This transcript has been edited for clarity.
Andrew N. Wilner, MD: Welcome to Medscape. I’m Dr Andrew Wilner. Today, I have the pleasure of speaking with Dr Lucas Elijovich. Lucas is a colleague of mine, and he’s also a specialist in critical care and director of neurocritical care at University of Tennessee Health Science Center (UTHSC), where we both work. Welcome, Lucas.
Lucas Elijovich, MD: Thanks, Andrew. It’s a pleasure to be with you. I appreciate Medscape’s invitation to talk about the update on the brain death criteria and guidelines.
Defining Death and Saving Lives
Wilner: As a neurocritical care physician, I thought that the updated version of the brain death guidelines is very pertinent for you and your colleagues. I thought it’s worth a discussion. I remember the last update was in 2010, where they decided that the previous update was acceptable.
I wanted to talk about this latest 2023 update of the brain death guidelines. I know you’ve had a chance to look at it. How are you going to use it in your daily work?
Elijovich: First, it’s part of the everyday work of a neurointensivist. I think all neurointensivists, and really all critical care physicians, need to review it. It hasn’t changed tremendously since the last version, but there are some aspects that we’ll talk about today.
The other thing I would say is that it’s a very rigorous look at these guidelines, and a reevaluation of them. There’s a consensus of specialists, ranging from neurosurgeons, neurologists, and medical critical care doctors to radiologists and pediatricians.
One of the primary goals of this new guideline was to merge the pediatric and adult guidelines together, which I think makes sense so you don’t have to go looking in multiple places. When you’re dealing with teenagers, who may bridge some of these clinical situations, it’s good to have all the information in one place. I was pleased to see that.
The methodology was a modified Delphi consensus to come up with the recommendations and revisions. We’re not going to go into that methodology, but you can look it up. I think it is very rigorous, and it’s clearly multidisciplinary. I think it’s very well done.
Wilner: To put these guidelines in perspective, as a neurocritical care physician, how often in a week would you need to apply these brain death guidelines? How often in a month? How necessary are they?
Elijovich: They’re vital to what we do, especially. They’re not just vital to the individual patient; they’re vital to the community. One of the things that happens when patients die — and happens to all of us — is that some of us are organ donors, and some of us don’t know that we want to be organ donors, but our families want us to be. Determining brain death is very important in that process. It’s vital to that process.
To your first question, this happens every day in the neurocritical care unit. I was on service 2 weeks ago, and we did this almost every day, unfortunately. Sometimes, that results in a gain of multiple people’s lives and saving people’s lives. As a fellow, one of the most transformative things that happened to me when I was at UCSF was that the organ donor network in California would send us letters if we were involved in the care of someone who donated and tell us that we saved lives. These criteria don’t just help us define death, but they help us save lives.
Wilner: It’s a formal way that everyone agrees upon to say that this patient is clinically dead, is not going to wake up, and that it’s acceptable to proceed with organ procurement?
Elijovich: It’s not always about organ procurement. Sometimes, it’s just about being able to give a real prognosis and let families begin the grieving process and know what really happened. That’s equally, if not more, important.
That’s our first duty, and one of the things that this guideline talks about is that it’s a duty of a critical care physician or neurocritical care physician to determine the extent of injury and when brain death — or death by neurological criteria, as it’s discussed in this document — is suspected to define that and that you don’t need consent. It’s part of normal medical care to identify death by neurological criteria or brain death.
EEG No Longer Required
Wilner: In the old days, we used to use EEG as a way to say the patient is brain dead. The new guidelines have dispensed with that. What do you think?
Elijovich: I think it’s reasonable for several reasons. One, we have better ways to do what’s called ancillary testing than EEG. A scientific reason why is because death by neurological criteria is defined by loss of consciousness, first by having a recognized catastrophic neurological injury, then the absence of brain stem reflexes, and not initiating breathing when a proper stimulus is provided.
The EEG, as you well know and as neurologists know, measures cortical activity, but doesn’t measure brain stem function. There’s concern about calling someone dead, or death by neurological criteria, when they’re actually not. They may still have a devastating injury. There are better ways of doing ancillary testing, including brain blood flow studies, which are noninvasive.
Wilner: I want to follow up on that. The guidelines are very clear that the ancillary studies are only necessary if you can’t complete the proper clinical exam, including the apnea test.
Elijovich: Correct.
Wilner: I know that there are places that shortchange the clinical exam and go right to a flow study. What do you think about that?
Elijovich: It’s not necessary. I think that’s important for everyone to understand. If you can do a neurological exam and if there aren’t barriers to testing cortical function in the brain stem, then you should do an apnea test.
In Memphis, at least, we have patients who are very, very sick with premorbid conditions and it’s not just a catastrophic brain injury. Then it becomes challenging to do an apnea test because they’ll have hemodynamic instability. They’re already on multiple pressors, and so you worry that they will have a cardiac arrest during the apnea test.
You have to evaluate that. The guidelines talk about that and when you should consider an ancillary test. If you can do a clinical exam and an apnea test, that is legal and medical death or death by neurological criteria.
Nothing Controversial
Wilner: Do you think these guidelines will be accepted nationally? Is there any reason to object?
Elijovich: I think they will. There’s nothing in them that’s controversial. They addressed and discussed several topics that were holes and that maybe we needed to address or start to think about to make them even, I would say, more accepted.
Wilner: One last question. The guidelines insist that only one brain death exam is necessary for adults. I think with children, they’re still waffling a little bit. You still need two, just to be sure. They said, with an adult, you can be sure after one exam. Do you think one exam is enough?
Elijovich: I think it is. I think what makes one exam acceptable is understanding the guideline and understanding the boxes you need to check before doing the clinical exam. There are several examples, such as terribly deranged temperature or a patient who eats in hypothermic. You have to give them the appropriate amount of time to be warm. The guideline addresses that. Similarly for metabolic disorders.
Once you check all those boxes, a good clinical exam and an apnea test or an ancillary test is sufficient and has been since these kinds of guidelines have been put in place, I think, in the 1960s when the Harvard criteria were initially published.
Wilner: Lucas, I want to thank you very much for this great discussion on the new brain death guidelines from the American Academy of Neurology.
Elijovich: Thank you, Andrew. Again, thanks to Medscape for inviting me. I think it’s an important guideline. As I said, the emphasis I would leave with people is that even when patients have these horrific injuries, there are many things that a neurologist or a critical care doctor can do for them, for their families, and for the community.
Wilner: Thank you very much.
