observation period.

•  Importance of this publica8on – Con8nues to add important informa8on about brain death in children and adults reinforcing that when the diagnosis of brain death is properly made, recovery of neurologic func8on does not occur

•  Important considera8ons for children – Limited number of children in this study

•  Of the 82 pediatric pa8ents, 15 children < 5 years of age with no children < 2 years of age reported in this study

•  RegreVably, 116 pa8ents sustained a cardiac arrest while awai8ng a second brain death examina8on, and an addi8onal 50 pa8ents arrested aIer the second brain death examina8on following the brain death interval. Cardiac arrest was a direct result of the requirement of a second clinical examina/on and observa/on period.

Important considerations when determining brain death

n  Diagnosing brain death should never be rushed or take a priority over the needs of the patient and family

n  Patients should continue to be supported until a diagnosis of brain death is made or a decision to withdraw life-‐sustaining medical therapies is decided upon

n  If there is any uncertainty about the examination or ancillary study, the observation period should be prolonged

Apnea testing

§  To determine brain death, coma and apnea must coexist § Apnea testing must be performed safely   Apnea testing should only be pursued after the patient has met established prerequisite and clinical criteria (complete loss of brain stem reflexes) for brain death testing

  Specific recommendations regarding apnea testing are made in the adult and pediatric brain death guidelines

  Patients should be adequately preoxygenated to minimize complications and ensure the greatest chance of successfully completing this test

  Patients should be removed from mechanical ventilation to reduce any chance of false triggering of the ventilator


§  Apnea testing   Apnea testing must be performed safely   The apnea test should be aborted if oxygen saturations fall below 85%, if hemodynamic instability occurs, or if a PaCO2 level of 60 mm Hg cannot be safely achieved. In this instance, the patient should be placed back on ventilator support with appropriate treatment to restore normal oxygen saturations and a normal carbon dioxide level.

  Care should be taken if tracheal insufflation of oxygen is used to prevent barotrauma and CO2 washout

•  Ques%on: Are there new ancillary test that accurately iden8fy pa8ents with brain death? – Conclusion:

•  There is insufficient evidence to determine if newer ancillary tests accurately confirm the cessa8on of func8on of the en8re brain.

n  4 vessel angiography remains the gold standard n  Difficult to accomplish in small infants and requires technical

expertise which may not be available at every center n  May require transport of a critically ill child to the angiography

suite

n  Electroencephalography (EEG) n  Remains an accepted means to determine brain death n  EEG is influenced by factors such as sedative agents and

hypothermia

n  Radionuclide cerebral blood flow (CBF) study n  May not be available at every institution n  May require transport of a critically ill patient to the nuclear

medicine suite unless a portable gamma camera is available

Considerations when selecting a neurodiagnostic study to assist with determination of brain death

Neurodiagnostic (Ancillary)testing

n  EEG and radionuclide CBF are the two most widely available and useful ancillary studies to assist with the diagnosis of brain death in children

n  Radionuclide CBF study have been used extensively with good experience. This study is becoming a standard in many institutions.

Is one test better than the other?

n  Each test is considered acceptable as an ancillary study

n  Some believe that EEG may be more specific, although less sensitive than radionuclide CBF testing n  EEG testing evaluates

cortical and cellular function

n  Radionuclide CBF evaluates flow and uptake into brain tissue

•  Are there new ancillary test that accurately iden8fy pa8ents with brain death? – MRI and magne8c resonance angiography – CT angiography – Somatosensory evoked poten8als – Bispectral index – Conclusion:

•  Because of a high risk of bias and inadequate sta8s8cal precision, there is insufficient evidence to determine if any new ancillary tests accurately iden8fy brain death.


§  Recommendations for ancillary studies   Ancillary studies are not mandatory and are not a substitute for the neurologic examination

  EEG and CBF studies remain accepted ancillary studies to assist with making the diagnosis of brain death. 4 vessel angiography can be pursued if available.

  Ancillary studies may be used to assist the clinician in making the diagnosis of brain death   When components of the examination or apnea testing cannot be completed safely as a result of the underlying medical condition of the patient

  If there is uncertainty about the results of the neurologic examination   If medication effect may be present   To reduce the interexamination observation period

Neurodiagnostic (Ancillary) testing in infants and children

n  The following ancillary studies have not been sufficiently studied in children and cannot be recommended as ancillary studies to assist with the determination of brain death in children at this time n  Transcranial doppler study n  Computed tomography angiography n  Computed tomography perfusion using arterial spin

labeling n  Nasopharyngeal somatosensory evoked potential studies n  Magnetic resonance imaging n  Magnetic resonance angiography n  Perfusion magnetic resonance imaging

Differences between pediatric and adult brain death guidelines

Adult Pediatric

§  18 years of age and older 111

111

§  Apnea testing ú  > 60 mm Hg or > 20 mm Hg above

baseline

§  Ancillary studies: not needed for the clinical diagnosis of brain death ú  Rather than ordering ancillary tests, physicians

may decide not to proceed with the declaration of brain death if clinical findings are unreliable.

