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July 21, 2020; 95 (3) Article

Determination of death by neurologic criteria around the world

View ORCID ProfileAriane Lewis, Azza Bakkar, Elana Kreiger-Benson, Andrew Kumpfbeck, Jordan Liebman, Sam D. Shemie, Gene Sung, Sylvia Torrance, David Greer
First published June 23, 2020, DOI: https://doi.org/10.1212/WNL.0000000000009888
Ariane Lewis
From the NYU Langone Medical Center (A.L.); NYU School of Medicine (A.B., E.K.-B., A.K., J.L.), New York; Montreal Children's Hospital (S.D.S.), McGill University, Quebec; Canadian Blood Services (S.D.S., S.T.), Ottawa, Ontario; LAC and USC Medical Center (G.S.), Los Angeles, CA; and Boston University School of Medicine (D.G.), MA.
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Azza Bakkar
From the NYU Langone Medical Center (A.L.); NYU School of Medicine (A.B., E.K.-B., A.K., J.L.), New York; Montreal Children's Hospital (S.D.S.), McGill University, Quebec; Canadian Blood Services (S.D.S., S.T.), Ottawa, Ontario; LAC and USC Medical Center (G.S.), Los Angeles, CA; and Boston University School of Medicine (D.G.), MA.
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Elana Kreiger-Benson
From the NYU Langone Medical Center (A.L.); NYU School of Medicine (A.B., E.K.-B., A.K., J.L.), New York; Montreal Children's Hospital (S.D.S.), McGill University, Quebec; Canadian Blood Services (S.D.S., S.T.), Ottawa, Ontario; LAC and USC Medical Center (G.S.), Los Angeles, CA; and Boston University School of Medicine (D.G.), MA.
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Andrew Kumpfbeck
From the NYU Langone Medical Center (A.L.); NYU School of Medicine (A.B., E.K.-B., A.K., J.L.), New York; Montreal Children's Hospital (S.D.S.), McGill University, Quebec; Canadian Blood Services (S.D.S., S.T.), Ottawa, Ontario; LAC and USC Medical Center (G.S.), Los Angeles, CA; and Boston University School of Medicine (D.G.), MA.
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Jordan Liebman
From the NYU Langone Medical Center (A.L.); NYU School of Medicine (A.B., E.K.-B., A.K., J.L.), New York; Montreal Children's Hospital (S.D.S.), McGill University, Quebec; Canadian Blood Services (S.D.S., S.T.), Ottawa, Ontario; LAC and USC Medical Center (G.S.), Los Angeles, CA; and Boston University School of Medicine (D.G.), MA.
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Sam D. Shemie
From the NYU Langone Medical Center (A.L.); NYU School of Medicine (A.B., E.K.-B., A.K., J.L.), New York; Montreal Children's Hospital (S.D.S.), McGill University, Quebec; Canadian Blood Services (S.D.S., S.T.), Ottawa, Ontario; LAC and USC Medical Center (G.S.), Los Angeles, CA; and Boston University School of Medicine (D.G.), MA.
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Gene Sung
From the NYU Langone Medical Center (A.L.); NYU School of Medicine (A.B., E.K.-B., A.K., J.L.), New York; Montreal Children's Hospital (S.D.S.), McGill University, Quebec; Canadian Blood Services (S.D.S., S.T.), Ottawa, Ontario; LAC and USC Medical Center (G.S.), Los Angeles, CA; and Boston University School of Medicine (D.G.), MA.
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Sylvia Torrance
From the NYU Langone Medical Center (A.L.); NYU School of Medicine (A.B., E.K.-B., A.K., J.L.), New York; Montreal Children's Hospital (S.D.S.), McGill University, Quebec; Canadian Blood Services (S.D.S., S.T.), Ottawa, Ontario; LAC and USC Medical Center (G.S.), Los Angeles, CA; and Boston University School of Medicine (D.G.), MA.
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David Greer
From the NYU Langone Medical Center (A.L.); NYU School of Medicine (A.B., E.K.-B., A.K., J.L.), New York; Montreal Children's Hospital (S.D.S.), McGill University, Quebec; Canadian Blood Services (S.D.S., S.T.), Ottawa, Ontario; LAC and USC Medical Center (G.S.), Los Angeles, CA; and Boston University School of Medicine (D.G.), MA.
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Determination of death by neurologic criteria around the world
Ariane Lewis, Azza Bakkar, Elana Kreiger-Benson, Andrew Kumpfbeck, Jordan Liebman, Sam D. Shemie, Gene Sung, Sylvia Torrance, David Greer
Neurology Jul 2020, 95 (3) e299-e309; DOI: 10.1212/WNL.0000000000009888

