29 November, 2019
Update to the forms for Diagnosing Death using Neurological Criteria
The Intensive Care Society is delighted to share updated Forms for the Diagnosis of Death using Neurological Criteria 2019.
Since 2012, the Intensive Care Society and Faculty of Intensive Care Medicine (FICM) have endorsed forms for the Diagnosis of Death using Neurological Criteria (brain-stem death), which are consistent with and should be used in conjunction with, the Academy of Medical Royal Colleges (AOMRC) - A Code of Practice for the Diagnosis and Confirmation of Death.
A working group from the Society reviewed the current forms and considered that the forms have proven helpful to clinicians, improved consistency of practice and are in widespread use across the UK. Only minor changes or clarifications were required for this 2019 update. The updated forms have been re-endorsed by The Society and FICM and should replace the older versions.
Summary key changes:
- The previous two versions of the form were entitled ‘abbreviated’ and ‘full’. This could imply the abbreviated version was somehow deficient. The abbreviated version is now called ‘short version’ and the full version ‘long version’.
- Hyperlinks to paediatric and neonatal versions of the forms are now given.
- Red Flags – circumstances where extra caution is required, have proven very helpful and allow any lessons from the worldwide literature and experience to be shared quickly and easily. Following a case in the UK (unpublished) to give more clarity Red Flag 2 is changed to: “Testing < 24 hours of the loss of the last brain-stem reflex, where aetiology primarily anoxic damage.” Previously it was unclear when the 24 hours commenced.
- One of the identified areas of confusion in the forms is that some clinicians interpret that prior to testing there is an absolute requirement to achieve normal respiratory parameters (eg paCO2 < 6.0 kPa) and only at the time of the apnoea test is the paCO2 allowed to rise. This can lead to fruitless efforts to lower paCO2 and then once achieved, raise immediately for apnoea test. (This was despite the 2014 version of this form using the phrase in italics: ‘if possible’.) Dr Alex Manara and Prof Stephen Bonner, who were members of the working party which authored the AoMRC Code, have explained that this was not the intention in the Code. Their interpretation is that the outlined respiratory parameters in the Code were intended as guides aimed at maintaining stability for the hours before testing and not necessarily preconditions to commence testing. The forms have been clarified to make this point.
- Mapleson B corrected to Mapleson C. This is now described as the recommended method for the apnoea test rather than suction catheter.