§  Acceptable ancillary studies ú  EEG ú  Nuclear scan ú  Cerebral angiogram

*Preferred tests

§  > 37 weeks gestational age to 18 years of age ú  * Trauma population

§  Apnea testing ú  > 60 mm Hg and > 20 mm Hg above

baseline

§  Ancillary studies: not required unless physical exam and apnea test cannot be completed

§  Acceptable ancillary studies ú  EEG ú  Nuclear scan ú  Cerebral angiogram

Differences between pediatric and adult brain death guidelines

Adult Pediatric

§  Number of examinations

§  1 examination

Some states may require 2 examinations

§  Observation period: none specified

§  Number of examinations

§  2 examinations

2 different attending physicians must perform the examination

§  Observation period based on age ú  24 hours for infants less than 30 days ú  12 hours for children 31 days of age or

older

James Fackler, MD, Brahm Goldstein, MD, Crit Care Med 2011(39)2197-2198

We strongly suggest that this checklist be incorporated into the patient’s medical

record as it will guide clinicians during a high-stress period and provide definitive documentation of the specific steps and timeline followed for determination and

declaration of brain death for clinical and medical legal purposes.


§  Terminology ú  Different terms for one clinical state

  Brain death   Neurologic death   Total brain failure   Irreversible coma   Brain infarction   Brain arrest

Communicating with families •  Communication should be in simple terminology

allowing parents and family members to understand their loved one has died

•  Avoid terms such as “brain death” –  Your loved one has suffered a severe injury that has caused

the brain to stop working –  Your loved one has died

•  Allow families to be present during the examination and apnea test

•  Families may become confused or angry if discussions regarding withdrawal of support or medical therapies after declaration of death are entertained.

•  It should be made clear that once death has occurred, continuation of medical therapies is no longer an option, unless organ donation is planned.

Cyanotic heart lesion and brain death

§  You are treating a patient with cyanotic heart disease who has a baseline saturation of 70-‐75%. Can you determine brain death in this patient? In a normally saturated patient, based on the revised pediatric guideline, the apnea test should be terminated when oxygen saturations fall below 85%. ú  There is no published reports on how to approach a cyanotic patient ú  The patient is in a desaturated state which is different from

desaturating ú  If the patient desaturated, how low would you allow the saturations to

drop before terminating the apnea test? ú  In this instance, an ancillary study would likely need to be pursued to

assist with the determination of death

Hypothetical adolescent trauma patient

§  Car accident, 3 teenagers ages 16, 17, 18 years §  No brainstem reflexes with apnea noted 12 hours

later §  Bed A: 16 y, SCCM/AAP/CNS guidelines

ú  Wait and do a second exam, cardiac arrest

§  Bed B: 17 y, SCCM/AAP/CNS guidelines ú  Wait and do a second exam, family devastated, they want

closure and do not want to wait. Family denies organ donation

§  Bed C: 18 y, AAN Guidelines ú  One exam is performed and organ donation occurs

Hypothetical adolescent trauma patient (cont)

§  Is there a difference in the physiology of these three patients?

§  Should these patients be treated under the pediatric or adult brain death guidelines?

§  Should one examination and an apnea test be performed or should 2 examinations and apnea tests be performed?

The committee recognizes differences in age criteria for pediatric trauma patients

Where are we today? n  Brain death remains a clinical diagnosis based upon the

absence of brainstem and hemispheric function n  Apnea testing is essential to the determination of brain death

and should be performed in conjunction with the clinical examination

n  Brain death can be diagnosed in infants < 7 days of age n  The younger the child, the more cautious one should be in

determining brain death n  Care must be taken when the patient has sustained an anoxic

insult or has undergone cardiopulmonary resuscitation n  Ancillary studies can assist in making the determination of

brain death when the clinical examination criteria and apnea testing cannot be completed and documented

n  If there is any concern regarding declaration of death, the observation period should be extended and additional examinations or use of ancillary studies should be pursued to make the appropriate diagnosis

Future directions

n  Further information is needed before we can state that a single neurologic examination is sufficient to declare brain death in infants and children

n  Further research into validity of newer ancillary tests is warranted to see how they compare and if they are more accurate and reliable than currently available tests

n  We must work with national medical societies and organizations to achieve a uniform approach to declaring brain death that can be incorporated into all hospital policies while understanding that differences in children and adults exists

Working to standardize the determination of brain death in infants and children

n  SCCM is currently working on a toolbox n  Online resource for medical providers tasked with determining brain death in children n Full guideline n Examination criteria n Brain death checklist n Tables, appendices n Training video demonstrating the neurologic examination

Implications for donation and transplantation

n  The OPO coordinator will face greater challenges and must continue to rely on their ability to perform a brain death examination

n  The OPO must verify that the patient meets criteria for brain death prior to organ recovery

n  This increased responsibility can have profound social and political implications for families and physicians in the ICU setting

“The diagnosis of brain death still requires the thoughtful, mature judgment of a knowledgeable physician who takes all

the facts into careful deliberation in each case.”— “The diagnosis of brain death should remain a clinical one to be made at the bedside by knowledgeable physicians who, in concert with grieving families, make the most agonizing of all life’s events (the death of a child) as bearable as

possible for all concerned.” —Freeman JM, Ferry PC — New brain death guidelines in children: further confusion. Pediatrics. 1988;81:301-‐303.35

Thomas A. Nakagawa, M.D., FAAP, FCCM Wake Forest University School of Medicine

Department of Anesthesiology

[email protected]

(336) 716-7194

Documents

Diagnosis of Brain Death 2012 ARORA