Ethics Committee Core Curriculum
Determination of Death
Consensus Conference
Consensus Guidelines Attachment B
DETERMINATION OF DEATH IN CHILDREN LESS THAN ONE YEAR OF AGE
1. General Statement Policy
The brains of infants and young children have increased resistance to damage and may recover substantial functions even after exhibiting unresponsiveness on neurological examination for longer periods as compared to adults. Physicians should be particula
rly cautious when applying neurological criteria to determine death in children younger than one year.
2. Clinical History and Examination*
*(Taken from Task Force for the Determination of Brain Death in Children 1987 Report)
The critical initial assessment is the clinical history and examination. The most important factor is determination of the proximate cause of coma to ensure absence of remediable or reversible conditions.
Most difficulties with the determination of death on the basis of neurological criteria have resulted from
overlooking this basic fact. Especially important are detection of toxic and metabolic disorder, sedative-hypnotic drug, paralytic agents, hypothermia, hypotension, and surgically remediable conditions. The
physical examination is necessary to determine the failure of brain function.
3. Physical Examination Criteria
a. Coma and apnea must coexist. The patient must exhibit complete loss of consciousness, vocalization, and volitional activity.
b. Absence of brainstem function as defined by:
1) Midposition or fully dilated pupils which do not respond to light. Drugs may influence and invalidate pupillary assessment.
2) Absence of spontaneous eye movements and those induced by occulocephalic and caloric (oculovestibular) testing.
3) Absence of movement of bulbar musculature including facial and oropharyngeal muscles. The corneal, gag, cough, suckling, and rooting reflexes are absent.
4) Respiratory movements are absent with the patient off the respirator. Apnea testing using standardized methods can be performed, but is done after other criteria are met.
c. The patient must not be significantly hypothermic or hypotensive for age.
d. Flaccid tone and absence of spontaneous or induced movements, excluding spinal cord events such as reflex withdrawal or spinal myoclonus, should exist.
e. The examination should remain consistent with brain death throughout the observation and testing period.
4. Observation Periods According to Age
The recommended observation period depends on the age of the patient and the laboratory tests utilized.
Seven days to two months - Two examinations and electroencephalograms (EEGs) separated by at least
48 hours.
Two months to one year - Two examinations and EEGs separated by at least 24 hours. A repeat
examination and EEG are not necessary if a concomitant radionuclude angiographic (CRAG) study demonstrates no visualization of cerebral arteries.
5. Laboratory Testing
Electroencephalography - Electroencephalography to document electrocerebral silence should, if performed, be done over a 30-minute period using standardized techniques for brain death determinations.
In small children it may not be possible to meet the standard requirement for 10-cm electrode separation.
The inter-electrode distance should be decreased in proportion to the patient's head size. Drug
concentrations should be insufficient to suppress EEG activity.
Angiography - A cerebral radionuclude angiogram (CRAG) confirms cerebral death by demonstrating the lack of visualization of the cerebral circulation. A technically satisfactory CRAG that demonstrates arrest
of carotid circulation at the base of the skull and absence of intracranial arterial circulation can be
considered confirmatory of brain death, even though there may be some visualization of the intracranial
venous sinuses. The value of this study in infants under two months is under investigation. Contrast
angiography can document lack of effective blood flow to the brain.
Direct questions about the posting of this report to
Dr. Brad Truax
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Last Revised 3/20/97