Brain Death Challenges - Eight Suggestions for Determination of Death by Neurological Criteria

Here are some of the challenges that have been articulated in meetings and in the hotel bars in Havana this week.

1. We must get more precise and accurate in how we determine death by neurological criteria. We are presently allowing false positives. These must be eliminated.  

2. We should ensure that the clinicians conducting the DDNC test are qualified. This can be done through institutional credentialing or through other vetting processes.

3. We should raise the AAN standards to include ancillary testing as an automatic part of the protocol. Some institutions have done this on their own. 

4. Even if the AAN criteria were sufficient, there is massive variability. This must be eliminated or else it is unclear what a DDNC really means. 

5. While there are more challenges, they are only individual case reports. That level of evidence is insufficient to dictate guidelines. Moreover, these case reports have not been vetted as carefully as necessary (e.g. through peer review).

6.  Brain death, like anything else, is not and never will be 100% accurate. Scientists want 100% certainty. Clinicians know this is not possible. 

7.  Instead of focusing on DIAGNOSIS, we should frame the determination as one of PROGNOSIS - the patient will never recover, interact...

8. Just as the 30-year-old medical futility debate (1988-2018) has finally rejected clothing value judgments in the objective, scientific clothing of "futility" vocabulary, we should not frame value judgments about what kind of brain injury is worth treating using the objective, scientific clothing of "brain death" vocabulary.