The IRREVERSIBLE cessation of ALL functions of the ENTIRE brain, including the brainstem
Cold caloric response: Mnemonic is "COWS"- Cold, Opposite, Warm, Same and describes the FAST phase of nystagmus in the patient with an intact brainstem. Hence, there will be a slow phase toward the side you injected the cold water and then a fast beat away from the side you injected the cold water if the brainstem is intact. A video of the procedure can be found here
Oculocephalic Response or "Doll's Eyes" maneuver: Can only be done if the patient has a stable cervical spine. As you turn the head laterally, with an intact brainstem, the eyes should not stay fixed in position but should deviate back towards the midline (ie so that the gaze is looking at the ceiling rather than laterally). A video of the procedure can be found here
University of Michigan Health System Policy
Issued: 12/85 Last Reviewed: 9/12 Last Revised: 9/12
I. POLICY STATEMENT
It shall be the policy of the University of Michigan Hospitals and Health Centers (UMHHC) that the guidelines specified herein be utilized in the determination of patient brain death.
II. POLICY/PROCEDURE PURPOSE
The purpose of this policy is to provide guidelines for the use of clinicians in the determination of patient brain death.
Brain Death - the IRREVERSIBLE cessation of ALL functions of the ENTIRE brain, including the brainstem. Decisions about prognosis and withdrawal of artificial life support do NOT usually require determination of brain death (institutional guidelines for terminating treatment are available at the following web site:http://www.med.umich.edu/adulthics/Witholding_Life_Sustaining_Tx.pdf.)
The determination of brain death is made by a physician based on accepted medical standards. Michigan State law does not set forth the standards, so each hospital must establish guidelines for brain death. The state Determination of Death law (Act 90 of 1992) is attached as the Exhibit A.
IV. POLICY STANDARDS
A. GENERAL GUIDELINES FOR ESTABLISHING BRAIN DEATH
The cause of the condition should be established if at all possible. Brain death determination should not be made in the presence of potentially reversible conditions and conditions such as cardiovascular SHOCK, DRUG INTOXICATION, or HYPOTHERMIA (see section IV. C.2.), in which brain death cannot be determined reliably. The diagnosis of potentially reversible conditions should be based on clinical grounds (medical history, physical and neurological examinations), and documented by the appropriate laboratory tests. The diagnosis of brain death is BASED UPON CLINICAL CRITERIA. The staff physician determining brain death should determine the following:
1. There has been loss of ALL FUNCTIONS of the ENTIRE BRAIN, including the brainstem; and
2. The loss of all functions of the entire brain is IRREVERSIBLE.
B. CLINICAL CRITERIA FOR DOCUMENTING LOSS OF ALL FUNCTIONS OF THE ENTIRE BRAIN
1. ABSENT CEREBRAL FUNCTION
The patient must be in deep coma. That is, there is no perception or response to external stimuli. Decerebrate and decorticate responses are absent.
2. ABSENT BRAINSTEM FUNCTIONS
The following reflexes are absent:
a) Pupillary light response.
b) Corneal reflex.
c) Oculocephalic reflex.
d) Oculovestibular reflex.
e) Gag reflex.
e) Respiratory reflex.
The absence of spontaneous respiration, in the presence of hypercarbia (paCO2 greater than 60 mm Hg AND at least 20 mm Hg above the baseline paCO2) should be observed by a physician and carefully documented. An accepted method is to ventilate the patient with pure oxygen or an oxygen and carbon dioxide mixture for ten (10) minutes before withdrawal of the ventilator, followed by passive flow of oxygen. This procedure allows paCO2 to rise without hazardous hypoxia. Hypercarbia adequately stimulates respiratory effort within 30 seconds when the paCO2 is greater than 60 mmHg. A 10 minute period of apnea is usually sufficient to attain this level of hypercarbia. Testing of arterial blood gases should be used to confirm this level.
