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New guidance on brain death could ease debate over when life ends

You ‘re dead when the brain stops functioning-absolutely and irreversibly. However it’s not always straightforward to draw the line between life and brain death.

A new study seeks to explain the distinction, maybe helping to alleviate family members’ pain with a loved one whose brain has died but whose heart still beats. Brain death has been an accepted scientific phenomenon for decades. But there is a lot of variance in how people identify it, says Gene Sung, a University of Southern California neurocritical care physician in Los Angeles. “Showing that there is some worldwide consensus, understanding and agreement at this time will hopefully help minimize misunderstanding of what brain death is,” Sung says.

Sung and his colleagues gathered doctors from medical societies across the globe as part of the World Brain Death Project to create a consensus about how to recognize brain death. The group, including critical care, neurology, and neurosurgery experts, reviewed established brain death research (which was slim) and used their clinical experience to write the guidelines, published in JAMA on August 3. The final product contained, in addition to the key recommendations, 17 supplements that discuss legal and religious issues, include checklists and flowcharts and also track the history of important medical advances. “Basically, we wrote a book,” says Sung.

The minimum standard to assess brain death is “a successful, comprehensive clinical examination,” says Sung. Before the examination even happens, doctors should verify that a person has had a neurological injury or condition that could cause brain death. Clinicians should then look for other explanations, conditions that might imitate brain death but are actually reversible. Cooling the body, a heart attack treatment technique, will temporarily cause brain activity to vanish, the study states. So, certain narcotics, alcohol, and other contaminants can. An assessment of brain death should include a series of physical response tests which require a functional brain: “Children can recover from a lot of different things differently from adults,” Sung says. “We want to really make sure they have had a devastating injury.”

Clarity over brain death from medical practitioners is long overdue, says Stanford University pediatric neurologist Paul Graham Fisher. Yet, he says, this is just a first move. “The snag is that the nonmedical part of the world has to buy in, too.”

According to Fisher, diverse cultural , religious and even legal powers obstruct a straightforward and widely recognized concept of brain death. “You’re still going to have people, on an individual level or a societal level, who may not buy in,” Fisher says.

He points to the example of Jahi McMath, a woman from Oakland, Calif., whose parents refused to believe that she had been brain-dead following complications from a 2013 tonsillectomy. She lived up to five years on a ventilator and tube feedings. In 2018 her liver failed, according to a statement from the lawyer for her family.
Different regions have their own rules for determining brain death, and even different hospitals do. For example , New Jersey lets family members object to a declaration of brain death based on religious or moral convictions. A person can be brain-dead in Pennsylvania, Fisher points out, “but as soon as you cross the Delaware River, you can say, ‘I object to it.'”

Some nations too are doing things differently. Some integrate brain scans into the assessment process , for example, on whether someone is brain-dead. The recommendations could change as work progresses.

“We can always learn more,” Sung says. “And if we learn more, we may have to change our recommendations.” But for now, “this is the best that we know.”

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