Review Article | Published:

Controversies in defining and determining death in critical care

Nature Reviews Neurology volume 9, pages 164173 (2013) | Download Citation

Abstract

Circulatory–respiratory or brain tests are widely accepted for definition and determination of death, but have several controversial issues. Both determinations have been stimulated by organ donation, but must be valid independently of this process. Current controversies in brain death include whether the definition is conceptually coherent, whether the whole-brain or brainstem criterion is correct, whether one neurological examination or two should be required, and when to conduct the examination following therapeutic hypothermia. Controversies about the circulatory determination of death include the minimum duration of asystole that is sufficient for death to be declared, and whether the distinction between permanent and irreversible cessation of circulatory functioning is important. In addition, the goal of organ donation raises issues such as the optimal way to time and conduct the request conversation with family members of the patient, and whether the Dead Donor Rule should be abandoned.

Key points

  • Death can be determined by circulatory–respiratory or brain tests

  • All brain death practices use the whole-brain or brainstem criterion of death

  • Controversies about brain death focus on the coherence of the concept, the extent of necessary neuronal damage, and the tests required to prove irreversibility

  • Controversies about circulatory death focus on the required duration of asystole before death can be declared, and whether permanent or irreversible cessation should be the standard

  • The option of organ donation should be presented to families of deceased patients, but the optimal timing of and approach to the donation request remain unclear

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  1. Neurology Department, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.  bernat@dartmouth.edu

    • James L. Bernat

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The author declares no competing financial interests.

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https://doi.org/10.1038/nrneurol.2013.12

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