3. OPTIONAL CONFIRMATORY TESTS
The determination of brain death may be made on the basis of clinical observations alone (over the appropriate time interval-see below). However, when it is necessary to make the determination of brain death as soon as possible, or when there is uncertainty about the interpretation of the clinical examination, the clinical diagnosis may be confirmed by one of the following diagnostic tests. Hypothermia and circulatory shock should be corrected before performing these tests. On rare occasions these tests may result in false negative or false positive outcomes. When circumstances suggest that a test result is unreliable, clinical judgement is required.
a) Radionuclide cerebral angiogram. This test may be performed portably (emergency room or intensive care unit) and on an urgent basis. The complete cessation of circulation to the normothermic brain is incompatible with survival of brain tissue.
b) Four-vessel cerebral angiogram. This test must be performed in the angiography suite.
c) Electroencephalogram. This test should be performed according to published Guidelines for performing EEGs in cases of suspected brain death (American Electroencephalographic Society). The EEG is used to verify irreversible loss of cerebral cortical functions.
C. CLINICAL CRITERIA FOR IRREVERSIBILITY
Irreversibility is recognized when the evaluation discloses each of the following:
1. The cause of the coma is established and is sufficient to account for the loss of brain functions.
In addition to careful medical history and clinical examination, MRI or CT brain scan, drug screening, EEG, 4 vessel or radionuclide angiography, lumbar puncture or other diagnostic procedures may be needed to establish the cause of coma. In each case, the appropriate diagnostic procedures should be determined by the attending physician and neurological or neurosurgical consultant.
2. Reversible conditions that can prevent reliable interpretation of the physical examination have been excluded.
The most important reversible conditions are sedation, hypothermia, neuromuscular blockade, and shock. The following guidelines are recommended.
a) In the presence of exogenous intoxication, brain death cannot be declared until the intoxicant is metabolized to a level insufficient to account for the physical examination and intracranial circulation is tested and found to have ceased.
b) Before irreversible cessation of brain functions can be determined, the following should also be corrected:
i. Hypothermia: patient must be rewarmed to a core temperature of at least 35.0 degrees C (i.e. 95 degrees F) and ideally to 36.0 degrees C (i.e. 96.8 degrees F) or greater.
ii. Circulatory shock.
In cases of severe metabolic abnormalities, these abnormalities should be corrected, if possible, before determination of brain death is made.
3. The cessation of all brain functions continues to exist after an appropriate period of observation and/or trial of therapy. The appropriate period of observation required to confirm irreversibility will vary depending upon the patient's age and clinical conditions of the case. For patients less than 18 years of age, there must be an interval of at least 24 hours between cardiopulmonary resuscitation and brain death determination.The following observation periods are recommended as a general guide. For infants born before full term, the corrected gestational age should be used (i.e. calculated with respect to the full-term date rather than the date of birth). Note that infants less than 37 weeks of gestation can not be declared brain dead.
a) Age greater than or equal to 31 days.
1) With confirmation by angiography or EEG, two clinical examinations at least one hour apart.
2) If confirmation by EEG or angiography is not done, yet an IRREVERSIBLE CAUSE is WELL ESTABLISHED, two clinical examinations at least 12 hours apart.
b) Term newborn (37 weeks gestation) - 30 days of age
1) Two clinical examinations - MINIMUM 24 HOURS APART. Confirmatory tests cannot be used to shorten this interval.
D. RESPONSIBILITY OF DETERMINING BRAIN DEATH
Formal determination of brain death requires documentation of two clinical examinations, each with a note in the hospital record signed by an attending physician.
For patients 18 years of age or older:
1. The first of the two required examinations may be by a resident physician training in neurology, pediatric neurology, or neurosurgery or it may be by an attending physician who is a (pediatric or adult) neurologist or neurosurgeon.
2. The second examination must be performed by an attending physician who is a (pediatric or adult) neurologist or neurosurgeon. This physician must not be one of the primary physicians responsible for the patient's care.
3. The two required clinical examinations may be performed by different physicians or by the same physician (if that physician meets the requirements to perform the second examination).
