Memorandum by Dr Martin Smith
Thank you for asking me to clarify some of the
current issues around the diagnosis of brainstem death.
The clinical criteria for the diagnosis of brainstem
death in the UK were refined over many years in the 1970s by the
Conference of Medical Colleges and their Faculties in the UK and
published as a Code of Practice by the Department of Health in
1998. In the UK there is no statutory definition of death but
English law has adopted these widely accepted criteria and considers
death to be "the irreversible loss of the capacity for consciousness,
combined with the irreversible loss of the capacity to breathe".
The diagnostic algorithm in the UK has three
sequential but interdependent steps. Certain pre-conditions must
be fulfilled and potentially reversible cause of coma excluded
before clinical tests of brainstem function, including an apnoea
test, are performed. The UK criteria are robust, well established
and used as the basis for the diagnosis of brainstem death in
many other countries in the world.
An updated Code of Practice for the diagnosis
of death has recently been agreed, following wide consultation,
by the Academy of Medical Royal Colleges (AMRC) and, for the first
time, includes guidance on the diagnosis of death by cardiovascular
criteria. The updated Code is in two parts—Part 1 deals
with the diagnosis of death and Part 2 with issues relating to
organ donation. The guidance for the diagnosis of brainstem death
(now called diagnosis of death by neurological criteria) will
be essentially unchanged from the 1998 Code but additional clarification
is provided for some of the areas that have previously been the
cause of concern for some, eg clarification of serum electrolyte
levelsprior to testing.
I am aware that final draft of the Code was
agreed by the AMRC some time ago and is currently with the Department
of Health awaiting endorsement. There has been some delay in obtaining
this endorsement and several groups in addition to the AMRC, including
the Organ Donation Taskforce and the UK Transplant Donation Advisory
Group, have been lobbying the DH to expedite its publication.
Dr Martin Smith
Consultant in Neuroscience Critical Care
Chairman, UK Transplant Donation Advisory Group
June 2008
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