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"Brain Death"
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Lucid dying : the new science revolutionizing how we understand life and death
From internationally renowned expert in resuscitation and near-death experience Sam Parnia comes a groundbreaking look at what happens to us when we die, based on the largest-ever research study run on near-death experiences.
BOOK
Cognitive Motor Dissociation in Disorders of Consciousness
Among 241 persons with disorders of consciousness who had no observable response to commands, 25% had a verifiable response to commands on EEG or functional MRI, a condition known as cognitive motor dissociation.
Journal Article
The undead : organ harvesting, the ice-water test, beating-heart cadavers-- how medicine is blurring the line between life and death
Science writer Dick Teresi examines how death is determined by the medical community and explores organ trafficking, brain death, and near-death experiences.
Book
A brain-based definition of death and criteria for its determination after arrest of circulation or neurologic function in Canada: a 2023 clinical practice guideline
This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as recommendations for death determination by circulatory criteria for potential organ donors and death determination by neurologic criteria for all mechanically ventilated patients regardless of organ donation potential. This Guideline is endorsed by the Canadian Critical Care Society, the Canadian Medical Association, the Canadian Association of Critical Care Nurses, Canadian Anesthesiologists’ Society, the Canadian Neurological Sciences Federation (representing the Canadian Neurological Society, Canadian Neurosurgical Society, Canadian Society of Clinical Neurophysiologists, Canadian Association of Child Neurology, Canadian Society of Neuroradiology, and Canadian Stroke Consortium), Canadian Blood Services, the Canadian Donation and Transplantation Research Program, the Canadian Association of Emergency Physicians, the Nurse Practitioners Association of Canada, and the Canadian Cardiovascular Critical Care Society.
Journal Article
The reason you're alive
After sixty-eight-year-old David Granger crashes his BMW, medical tests reveal a brain tumor that he readily attributes to his wartime Agent Orange exposure. He wakes up from surgery repeating a name no one in his civilian life has ever heard--that of a Native American soldier whom he was once ordered to discipline. David decides to return something precious he long ago stole from the man he now calls Clayton Fire Bear. It may be the only way to find closure in a world increasingly at odds with the one he served to protect. It may also help him to finally recover from his wife's untimely demise. As David confronts his past to salvage his present, a poignant portrait emerges: that of an opinionated and good-hearted American patriot fighting like hell to stay true to his red, white, and blue heart, even as the country he loves rapidly changes in ways he doesn't always like or understand. Hanging in the balance are Granger's distant art-dealing son, Hank; his adoring seven-year-old granddaughter, Ella; and his best friend, Sue, a Vietnamese American who respects David's fearless sincerity. Through the controversial, wrenching, and wildly honest David Granger, Matthew Quick offers a no-nonsense but ultimately hopeful view of America's polarized psyche.
Infratentorial brain injury and death by neurologic criteria in Canada: a narrative review
There are two anatomic formulations of death by neurologic criteria accepted worldwide: whole-brain death and brainstem death. As part of the Canadian Death Definition and Determination Project, we convened an expert working group and performed a narrative review of the literature. Infratentorial brain injury (IBI) with an unconfounded clinical assessment consistent with death by neurologic criteria represents a nonrecoverable injury. The clinical determination of death cannot distinguish between IBI and whole-brain cessation of function. Current clinical, functional, and neuroimaging assessments cannot reliably confirm the complete and permanent destruction of the brainstem. No patient with isolated brainstem death has been reported to recover consciousness and all patients have died. Studies suggest a significant majority of isolated brainstem death will evolve into whole-brain death, influenced by time/duration of somatic support and impacted by ventricular drainage and/or posterior fossa decompressive craniectomy. Acknowledging variability in intensive care unit (ICU) physician opinion on this matter, a majority of Canadian ICU physicians would perform ancillary testing for death determination by neurologic criteria in the context of IBI. There is currently no reliable ancillary test to confirm complete destruction of the brainstem; ancillary testing currently includes evaluation of both infratentorial and supratentorial flow. Acknowledging international variability in this regard, the existing evidence reviewed does not provide sufficient confidence that the clinical exam in IBI represents a complete and permanent destruction of the reticular activating system and thus the capacity for consciousness. On this basis, IBI consistent with clinical signs of death by neurologic criteria without significant supratentorial involvement does not fulfill criteria for death in Canada and ancillary testing is required.
Journal Article
If cats disappeared from the world
The postman's days are numbered. Estranged from his family, living alone with only his cat Cabbage to keep him company, he was unprepared for the doctor's diagnosis that he has only months to live. But before he can tackle his bucket list, the Devil appears to make him an offer.
BOOK
Brain function in coma, vegetative state, and related disorders
We review the nosological criteria and functional neuroanatomical basis for brain death, coma, vegetative state, minimally conscious state, and the locked-in state. Functional neuroimaging is providing new insights into cerebral activity in patients with severe brain damage. Measurements of cerebral metabolism and brain activations in response to sensory stimuli with PET, fMRI, and electrophysiological methods can provide information on the presence, degree, and location of any residual brain function. However, use of these techniques in people with severe brain damage is methodologically complex and needs careful quantitative analysis and interpretation. In addition, ethical frameworks to guide research in these patients must be further developed. At present, clinical examinations identify nosological distinctions needed for accurate diagnosis and prognosis. Neuroimaging techniques remain important tools for clinical research that will extend our understanding of the underlying mechanisms of these disorders.
Journal Article
Pharmacologic and toxicologic confounders in brain death determination: a multidisciplinary guide
Background
The assessment of comatose ICU patients presents several challenges with respect to the etiology, depth and ultimate outcome. The acceptance in 1959 of the worst-outcome scenarios of coma, i.e. brain death, and the publication of the Harvard Brain Death Criteria in 1968, were key developments in the management of irreversible coma. Pharmacologic confounders often complicate coma assessments, including brain-death determination. Moreover, associated clinical factors during coma, such as organ failure, hypothermia, prolonged continuous infusions, intoxication, and extreme obesity often alter drug metabolism and clearance. Such circumstances may further complicate standard assessments, and guideline recommendations often do not account for altered pharmacokinetics and pharmacodynamics.
Main text
The assessment of comatose patients involves complex pharmacologic considerations that significantly impact diagnostic accuracy. Accurate differentiation between pharmacologic, metabolic, and structural causes of coma is essential, particularly since drug-related unconsciousness generally carries a more favorable prognosis than other etiologies. Nonetheless, for best outcomes, it is imperative that the etiology of any drug-induced coma be determined as early as possible. It is important to recognize, however, that routine toxicology screens are not comprehensive. Additionally, the interplay between hypothermia and drug metabolism poses unique challenges, as core temperature significantly affects pharmacokinetic parameters such as hepatic metabolism, leading to reduced drug clearance. Multiorgan dysfunction, common after severe neurological injury, further complicates these assessments. Overdose scenarios introduce additional complexity. While ancillary testing may aid in diagnosis of brain death, they have limitations, particularly in cases of profound intoxication. Additionally, premature use of ancillary testing could lead to misdiagnosis. This review is organized into two main sections: Part I examines general coma and its associated pharmacologic considerations, followed by Part II which focuses on brain death.
Conclusion
Accurate assessment of coma and brain death often requires a multidisciplinary approach, integrating expertise in neurology, pharmacy, critical care, and toxicology. Current brain death guidelines provide a framework but leave open critical gaps in pharmacologic and toxicologic confounders. This review article highlights the importance of multidisciplinary approach to the care of coma and brain death patients and further research to refine diagnostic accuracy and mitigate the risks of premature brain death declarations.
Journal Article