4. Only one apnea test is required. It can be performed with either of the two required clinical examinations, or at any time in between. A physician must be present throughout the entire apnea test, and that physician must document the absence of spontaneous respirations and the maximum paCO2 measured. The physician witnessing the apnea test does not need to be an attending physician and does not need to be a neurologist or neurosurgeon (or training to be one).
For patients less than 18 years of age:
1. At least one of the two required examinations must be performed by an attending physician who is a (pediatric or adult) neurologist or neurosurgeon.
2. The other required examination must be performed by an attending physician who is either a (pediatric or adult) neurologist or neurosurgeon or a specialist in pediatric critical care medicine.
3. The attending physician who performs the second clinical examination cannot be the same attending physician who performs the first clinical examination.
4. An apnea test must be performed with each of the two examinations. A physician must be present throughout the entire apnea test, and that physician must document the absence of spontaneous respirations and the maximum paCO2 measured. The physician witnessing the apnea test does not need to be an attending physician, and does not need to be a neurologist or neurosurgeon (or training to be one).
For all patients, regardless of age:
1. Each of the two notes should include careful description of neurological examination, observation periods, and the results of diagnostic and confirmatory tests, and should be signed by an attending physician.
2. Brain death should be declared only after both examinations have been completed and the attending physician performing the second examination has documented in the hospital medical record that all criteria for brain death have been met.
E. DETERMINATION OF DEATH PRIOR TO REMOVAL OF LIFE SUPPORT SYSTEMS
Michigan law says that death occurs when ALL functions of the ENTIRE brain, including the brainstem cease. When it has been determined that a patient meets all criteria for brain death, death is to be pronounced before artificial means of supporting respiratory and circulatory functions are terminated. Once death has been declared, the patient can be removed from life support systems even over family objections. However, discretion should be used and the family counseled. It may be prudent to leave a brain dead patient on support systems for a short period for the family to adjust.
Michigan has adopted the Uniform Anatomical Gift Act. If assistance is required in facilitating organ donation, the appropriate contact phone numbers are: Transplant Society of Michigan - Gift of Life (TSM) (1-800-482-4881) or their local Ann Arbor number (973-1577). The Act states that time of death for the donor shall be determined by the physician who attends the donor at the death, or, if none, the physician who certifies the death. The attending or certifying physician shall not participate in the procedures for removing or transplanting a physical part. The process of requesting donations, in accordance with the Uniform Anatomical Gift Act, is outlined in UMHHC policies 02-05-003 Organ, Tissue and Eye Donation.
V. PROCEDURE ACTIONS
As appropriate to the patient.
Exhibit B - Clinical Exam for Brain Death Determination
UMHHC policy 02-05-003 Organ, Tissue and Eye Donation
UMHS Guidelines for Terminating Life Support:http://www.med.umich.edu/adulthics/Witholding_Life_Sustaining_Tx.pdf
Determination of Death Act, Public Act 90 of 1992
Uniform Anatomical Gift Act, Public Act 186 of 1986 (effective October 7, 1986)
Author: Cerebral Death Determination Committee, Douglas Gelb, M.D., Chairman
Approved by: Executive Committee on Clinical Affairs - 7/24/90; 6/10/97; 6/12/01; 2/13/07; 2/10/09; 9/25/12
Approved by: Executive Director, UMHHC - 10/31/01; 6/21/07; 3/20/09; 10/1/12
Reviewed by the Office of Clinical Affairs, 9/8/04 - No changes required.
1) Nakagawa TA, Ashwal S, Mathur M, Mysore MR, Bruce D, Conway EE Jr, Duthie SE, Hamrick S, Harrison R, Kline AM, Lebovitz DJ, Madden MA, Montgomery VL, Perlman JM, Rollins N, Shemie SD, Vohra A, Williams-Phillips JA; Society of Critical Care Medicine; Section on Critical Care and Section on Neurology of the American Academy of Pediatrics; Child Neurology Society. Guidelines for the determination of brain death in infants and children: an update of the 1987 Task Force recommendations. Crit Care Med. 2011 Sep;39(9):2139-55. doi: 10.1097/CCM.0b013e31821f0d4f. PubMed PMID: 21849823.