Deciding Who Is Dead: Physician Group Issues New Statement

A single word clarification is the only revision the Uniform Determination of Death Act (UDDA) needs, the American College of Physicians (ACP) stated.

In a new position paper, the ACP joined the ongoing debate that could reshape the cardiorespiratory and neurologic standards determining death.

The ACP supported replacing the word “irreversible” in the UDDA with “permanent” to define circulatory determination of death, wrote Matthew DeCamp, MD, PhD, of the University of Colorado in Aurora, and Kenneth Prager, MD, of Columbia University Irving Medical Center in New York City, in Annals of Internal Medicine.

The group otherwise affirmed the UDDA and its principles. It backed maintaining separate, independent cardiorespiratory and neurologic standards of determining death, and supported retaining the whole brain death standard as opposed to “higher brain” function standards. It called for aligning medical testing with standards of determining death, and not the reverse.

The ACP statement also advocated separating issues about determination of death from organ transplantation and affirmed the importance of the dead donor rule, which says that organ procurement cannot cause death.

“We don’t believe the UDDA is fundamentally broken,” DeCamp, a consultant to ACP, said in an interview with MedPage Today.

“In the past 5 years or so, there’s been increasing attention to the concept of brain death by ethicists, legal scholars, and others,” he pointed out. Complicated disagreements about the determination of death have gained widespread media attention, and “there have been proposals for changing the UDDA itself,” he said. “Together, these made it important for ACP to analyze this issue now.”

In 2020, the Uniform Law Commission, which advises states about determination of death laws, appointed a committee to study whether the 40-year-old UDDA needed revision. Several groups have proposed changes, including ways to clarify death by neurologic criteria.

In July 2023, Neurology published a series of articles outlining the most important brain death controversies the Uniform Law Commission faces.

‘Irreversible’ versus ‘Permanent’

Questions have emerged about the use of the word “irreversible,” the ACP committee said.

The UDDA states that an “individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.”

The ACP called for replacing the word “irreversible” with “permanent” in the first clause, so it would read that an individual “who has sustained either (1) permanent cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead.”

“Permanent” would apply only to circulatory and respiratory functions; “irreversible” would remain for brain death, the ACP proposed.

The terms “permanent” and “irreversible” are not synonymous, observed James Bernat, MD, of Dartmouth Geisel School of Medicine in Hanover, New Hampshire, who wasn’t involved with the ACP paper.

The distinction was proposed in 2010 to clarify death in organ donors after circulatory determination of death (DCDD), Bernat told MedPage Today.

Prevailing DCDD protocols permit donors to be declared dead once their heartbeat and circulation completely ceased for 5 minutes, he explained. Critics pointed out that, even when donors have do-not-resuscitate orders, it might be possible to successfully resuscitate them after their heartbeat and circulation had stopped for 5 minutes, he added.

“If the circulatory criterion of the UDDA were revised by substituting the adjective ‘permanent’ for ‘irreversible,’ it would make explicit that current death determination practices in DCDD donors are lawful,” Bernat said.

Advances in re-establishing postmortem circulation through extracorporeal membrane oxygenation (ECMO) or normothermic regional perfusion — a transplant protocol emerging in U.S. hospitals — have made the relationship between the circulatory and brain criteria of the UDDA more consequential, Bernat noted in a recent essay.

More Education, Better Communication

The ACP also called for more education about how death is determined. Training for medical students, residents, and fellows may help improve communication skills over the long term, the committee suggested. Broad public education about determining death also is needed.

“The determination of death is something that happens every day. It is a profound and solemn act that physicians and other clinicians engage in,” DeCamp said.

“We hope the ACP paper helps practicing physicians understand, even more clearly than they already do, just how important the standards for the determination of death are,” he added. “They intersect the fundamental values of the profession — values like honesty, transparency, integrity, and respect.”