Updated form to support the diagnosis of death using neurological criteria

In 2021 in the UK, a diagnosis of death using neurological criteria had to be reversed. The case had a very specific set of circumstances, likely to only be encountered in neuroscience centres in the UK, specifically the use of bilateral therapeutic decompressive craniectomy as a treatment for severe traumatic brain injury.

An expert group reviewed the case and made recommendations, which have been accepted by the Intensive Care Society Society and Faculty of Intensive Care Medicine.

The main recommendation was that ‘Therapeutic decompressive craniectomy’ should be added as a red flag to the nationally endorsed testing forms. Red flags being situations where diagnostic caution is advised, and consideration should be made to delay testing and/or perform ancillary investigations.

This is in addition to the existing red flags:

1. Testing < 6 hours of the loss of the last brain-stem reflex
2. Testing < 24 hours of the loss of the last brain-stem reflex, where aetiology primarily anoxic damage
3. Hypothermia 24 hour observation period following re-warming to normothermia recommended
4. Patients with any neuromuscular disorders
5. Steroids given in space occupying lesions such as abscesses
6. Prolonged fentanyl infusions
7. Aetiology primarily located to the brainstem or posterior fossa

IN addition, during the review the expert group used the opportunity to improve the nationally endorsed testing forms by:

• Giving more prominence to the red flags to ensure they are seen and accounted for
• Specifically, advising that clinicians should consider the need to delay testing and/or perform ancillary investigations if a red flag
• Enhancing clarity and emphasis. This included removing symbols for greater or lesser than in the testing form questions

The diagnosis of death using neurological criteria is an important diagnosis made almost exclusively in the UK by intensive care doctors. We would ask that you update older versions of the nationally endorsed forms with updated versions.