While establishing that someone is brain dead is a straightforward medical examination that includes testing reflexes and determining whether a person can breathe on his own, a Mayo Clinic neurologist has found the procedures surrounding this examination vary widely throughout the world. This, he says, could cause unnecessary delay in declaring someone brain dead.
The official declaration of brain death is a necessary step for withdrawal of life support and to allow organ donation. However, "procedures such as prolonged observation of the patient and a requirement for specialized physicians to declare death might unnecessarily prolong the declaration of death and potentially jeopardize organ donation," says Dr. F.M. Eelco Wijdicks of the Mayo Clinic in Rochester, Minn.
"I haven't seen any data that shows how many organs have been lost in this way, but it's a reasonable concern," says Dr. Stuart Youngner, director of the Center for Biomedical Ethics at Case Western Reserve University in Cleveland. "Simple tests should be used."
In a survey of the guidelines in 80 countries around the world, the results of which appear in this week's issue of Neurology, Wijdicks found that: many countries require more than one physician to declare someone brain dead; some specify the declaration be made by a specialist such as a neurologist; some mandate there be a 24-hour waiting period after the declaration before life support is removed.
"There is a set of criteria [for determining brain death] that is simple, but which over the years have been widely expanded," he says, "and the reasons seem more procedural than cultural or religious."
Wijdicks would like doctors to assess the guidelines in their countries to see if all the mandated criteria are necessary, or perhaps an international task force be established to "come up with a generally agreed upon criteria."
For his survey, doctors were contacted in most countries of the world and asked for their guidelines surrounding declaration of brain death. Data was collected from 80 countries in addition to the United States, primarily those in Europe, South America and Asia. Only five African countries responded.
In this country, a 1983 law mandates the criteria for declaring brain death, which include testing for brain stem reflexes and breathing ability. Some states have expanded upon the criteria requirements, including requiring two physicians or mandating physicians have certain academic qualifications or specialized medical skills.
Other variations in procedures throughout the world include the waiting time after the declaration of brain death, which is six hours in this country, but can be up to three days in Hungary, and requiring lab tests.