The American College of Physicians (ACP) has issued a new position paper on determination of death that includes a clarification to the 1981 Uniform Determination of Death Act (UDDA), but otherwise reaffirms the current standards.
The clarification replaces the word "irreversible" with "permanent" with regard to the cessation of circulatory and respiratory functions but retains "irreversible" to describe brain death.
"Today, irreversible is understood to encompass circumstances in which physiologic functions cannot resume (that is, it is not biologically possible)," the position paper states. "The term permanent is understood to encompass not only circumstances in which physiologic functions cannot resume (that is, are irreversible) but also those in which function will not resume (for example, because resuscitation, although possible, will not be pursued out of respect for the patient's preferences)."
"We emphasize in the statement that the UDDA is not fundamentally broken," Matthew DeCamp, MD, PhD, associate professor of medicine at the University of Colorado, Aurora, and consultant to the ACP on ethics policy issues, told Medscape Medical News. "A major revision is not needed. We propose a minor change in the cardiorespiratory standard."
"We hope that the position paper, with its concision and clarity, along with the references that are included therein, are enough to help clinicians even more effectively communicate with patients and families about death and dying," added DeCamp, the lead author of the position paper.
The position paper was published online September 4 in Annals of Internal Medicine.
Timeless Values
The position paper was developed on behalf of the ACP's Ethics, Professionalism and Human Rights Committee (EPHRC). After an environmental assessment to determine the scope of issues and literature reviews, the EPHRC discussed drafts of the paper, which was reviewed and revised by the ACP Board of Governors, Board of Regents, Council of Early Career Physicians, Council of Resident/Fellow Members, Council of Student Members, and other committees and experts.
Other than the change from "irreversible" to "permanent," the paper reinforces the tenets of the existing UDDA by stating the following positions:
Position 2 supports maintaining circulatory and whole brain (neurologic) standards for determining death as separate, independent standards.
Position 3 supports retaining the whole brain standard for determining death according to neurologic criteria and opposes "higher brain" function standards.
Position 4 recommends that the medical tests used for determining death align with standards of death determination, not vice versa, and that the language of the UDDA that a "determination of death must be made in accordance with accepted medical standards" be maintained without changes.
Position 5 states that determination of death is a distinct issue from organ transplantation and reaffirms the fundamental ethical importance of the dead donor rule.
Position 6 recommends that additional education be directed toward physicians and other clinicians, and the general public, regarding determination of death and communication about death and the dying process.
"Our statement emphasizes that some values are truly timeless," DeCamp said. "These include transparency, honesty and integrity, and the commitment to put patients' welfare first — and those values won't change."
"I hope our statement makes clear the way that determination of death intersects those fundamental values and how important it is to uphold those values and maintain trust in physicians and the profession as a whole."
DeCamp acknowledges "a diversity of views," on the topic, noting that proposed changes to the UDDA were one motivation for the position paper. "We also acknowledge that new technologies and therapies can present the need to revisit foundational concepts," he said.
DeCamp can't say whether there might be a future revision to the position paper, but noted, "I would say that we're always willing to revisit these fundamental concepts in the face of new technologies."
"Permanency Is Paramount"
Commenting on the position paper for Medscape Medical News, David M. Greer, MD, professor and chair of the Department of Neurology at the Boston University School of Medicine, said he thinks "there are a few areas where it comes up short."
"Although I applaud their position that the word 'permanent' should be used for cardio-respiratory death, I do not agree with their argument that the word 'irreversible' should still be used for brain death, instead of 'permanent,' " said Greer, chair of the Academic Neurology Committee for the American Academy of Neurology and a co-author on both the current AAN brain death guidelines and an upcoming revision of those guidelines.
"In my opinion, there should not be two different standards for death, and permanency is paramount for both," he contends. "Their argument that using the word 'permanent' would not apply in conditions such as hypothermia or drug intoxication is faulty. Clinicians know never to determine brain death in those circumstances, as prerequisites are clearly not met."
Regarding position 2, Greer said: "One could argue that the brain is the 'end organ' that needs to be 'dead' on definitions of both cardiorespiratory and brain, and they do not give enough credence to that argument."
On position 3, Greer agrees that "higher brain" death should never be accepted conceptually. However, he said that the ACP could have taken the position that "brainstem death," as used in the UK and some other countries, "is similarly unacceptable."
Regarding position 4, Greer agrees that the medical tests should align with the clinical picture; however, he said, "it would have been much more helpful for them to lobby for a singular, national standard that establishes minimum criteria," such as new guidelines coming out soon from the American Academy of Neurology, in collaboration with other societies.
"Having people be dead in one state and not another is still problematic," he said, "and they are missing an opportunity to help establish this national standard in this position statement."
Finally, regarding position 5, the ACP "takes a very strong position against thoracoabdominal normothermic regional perfusion, and this is not a settled issue," Greer said. "Many will disagree with this position, and they could have left room for medical advances in this regard. This will likely be very controversial and receive significant backlash from the medical community, in my opinion."
For now, Greer advises clinicians that "permanence of the condition (death by cardio-respiratory or neurological criteria) remains paramount. The process must remain meticulous, sound and thorough, and when in doubt about the diagnosis of brain death, always err on the side of not declaring the patient dead."
"Newer ancillary tests are being evaluated, but still need to be validated against 'gold standards,'" he said. "The clinical examination remains central to the determination in all cases, even when an ancillary test will be necessary."
Like the ACP, he concludes that education of students, residents, and practicing clinicians, "is essential to ensure sound practice of brain death determination in the future."
Financial support for the development of this paper came exclusively from the ACP operating budget.
Ann Intern Med. Published online September 4, 2023. Full text
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Cite this: ACP Revises Standard on Cardiorespiratory Death Determination - Medscape - Oct 06, 2023.
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