Reader Response: Revise the UDDA to Align the Law with Practice through Neuro-Respiratory Criteria
Mohamed Y.Rady, Consultant Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona
Submitted January 26, 2022
Omelianchuk et al. propose a revision of the UDDA to align with the medical standards for brain injury that include a permanent loss of the capacity for consciousness, spontaneous breathing, and brainstem reflexes.1 Evidence has challenged the assumption that the American Academy of Neurology’s standard can measure the presence or absence of consciousness and the capacity for spontaneous recovery of consciousness with time.2
First, the standard relies on the testing of a subset of cranial nerve motor reflexes. Consciousness is a function of the central nervous system and cannot be assessed by testing cranial motor reflexes, because of the dissociation of consciousness from motor function in the injured brain.2
Second, the standard dismisses preserved hypothalamic and diencephalon functions that indicate persistent intracranial blood flow sufficient to maintain the structural viability and connectivity of the central nervous system, as well as trigger potential spontaneous recovery of consciousness.3 The standard also asserts that cessation of consciousness within days is permanent when ceased neurologic functions, including consciousness, have been documented to recover spontaneously in the severely injured brain after several weeks and months.4,5
Disclosure
The author reports no relevant disclosures. Contact [email protected] for full disclosures.
References
Omelianchuk A, Bernat J, Caplan A, et al. Revise the UDDA to Align the Law with Practice through Neuro-Respiratory Criteria [published online ahead of print, 2022 Jan 25]. Neurology. 2022;10.1212/WNL.0000000000200024.
Shewmon DA. Statement in Support of Revising the Uniform Determination of Death Act and in Opposition to a Proposed Revision [published online ahead of print, 2021 May 14]. J Med Philos. 2021;jhab014. doi:10.1093/jmp/jhab014
Shewmon DA, Salamon N. The MRI of Jahi McMath and Its Implications for the Global Ischemic Penumbra Hypothesis. J Child Neurol. 2022;37(1):35-42. doi:10.1177/08830738211035871
Giacino JT, Katz DI, Schiff ND, et al. Comprehensive systematic review update summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research. Neurology. 2018;91(10):461-470. doi:10.1212/WNL.0000000000005928
Giacino JT, Katz DI, Schiff ND, et al. Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research [published correction appears in Neurology. 2019 Jul 16;93(3):135]. Neurology. 2018;91(10):450-460. doi:10.1212/WNL.0000000000005926
Omelianchuk et al. propose a revision of the UDDA to align with the medical standards for brain injury that include a permanent loss of the capacity for consciousness, spontaneous breathing, and brainstem reflexes.1 Evidence has challenged the assumption that the American Academy of Neurology’s standard can measure the presence or absence of consciousness and the capacity for spontaneous recovery of consciousness with time.2
First, the standard relies on the testing of a subset of cranial nerve motor reflexes. Consciousness is a function of the central nervous system and cannot be assessed by testing cranial motor reflexes, because of the dissociation of consciousness from motor function in the injured brain.2
Second, the standard dismisses preserved hypothalamic and diencephalon functions that indicate persistent intracranial blood flow sufficient to maintain the structural viability and connectivity of the central nervous system, as well as trigger potential spontaneous recovery of consciousness.3 The standard also asserts that cessation of consciousness within days is permanent when ceased neurologic functions, including consciousness, have been documented to recover spontaneously in the severely injured brain after several weeks and months.4,5
Disclosure
The author reports no relevant disclosures. Contact [email protected] for full disclosures.
References