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This article has a correction. Please see:

  • Determination of death by neurologic criteria around the world - October 27, 2020
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Abstract

Objective To identify similarities and differences in protocols on determination of brain death/death by neurologic criteria (BD/DNC) around the world.

Methods We collected and reviewed official national BD/DNC protocols from contacts around the world between January 2018 and April 2019.

Results We communicated with contacts in 136 countries and found that 83 (61% of countries with contacts identified, 42% of the world) had BD/DNC protocols, 78 of which were unique. Protocols addressed the following prerequisites and provided differing instructions: drug clearance (64, 82%), temperature (61, 78%), laboratory values (56, 72%), observation period (37, 47%), and blood pressure (34, 44%). Protocols did not consistently identify the same components for the clinical examination of brain death; 70 (90%) included coma, 70 (90%) included the pupillary reflex, 68 (87%) included the corneal reflex, 67 (86%) included the oculovestibular reflex, 64 (82%) included the gag reflex, 62 (79%) included the cough reflex, 58 (74%) included the oculocephalic reflex, 37 (47%) included noxious stimulation to the face, and 22 (28%) included noxious stimulation to the limbs. Apnea testing was mentioned in 71 (91%) protocols; there was variability in the technique and target across protocols. Ancillary testing was included as a requirement for all determinations of BD/DNC in 22 (28%) protocols.

Conclusions There is considerable variability in BD/DNC determination protocols around the world. Medical standards for death should be the same everywhere. We recommend that a worldwide consensus be reached on the minimum standards for BD/DNC.

Glossary

BD/DNC=
brain death/death by neurologic criteria;
IQR=
interquartile range

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Received September 19, 2019.
  • Accepted in final form December 29, 2019.
  • © 2020 American Academy of Neurology
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Letters: Rapid online correspondence

  • Author response: Determination of death by neurologic criteria around the world
    • Ariane Lewis, Neurointensivist, NYU Langone Medical Center
    • Sam D. Shemie, Pediatric Intensivist, Montreal Children's Hospital
    • Gene Sung, Neurointensivist, LAC and USC Medical Center
    • Sylvia Torrance, Canadian Blood Services, Canadian Blood Services
    • David Greer, Neurointensivist, Boston University School of Medicine
    Submitted July 13, 2020
  • Reader response: Determination of death by neurologic criteria around the world
    • Calixto Machado, Neurologist, AAN Corresponding Fellow, Institute of Neurology and Neurosurgery (Havana, Cuba)
    Submitted July 02, 2020
  • Author response: Determination of death by neurologic criteria around the world
    • Ariane Lewis, Neurointensivist, NYU Langone Medical Center
    • Sam D. Shemie, Pediatric intensivist, Montreal Children's Hospital
    • Gene Sung, Neurointensivist, LAC and USC Medical Center
    • Sylvia Torrance, Canadian Blood Services, Canadian Blood Services
    • David Greer, Neurointensivist, Boston University School of Medicine
    Submitted June 29, 2020
  • Reader response: Determination of death by neurologic criteria around the world
    • Nitin K. Sethi, Associate Professor of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center (New York, NY)
    Submitted June 26, 2020
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