What is the procedure for seeking a second (2nd) or third (3rd) opinion on patients declared brain dead?

From the Guidelines

To seek a second or third opinion on brain death determination, it is crucial to consult with the primary healthcare team and request additional evaluations by independent neurologists or specialists who were not involved in the initial diagnosis. The process should involve comprehensive neurological assessments following established brain death protocols, as outlined in the guidelines for the determination of brain death in infants and children 1. These assessments typically include testing for absence of brainstem reflexes, lack of response to painful stimuli, and confirmation of apnea (inability to breathe independently) 1.

Key considerations in the evaluation process include:

• Prerequisites for initiating a brain death evaluation, such as correcting hypotension, hypothermia, and metabolic disturbances, and discontinuing sedatives, analgesics, neuromuscular blockers, and anticonvulsant agents for a reasonable time period based on their elimination half-life 1.
• The importance of a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma, where coma and apnea must coexist to diagnose brain death 1.
• The role of ancillary studies, such as EEG and radionuclide CBF, which are not required to establish brain death unless the clinical examination or apnea test cannot be completed, and are not a substitute for the neurologic examination 1.

The hospital should arrange for these independent evaluations, ensuring that life support measures continue until all opinions are obtained and a final determination is made. This multi-opinion approach is essential for ensuring diagnostic accuracy and providing families with confidence in the medical conclusion, given the profound implications of brain death determination for end-of-life decisions and potential organ donation considerations. The guidelines emphasize the importance of a strong recommendation for the determination of brain death, which can only be made if greater than 80% of the committee members vote "yes" 1.

From the Research

Procedure for Seeking a Second or Third Opinion on Brain Dead Patients

• The process of seeking a second or third opinion on brain dead patients is not explicitly outlined in the provided studies, but it can be inferred that it involves a thorough clinical evaluation and potentially the use of ancillary tests such as CT angiography 2 or other imaging studies.
• The diagnosis of brain death is typically made using clinical criteria, including coma, absence of brainstem reflexes, and loss of central drive to breathe, as assessed with an apnea test 3.
• In situations where uncertainty exists or clinical testing cannot be performed, ancillary tests may be useful in demonstrating the absence of cerebral electrical activity or cerebral circulatory arrest 2.
• The use of hormone replacement therapy (HRT) in brain-dead organ donors has been studied, and the literature suggests that it may increase organ procurement rates 4.
• However, the ethical considerations surrounding the continued treatment of brain-dead patients are complex, and policies should be adopted to manage family insistence on continued treatment 5.
• The American Academy of Neurology has published updated guidelines on the determination of death by neurologic criteria, which assert that hypothalamic function is consistent with the neurological standard enshrined in the Uniform Determination of Death Act (UDDA) 6.

Clinical Evaluation and Ancillary Tests

• A comprehensive clinical evaluation, including assessment of coma, cranial nerves, motor testing, and apnea testing, is essential in determining brain death 3.
• Ancillary tests, such as CT angiography, perfusion scintigraphy, transcranial Doppler sonography, and MR angiography, may be used to support the diagnosis of brain death 2.
• The choice of ancillary test depends on the individual patient's circumstances and the availability of resources.

Ethical Considerations

• The ethical considerations surrounding the continued treatment of brain-dead patients are complex and involve balancing the family's wishes with the medical reality of the patient's condition 5.
• Policies should be adopted to manage family insistence on continued treatment, and healthcare professionals should make efforts to facilitate the transfer of brain-dead patients to alternative settings, such as long-term care facilities, when families insist on continued treatment despite being informed about the lack of potential for recovery of consciousness 5.