The problem with a dogmatic defense of the bedside brain death examination
Nathaniel M.Robbins, Assistant Professor of Neurology, Dartmouth Geisel School of Medicine
Published January 26, 2019
I applaud the Brain Death Working Group for working towards uniform standards for determination of Brain Death.1 Misdiagnosis, stemming from suboptimal practices, erodes public trust in physicians’ expertise and the very concept of brain death. However, dogmatic defense of the clinical examination as the gold standard, assessing “entire brain function,” may also undermine public trust. A clinical brain death examination detects motoric responses originating in the brainstem. When the inciting event affects the brainstem—without fatal intracranial hypertension and herniation—the cerebrum, and visual and olfactory input, may be spared.2,3 fMRI, or other modalities that don’t rely on motor output, could identify cerebral activity in these cases.3–5 The American Academy of Neurology may be "...unaware of any cases in which compliant application of the Brain Death Guidelines led to inaccurate determination of death with return of any brain function, including consciousness...,"1 but this statement is misleading since consciousness cannot be evaluated at the bedside if there is no motor output. The clinical exam may be sufficiently specific for prognosis, but it does not assess entire brain function. Our professional society’s proclamations must be intellectually honest and 100% defensible, or we risk undermining the very public trust for which we fight.
References
Russell JA, Epstein LG, Greer DM, et al. Brain death, the determination of brain death, and member guidance for brain death accommodation requests: AAN position statement. Neurology Epub 2019 Jan 2.
Wijdicks EF, Pfeifer EA. Neuropathology of brain death in the modern transplant era. Neurology 2008;70:1234–1237.
Robbins NM, Bernat JL. Practice Current: When do you order ancillary tests to determine brain death? Neurol Clin Pract 2018;8:266–274.
Cruse D, Chennu S, Chatelle C, et al. Bedside detection of awareness in the vegetative state: a cohort study. Lancet 2011;378:2088–2094.
Monti MM, Vanhaudenhuyse A, Coleman MR, et al. Willful modulation of brain activity in disorders of consciousness. N Eng J Med 2010;362:579–589.
I applaud the Brain Death Working Group for working towards uniform standards for determination of Brain Death.1 Misdiagnosis, stemming from suboptimal practices, erodes public trust in physicians’ expertise and the very concept of brain death. However, dogmatic defense of the clinical examination as the gold standard, assessing “entire brain function,” may also undermine public trust. A clinical brain death examination detects motoric responses originating in the brainstem. When the inciting event affects the brainstem—without fatal intracranial hypertension and herniation—the cerebrum, and visual and olfactory input, may be spared.2,3 fMRI, or other modalities that don’t rely on motor output, could identify cerebral activity in these cases.3–5 The American Academy of Neurology may be "...unaware of any cases in which compliant application of the Brain Death Guidelines led to inaccurate determination of death with return of any brain function, including consciousness...,"1 but this statement is misleading since consciousness cannot be evaluated at the bedside if there is no motor output. The clinical exam may be sufficiently specific for prognosis, but it does not assess entire brain function. Our professional society’s proclamations must be intellectually honest and 100% defensible, or we risk undermining the very public trust for which we fight.
References
Footnotes
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