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Determination of Brain Death (1.2.16)

Determination of Brain Death (1.2.16) - Policies, Clinical, UW Health Clinical, Administrative, Legally Driven Care

1.2.16


UW HEALTH CLINICAL POLICY 1
Policy Title: Determination of Brain Death
Policy Number: 1.2.16
Category: UW Health
Type: Inpatient
Effective Date: December 28, 2017

I. PURPOSE

The purpose of this policy is to define standards for the determination of death by neurological criteria, also
known as “brain death”, in adult patients (defined as those 18 years of age and older for purposes of this
policy) in accordance with institutional, state, and federal requirements.

This policy does not apply to patients under 18.

II. DEFINITIONS

Determination of death by neurological criteria, also known as brain death, is defined as the irreversible loss
of the capacity for consciousness combined with the irreversible loss of all brain and brainstem functions,
including the capacity to breathe. Death determined by neurological criteria constitutes the death of the
individual, even though the heart continues to beat and spinal cord functions may persist.

III. POLICY ELEMENTS

A. State and Federal law require that a declaration of death be made in accordance with accepted medical
standards. According to Wisconsin Statutes section 146.71, an individual who has sustained either
irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the
entire brain, including the brain stem, is dead. This policy sets forth UW Health standards for the
determination of death by neurological criteria.
B. One licensed faculty physician is required to determine and document that a patient has suffered a total and
irreversible cessation of all brain function.
i. Critical Care Fellows and Neurology and Neurosurgery residents may perform the brain death
evaluation with indirect supervision if previously deemed competent by their training program.
ii. Brain death declaration will not be completed by any member of any organ recovery or transplant
team.

IV. PROCEDURE

If determination of brain death is based solely on the clinical examination all criteria from A-F must be met.

A. Establish irreversible and proximate cause of coma. The cause of coma can usually be established by
history, examination, neuroimaging, and laboratory tests.
i. Exclude the presence of a CNS-depressant drug effect by history, drug screen, calculation of
clearance or, if available, drug plasma levels below the therapeutic range. Prior use of hypothermia
(e.g., after cardiopulmonary resuscitation for cardiac arrest) may delay drug metabolism. If
necessary, review drugs and clearance times with pharmacy.
ii. There should be no recent administration or continued presence of neuromuscular blocking agents
(this can be defined by the presence of a train of 4 twitches with maximal ulnar nerve electrical
stimulation).
iii. There should be neither severe acidosis (pH must be greater than 7.20) nor a severe electrolyte,
endocrine, or other metabolic disturbance that could confound the clinical exam.
B. Achieve normal core temperature.
i. In most patients, a warming blanket is needed to raise the body temperature and maintain a normal
or near-normal temperature (>35°C). This is especially important in order to avoid delaying an
increase in P
a
CO
2
during the apnea test.
C. Achieve normal systolic blood pressure.
i. Hypotension from loss of peripheral vascular tone or hypovolemia (diabetes insipidus) is common;
vasopressors or vasopressin are often required. Neurologic examination is usually reliable with a
systolic blood pressure ≥ 90 mm Hg or a mean arterial pressure ≥ 60 mm Hg.
D. Perform one neurologic examination.
E. Coma.



UW HEALTH CLINICAL POLICY 2
Policy Title: Determination of Brain Death
Policy Number: 1.2.16

i. The patient should be observed for absence of spontaneous movement and absence of brain-
mediated responses to noxious stimuli applied cranially and peripherally.
F. Absence of brainstem reflexes (unless contraindicated or untestable).
i. The pupils must be non-reactive to bright light.
ii. If testing is not contraindicated (e.g. due to cervical spine injury), oculocephalic (“doll’s eye”) and
oculovestibular (ice water caloric) responses must be absent.
iii. Corneal reflexes must be absent.
There must be no movement of the head, face, or eyes in response to painful stimulation.
Pharyngeal (gag) and tracheal (cough) reflexes must be absent.
G. Apnea.
i. Unless contraindicated, an apnea test should be performed in all patients.
ii. The apnea test is meant to test for lack of responsiveness to CO2 challenge (PaCO2 equal to or
greater than 60 mm Hg, or a 20 mm Hg rise in PaCO2 above baseline PaCo2 in individuals who
are known CO2 retainers) or respiratory acidosis (pH equal to or less than 7.3) after an observation
period of 8 minutes. This test should be performed after preoxygenation with 100 % O2 for 10
minutes.
iii. If hemodynamic instability prevents completion of the test, the test should be aborted, and an
ancillary test performed.
H. Ancillary Testing.
i. In the case of severe irreversible brain injury of known cause and when the neurological
examination cannot be reliably performed or interpreted (for example in therapeutic medically
induced coma or hypothermia) ancillary testing may be performed to confirm the absence of blood
flow to the brain parenchyma, in which case brain death would be confirmed.
I. Communication with Family.
i. The patient’s family is not asked to participate in or to make the decision that the patient has met
neurological criteria for declaration of death. The family should be informed that evaluation for
neurological death is taking place, and also when the determination has been made. The family is
then informed that even though the patient has spontaneous cardiac activity, the patient is legally
dead. Family permission is NOT required for the removal of the ventilator when a determination of
death by neurological criteria has been made. However, a reasonable amount of time should be
allowed for the family to visit the patient and come to terms with the diagnosis prior to the removal
of the ventilator. Consideration should be given to patients and families with specific religious and
cultural beliefs regarding brain death and end-of-life care, and the Ethics Committee and/or
Spiritual Care Services may be helpful in resolving any disagreements.
J. Documentation of Death by Neurological Criteria.
i. Documentation of brain death will include a statement that reversible causes of coma were
excluded, clinical exam (including the absence of brain stem reflexes and apnea testing) and/or
ancillary tests performed, the date and time of death, and the physician signature. The date and
time of brain death will be the date and time of death recorded on the death certificate.

V. COORDINATION

Author: Neurologist, Neurosurgeon, and Critical Care physician
Senior Management Sponsor: SVP/Assoc Chief Med Officer
Reviewers: Nurse Manager-Neuro ICU, Radiologist, Respiratory Care Manager
Approval committees: UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: November 20, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer




UW HEALTH CLINICAL POLICY 3
Policy Title: Determination of Brain Death
Policy Number: 1.2.16

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

Wijdicks, EFM, Panayiotis, NV, Gronseth, GS, Greer, DM. Evidence-based guideline update: Determining
brain death in adults. Neurology. 2010;74:1911-1918.
Wijdicks EF. Determining brain death in adults. Neurology. 1995;45(5):1003-1011.
Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. A definition of
irreversible coma. JAMA. 1968;205(6):337-340.
Wisconsin Statutes section 146.71

VIII. REVIEW DETAILS

Version: Original
Last Full Review: December 2017
Next Revision Due: December 2020
Formerly known as: N/A