Brain Death: What’s in a name…?
#BD #DCD #DCDD #DNDD #WTF
There has been some recent controversy surrounding ‘brain death’1. Interestingly, this has not related to organ donation with which the term has become inextricably linked but rather to non-acceptance of ‘brain death’ as death. Of course, ‘brain death’ has been imbued with controversy for years. Controversies2 over the years have related to the concept itself – the idea that irreversible loss of brain function is a sufficient condition for the certification of death, and to the philosophical underpinning of the concept3 that was consequently re-formulated in a rather unsatisfactory manner4. And there have been challenges to the practical instantiation of the philosophical concept – challenges to the way in which irreversible loss of brain function is established and even some questioning of the certainty of the outcome.
Perhaps part of the ongoing controversy relates to the terminology. This has become more apparent with the re-emergence of cadaveric organ donation where the certification of death has not relied on the neurological (brain function) criterion. This was originally called non-heart-beating donation (NHBD) and then Donation after Cardiac Death (DCD). This latter term was never accurate and was altered to Donation after Circulatory Death to better reflect the statutory definition of death as irreversible cessation of circulation. Perhaps this change was also stimulated by a burgeoning interest in expanding cardiac transplantation to include this source of organs. The semantic difficulty of transplanting the heart from a donor whose death was defined by ‘cardiac death’ is obvious.
The problem with all of these terms – ‘brain death’, ‘cardiac death’ and ‘circulatory death’- is that they are inaccurate and potentially misleading. In most if not all jurisdictions, none of these exist as statutory entities. No patient can be certified or declared or even diagnosed as ‘brain dead’. Moreover, this term, at least, has lost a good deal of its cache as a result of its widespread inaccurate and even comical use. And the qualification of death leaves open the interpretation that there is another, more complete or unqualified form of death, perhaps ‘real death’.
Amongst the semantic difficulties has been the problem of finding terms that are more accurate and which are not too excessively clumsy for regular usage. Over the last few years in the American literature predominantly but also in European journals5-7, some new and more accurate terminology has emerged. This has predominantly resulted in a replacement of the inaccurate ‘DCD’ but has wider implications. The new term is ‘Donation after Circulatory Determination of Death’ abbreviated as DCDD. Somewhat less pervasive has been the companion term ‘Donation after Neurological Determination of Death’ (DNDD). At last with these we have a nomenclature that is accurate and not misleading. In this paradigm, it is death that is certified or declared or diagnosed and this accords with statutory definitions of death. Consistent with statutes, the variation is limited to the criterion used to determine that death has occurred. So the patient is simply dead, not ‘brain dead’ or cardiac dead’ or ‘circulatory dead’ or even really dead.
This change in terminology will have no impact on the other controversies that surround practice in this area. Concerns over the lack of a sound scientific construct underpinning the neurological determination of death8 persist as will concerns that current practice necessarily relies on legal fictions9. Nevertheless, the consistent use of accurate terminology might in some measure at least contribute to a broader and more widespread acceptance of these sometimes troublesome concepts. And it is difficult to see any downside.
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1. Magnus DC, Wilfond BS, Caplan AL. Accepting brain death. N Engl J Med 2014;370:891-894.
2. Bernat JL. Controversies in defining and determining death in critical care. Nature Rev Neurol 2013;9:164-173.
3. Shewmon DA. Chronic “Brain Death”: Meta-analysis and conceptual consequences. Neurology 1998;51:1538-1545.
4. The President’s Council on Bioethics (2008) Controversies in the determination of death. A White Paper of the President’s Council on Bioethics. Washington, DC. Available at: https://bioethicsarchive.georgetown.edu/pcbe/reports/death/.
5. Halpern SD, Hasz RD, Abt PL. Incidence and distribution of transplantable organs from donors after circulatory determination of death in U.S. intensive care units. Ann Am Thoracic Soc 2013;10:73-80.
6. Sourdon J. Dornbierer M. Huber S et al. Cardiac transplantation with hearts from donors after circulatory declaration of death: haemodynamic and biochemical parameters at procurement predict recovery following cardioplegic storage in a rat model. Eur J Cardiothorac Surg 2013;44:87-96.
7. Gries CJ, White DB, Truog RD et al. An official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: ethical and policy considerations in organ donation after circulatory determination of death. American Thoracic Society Health Policy Committee. Am J Respir Crit Care Med 2013; 188:103-109.
8. Truog RD. ‘Brain Death’ is a useful fiction. Crit Care Med. 2012;40:193-194.
9. Shah SK, Truog RD, Miller FG. Death and legal fictions. J Med Ethics 2011;37:719-722.
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