Brain Death

Introduction

Coma and brain death represent such vastly different descriptions of critically ill paitents to different people even though they have clearly defined medical definitions. To many non-medical providers coma represents a state of somnolence to which a patient often "awakens." Brain death is often thought of as extension of this idea or just the absense of noticable brain function from which one can regain function or recover. Although patients can recover from coma, brain death is irreversible. Lets talk about the definitions of comatose states before we describe brain death declaration and talk about difficult cases and ancillary testing.

Coma Definitions

Coma - A state of prolonged unconsciousness that can be caused by underlying illness, brain injury or traumatic brain injury

Stupor -

Persistant Vegetative State (AKA unresponsive wakefullness syndrome) -

Minimally Concious State

"Locked-in Syndrome"

Coma Scales

Glasgow Coma Scale (GCS) was initially defined and utilized with traumatic brain injury. Although it has several limitations, it is quick, easy to perform and remains one of the most used coma scores because of this. The Full Outline of Unresponsiveness (FOUR) is more novel and detailed score but remains simple and easy to use.

History

UDDA

The Uniform Declaration of Death act was drafted in 1981 by a President's commission study on brain death. This was then approved jointly by the AMA (American Medical Association) and the ABA (American Bar Association). This was drafted to serve as a model for states to approve and since its adoption has been approved by all states.

The UDDA states that determination of death may occur in an individual who has

irreversible cessation of circulatory and respiratory functions; or
irreversible cessation of all function of the entire brain, including the brain stem

Legal Significance

The purpose of the UDDA was largely to align a legal definition of brain death with criteria that was accepted by the medical community. Also since the advance of technology (largely ventilators), patients could be 'kept alive' with otherwise fatal conditions that never would survive and therefore the legal defintion of death required expansion. Several legal situations below demonstrate examples of the requirement of a legal standard of brain death.

Organ Donation - Death is required before organ transplant whether by brain death declaration or 'circulatory death.' Brain death declaration allows for continued organ support and perfusion allowing transplant services to match potential recipients and transplant more organs.
Criminal Cases - Difference between aggravated assualt and homicide requires legal declaration of death.
Tort Actions - Declaration of death is required for wrongful death lawsuits.
Estate Law - An individual's beneficiaries may not inherit one's estate until official declaration of death.
Life Insurance - Similar to estate law, death is required for insurance policies before disbursement of funds can be made to benificiaries.

Brain Death Declaration

Prerequisites for Brain Death

Cases to Beware of...

Trauma/cspine

Fullminant GBS

Posterior Fossa

Toxins

Hypothermia

Ancillary Testing

Coma and Brain Death

By: Charlie M. Andrews MD

Associate Professor of Emergency Medicine, Neurology and Neurosurgery