Nebraska Medicine Brain Death Criteria

Nebraska Medicine Policy Number: MS 29 

Purpose

To give an accurate and complete description required to establish a diagnosis of breath death/Death by Neurological Criteria (BD/DNC), and to describe the roles and responsibilities of various clinicians and staff members in the process. 

Scope

This policy applies to all patients at least 37 weeks corrected gestational age or older at Nebraska Medicine for whom a diagnosis of BD/DNC is considered. 

Background

Nebraska Medicine follows the definition of BD/DNC as established by the State of Nebraska in statute 71-7202 and utilizes the accepted medical standards for determining BD/DNC. 

A diagnosis of breath death is a clinical diagnosis that can only be established by a staff physician with privileges in neurology or critical/intensive care medicine. The staff physician will document the results of the brain death evaluation in the medical record. The time of death is determined at the time the evaluation is complete. Physicians in training, who are at an advanced level of training and deemed appropriate by the staff physician and working under the staff physician's direct supervision, can perform parts of the examination. The staff physician is fully responsible for the diagnosis, declaration, and documentation of brain death. 

Brain Death Evaluation

A complete brain death evaluation consists of three components. All three components must be completed to establish a diagnosis of brain death:

1. Establish permanent and proximate cause of coma
2. Establish absence of cortical function and brain stem reflexes by neurologic examination
3. Establish absence of spontaneous respirations by performing an apnea test 

Completion of the three components of the brain death evaluation is sufficient to establish a diagnosis of brain death. 

Ancillary Testing

Ancillary testing is not required if all three of the above components are completed. Ancillary tests may be used to support the diagnosis of brain death when uncertainty exists about the reliability of parts of the neurologic exam, when parts of the exam cannot be performed, or to shorten the interval between exams. the current acceptable ancillary tests are: Cerebral angiography, cerebral scintigraphy, and transcranial doppler (if age appropriate). 

The interpretation of these tests must be interpreted by a staff physician with the required level of expertise.

Special circumstances: 

1. Physicians with recognized or potential conflicts of interest in relation to the outcome of the patient's care must remove themselves from the BD/DNC evaluation. For instance, a transplant service physician whose patient expires and has the potential for organ donation should excuse himself/herself from declaring the patient brain dead.

References

1. Nebraska State Statute 71-7202. Determination of death. Source: Laws 1992, LB 906, 2. 
2. Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline. Neurology. Dec 12, 2023 issue: 101(24):1112-1132. Greer DM, Kirschen MP, Lewis A, Gronseth GS, Rae-Grant A, Ashwal S, Babu MA, Bauer DF, Billinghurst L, Corey A, Partap S, Rubin MA, Shutter L, Takahashi C, Tasker RC, Varelas PN, Wijdicks E, Bennett A, Wessels SR, Halperin JJ. 
3. The 2023 AAN/AAP/CNS/SCCM Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline. A Comparison with the 2010 and 2011 Guidelines. Ariane Lewis, MD https://orcid.org/0000-0002-075807320, Matthew P. Kirschen MD, PhD https://orcid.org/0000-0003-358502687, and David Greer, MD https://orcid.org/0000-0002-2026-8333 AUTHORS INFO & AFFILIATIONS. December 2023 issue. 

Related Policies and Procedures

Acute Bereavement Care -- TX02

Staff Accountability:

• Critical Care Medicine (09/2024)
• Medical Ethics Committee (09/2024)
• Pediatric Quality Committee (11/2024)
• Medical Staff Bylaws Committee NMC (11/2024)
• Medical Staff Medical Executive Committee NMC (11/2024)
• Board of Directors (11/2024)