Observation Time Prior to Determination of Death by Neurologic Criteria

The appropriate time to perform an evaluation for determination of death by neurologic criteria following a devastating brain injury is not quantifiable. Prior to determining death by neurologic criteria a patient must have an established neurologic diagnosis capable of resulting in the irreversible loss of the capacity for consciousness, all brainstem reflexes, and the ability to breathe spontaneously. Prior to determination of death by neurologic criteria, the presence of confounding factors must also be excluded. The time required for resolution of potential confounders varies based on the specific circumstances for individual patients. In this chapter, we examine the current standards and evidence for selection of the observation time prior to determination of death by neurologic criteria. We recommend that the following: (1) Patients with devastating brain injuries should be admitted to an intensive care unit to allow sufficient time for a specialist to assess them, exclude confounders, and communicate with families before performance of an evaluation for determination of death by neurologic criteria; (2) While individual circumstances may vary, evaluation for determination of death by neurologic criteria should not be performed until all potential confounders are resolved; and (3) In patients who have survived a cardiac arrest, the evaluation should be delayed 24–48 h from the time of return of spontaneous circulation (or 24–48 h after rewarming if treated with targeted temperature management).