BEGINNING in the late Nineteen-Nineties medical research was published that called into question both the meaning of the term “Brain Death” and the neurological criteria (especially the apnea test) used to confirm this diagnosis. Both the so-called “Doctrine of Imminent Asystole” (the heart will inevitable stop beating within a short period of time; usually 72 hours to one week) and the concept of the brain as the primary organ “of  integration” fell from favor as rationales for organ-procurement practices.

1918 UDDA Uniform Definition of Death

All 50 states have now adopted some version of the UDDA.  The original UDDA was approved for the United States in 1981 by the National Conference of Commissioners on Uniform State Laws, in cooperation with the American Medical Association, the American Bar Association, and the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research

1989 Pontifical Academy

Death… has in fact occurred when:

a) spontaneous cardiac and respiratory functions have irreversibly ceased, which rapidly leads to a total and irreversible loss of all brain functions, or

b) there has been an irreversible cessation of all brain functions, even if cardiac and respiratory functions which would have ceased have been maintained artificially.

2006_LACMA_LABA_Guidelines

Joint Committee on Biomedical Ethics of the Los Angeles County Medical Association and Los Angeles County Bar Association; Approved by the Los Angeles County Medical Association February 15, 2006 Approved by the Los Angeles County Bar Association March 22, 2006

NEUROLOGICAL DETERMINATION of DEATH (BRAIN DEATH)

The Uniform Determination of Death Act provides for the determination of death by either circulatory-respiratory or neurological criteria: “An individual who has sustained either [:]

(1) irreversible cessation of circulatory and respiratory functions, or

(2) irreversible cessation of all functions of the entire brain, including the brain stem,

is dead. A determination of death must be made in accordance with accepted medical standards.” (California Health & Safety Code Section 7180.) Separate Code sections also require that a death diagnosed on neurological grounds must be independently confirmed by a second physician, and that neither physician making such a determination shall participate in the procedures for removing or transplanting a body part from the deceased.

 Because “accepted medical standards” change in accordance with medical and technological progress, facilities should maintain current policies and procedures for determination of death by neurological criteria.

1. The attending physician should inform the surrogate decision-maker of the determination of death and the need to remove all medical interventions. The surrogate decision-maker should have an opportunity, if desired, to request confirmation of the neurological determination by a physician of the surrogate decision-maker’s choosing before ventilatory support or other such interventions are removed. The determination of death remains a medical decision, however.

2. Prior to removal of medical interventions, a physician or nurse involved in the case should, in appropriate circumstances, consult the hospital’s organ donation policy to determine whether further action is required regarding the donation of organs or other body parts. [1]

3. Individuals who meet the neurological criteria for the determination of death and who are maintained on a respirator retain some of the indicia ordinarily associated with life: bodily warmth, a moving chest, heartbeat, and normal skin color. Physicians should be sensitive to how this might be perceived by survivors and explain that notwithstanding the patient’s appearance, the patient meets the medical and legal criteria for death. Once death has been pronounced, all medical interventions should be withdrawn. Medical interventions may be continued to preserve the viability of organs for transplant or, in unusual circumstances, for a limited time at the request of the family.