Updated Brain-Death Guidelines Add Specificity (Podcast)

As one of medicine’s most definitive diagnoses, brain death can also be one of its most difficult for physicians and families. Clinical exposure to brain death has becomes less common while the expectation of precision continues to rise.

“Brain death is the death of [both] a brain and brainstem as a whole function, which can be difficult for many people to understand,” says Cleveland Clinic neurointensivist Dhimant Dani, MD. “They see that a brain is not working, but then they also see that the heart is beating.”

In the latest episode of the Neuro Pathways podcast, Dr. Dani joins Glen Stevens, DO, PhD, to discuss updated guidelines for determining brain death. In 2023, the American Academy of Neurology released new consensus guidelines, which included updating terminology from simply “brain death” to “brain death/death by neurologic criteria” (BD/DNC).

Other key changes included recommendations for both pediatric and adult patients in a single document; requirements for brain-death determination; criteria for examinations and examiners; apnea testing; ancillary testing; and communicating about brain death and declaring brain death to families.

“When we think of a brain-death exam, it starts with the prerequisite. Is the patient meeting that prerequisite?” says Dr. Dani. “The very important thing is that the injury to the brain has to be permanent. There should not be any form of reversibility.

Once that is determined, major confounders must be ruled out. That includes anything that can cause symptoms that mimic death, such as hypothermia, shock, metabolic derangements, certain medication and certain trauma injuries. Then, says Dr. Dani, a brain imaging CAT scan must support the diagnosis of irreversible brain injury.”

The podcast conversation also touches on:

• How brain death differs from coma and the vegetative state
• Why a neuroimaging is necessary
• How brainstem reflexes and apnea testing are assessed
• When ancillary testing is appropriate
• Why EEG is now considered obsolete in this setting
• The challenge of limited provider exposure and training

Click the podcast player above to listen to the 29-minute episode now, or read on for a short, edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

This activity has been approved for AMA PRA Category 1 Credit™ and ANCC contact hours. After listening to the podcast, you can claim your credit here.

Excerpt from the podcast

Podcast host Glen Stevens, DO, PhD:

The new guidelines, do they add specificity? Are they more objective? I assume that answer would be yes to that, but any specific examples?

Dhimant Dani, MD: There is more specificity, as well as there is more objectiveness to the new guidelines, which really helps a physician. A lot of nuances, like “normalization of metabolic derangement,” or a broader term, like “fixing metabolic issues” or “no major metabolic derangement” have been taken off.

Giving you an example, a specific temperature goal, which is … 36 degrees centigrade and above, in the past was not that as specific as what it is in 2023 guideline. Same thing with hemodynamic parameters, like a systolic blood pressure, but also adding a mean arterial pressure together. That has also added further guidance and stricter guidance for physicians to apply when they are performing a brain death (exam).

And, there is a new support and guideline for when to perform ancillary testing. Ancillary testing does not replace the brain death examination, but it supports the brain death examination. As you know, that ancillary testing does not focus on brain function, but on blood flow. When we think brain is dead, we think that that means that there should not be any blood flow to the brain. The ancillary test supports the diagnosis of lack of blood flow to the brain, which is something that is important. There has been more guidance on what level of metabolic derangement can cause changes in mental status and so forth. It has been described in a better way in the new guideline, and that is a very helpful and more accurate.